1

Pegasystems 2009
Overview of CTI & PegaCALL
along with
CPM for Healthcare
Matt Ruffing Matthew.Ruffing@pega.com
Rob Mills Robert.Mills@pega.com
Fran !ahn Fran.!ahn@pega.com
2
Pegasystems 2009
"gen#a

CTI

CTI What and why

PegaCALL architecture

Integration with PRPC

Application Flow

Terminology

CPM for Healthcare

eneric CPM HC !"M#

CPM HC Cla$$ $tructure

"na%ling CPM HC Wi&ard

CPM Wi&ard to create flow

'how new flow in HC wor(ing

)nder co*er$ of flow de$ign and $tructure

Changing )$er Interface of flow

#*er*iew of integration to e+ternal $y$tem$ with CPM

,ue$tion$
$
Pegasystems 2009
%hat is &'()

Computer Telephony Integration

Technology that allows telephony

events (call delivered to agent, call
transferred, etc) to be coordinated
or integrated with a computer

The timing of events is such that

telephony and computer events
occur practically simultaneously

*
Pegasystems 2009
Rules+,ri-en &omputer 'elephony
(ntegration .&'(/ with Pega&"00 for PegaR1023
I
- Legacy pre fetch to drive IVR processing and
call routing
I - Re use rules to drive IVR decisioning
I Adaptive screen pop for effective coordination
of call arrival
I
- Desktop and workflow based telephony controls
for improved call management
I ! Implement individually or incrementally
4
Pegasystems 2009
&'( Functions
Call Control

Customer data
pre-fetch

Call routing

Adaptive screen
pop

Desktop
Telephony

ACD!"# $ogin

%a&e available

'old(n-hold

Answer call

%a&e call

Disconnect call

Conference call

"lind transfer

)arm transfer
5
Pegasystems 2009
'elephony 'echnology in a &ontact
&enter

*nteractive +oice ,esponse (*+,)

*nteractive phone system that can respond to a callers input

(voice &eypad) and either complete pre-determined
services or assist in properly routing the call to the
appropriate agent-

Common -endor$. Avaya, /enesys, 0yntellect, 1uance

ACDCall ,outing

Automatic Call Distributor 2 a device that distributes large

volumes of incoming calls to agents- The ACD contains
logic that drives routing decisions based on multiple input
parameters- ,outing parameters can include a
combination of data about available agents and their s&ills,
and specific information about the callcaller

Common -endor$. Avaya, Aspect, Cisco

Computer Telephony *ntegration (CT*)

Technology that allows interactions on a telephone and a

computer to be integrated or coordinated- This allows for
an agent to receive both the voice call and the supporting
data at the same time- 0upporting data may come from
the *+,, the phone switch or other sources

Common -endor$. /enesys, Cisco, 3nvo4

6
Pegasystems 2009
%hy implement &'()
Cost 0avings

Avg- savings of 56 secondscall (/artner)

A contact center that handles 768callsday can

save over 56,666 agent hoursyear 9ust by
implementing a successful screen pop
*ncreased customer satisfaction

Customers don:t have to repeat information they

have provided to the *+,

Agents start the call more focused on the

customer:s issue
!romotes self-service use.

Adds perceived value to entering data in the self-

service *+,, once customers learn they will not
have to repeat information to an agent
*ncrease agent productivity.

!refetch and screen pops ma&e agents more

efficient

*ntegrated telephony features simplify agent

tas&s

7
Pegasystems 2009
Pega&"00 2nables PRP& applications with
&omputer 'elephony (ntegration .&'(/

*ncreased Agent !roductivity.

,etrieve customer information in advance

of the agent receiving the call

Deliver the call and the customer

information simultaneously

,ules driven screen pop delivers the right

customer data based on the agent, the
customer and the call

$ower Customer ;rustration.

Close the *+, /ap.

3liminate the need for the customer to

repeat information to an agent - *+,
data is passed to the agent as the call
arrives

Agents can &now the point at which the

customer <=eroed: out of the *+,

"!%-enabled CT* allows the agent to

continue service from that point
Transfer the call and the data.

!rovide the agent receiving the call with

details they need to continue service

Allow an agent to pic& up at the point in

the process where the last agent
ended

9
Pegasystems 2009
&'( (ntegration "pproach
& u s t o m e r 3 e r - i c e
8racle ,9
Mainframe: 83;$90
SQLNet
MQ or
SQL
(<R may access
legacy systems if
#esire#
Pro#uction
applications
&'( mi##le ware
may re=uest #ata
from Pega for pre+
route
&'( Mi##leware
re=uests a#>unct
route from Pega&all
1
2
3
5
6
7
8
9
4
Rules retrie-e ? e-aluate
#ata ? #etermine when;if
telephony functions are
re=uire# by &3R
Pega&"00 maintains
connection for P8P
an# &'( e-ents
&'( mi##leware places
caller in "&, =ueue as
instructe# ? notifies
Pega&"00 upon call
offering e-ent
Member #ial 700 @ an# is
#irecte# to (<R for (, prompt
&aller is #irecte# to (<R an#
prompte# for information nee#e# to
access profile
Pega&"00 monitors call arri-al on
premise an# may begin customer
looup by "A(.
(nformation is gathere# to satisfy
(<R #ata re=uirements from any
a-ailable source .see @4/
(<R: Pegasystem: or caller re=uest
opt out an# (<R attaches #ata to the
call for han#ling by the &'( mi##le
ware. &all is #irecte# to "&, or is
manage# by &'( mi##le ware to the
correct "&,.
&'( Mi##leware may optionally
re=uest final route input from
Pega&"00
Pegasystems uses any #ata
a-ailable to #ri-e rules engine to
#etermine possible route for call
P9B places call in =ueue an#
maintains up#ate with Pega&"00
-ia lin. &all is offere# to neCt
a-ailable agent in =ueue
Pega&"00 obtains message of call
offering: starts rules engine with
rele-ant #ata.
Pegasystem #ri-es #ata nee#e# for
P8P to the #estop using #ata
obtaine# in step 4 base# on
business rules.
,estop re=uests &'( functions
.conference: transfer: hol#: etc/ -ia
Pega&"00 interface metho#s
Pegasystem rules engine instructs
&'( Mi##leware as nee# -ia
Pega&"00 to perform nee#e#
functions re=ueste# by #estop
application.
7
2
3
5
6
8
8
9
4
1
1
"&,
10
Pegasystems 2009
Pega&"00 for PegaR1023
!igh 0e-el "rchitecture
PegaCALL Installation with enesys
(<R
PBX / ACD
'+3er-er
%in#ows 3er-er
Pega&"00 &'(
0in
Routing
Point
Dueue "
P3'A
Pega&"00
38"P &onnectors
PegaR1023 Process &omman#er
38"P 3er-ices
9ac+2n# 3ystems an# ,atabases
&ontaining Real+'ime &ustomer (nformation
Dueue 9
Dueue &
1
2
4

!
4
"

%orstation

#
"
'elephone
11
Pegasystems 2009
Pega&"00 for PegaR1023
CT* support for most ma9or ACD:s using industry
standard CT* middleware and routing platforms.

3nvo4 CT Connect

/enesys

Aspect Contact 0erver

Cisco *C%
0erver-side CT* integration

!rovides seamless integration of telephony events and

business processes

1o des&top D$$:s to install

,eal time adaptive screen pops

!uts the right customer information in front of the

agents

3liminates need for the customer to repeat to the

agent what they 9ust entered into the *+,

;ully configurable 2 can trigger different processes

based on the agent and customer profiles for
enhanced customer service
+oice and Data Transfer

Transfer customer and wor& ob9ect data with the call

12
Pegasystems 2009
&oming soonEE.
Configuration )i=ard 2 should allow basic connectivity and
features (screen pop) to be configured and running in
>6-?@ minutes, including call data mapping, custom
screen pop, etc- This will be a huge help during !AC:s
where CT* is reBuired-

0tateful telephony (/enesys only) 2 allows state to be

synchroni=ed between !egaCA$$ and the phone, so that
actions ta&en at the phone (ie put a call on hold) will be
reflected in the !egaCA$$ (*- This also introduces the
concept of a CT* Toolbar that can be embedded in C!%-

CT*$in& 'ot ;ailover 2 ability to have a hot standby CT*$in&

that will detect a failure in the primary lin& and ta&e
over automatically

The C!% C-7 release (566D) will include pre-configured

voicedata transfer capability, so that when a user
transfers the call, the active case(s) go with the call
automatically-
1$
Pegasystems 2009
'erms you nee# to nowF
Telephony

A1* 2 Automatic 1umber *dentification

D1*0 2 Dialed 1umber *dentification 0ervice

ACD 2 Automatic Call Distributor

0&ills "ased ,outing 2 A feature of many ACD:s that provide the ability to route calls based
on call type and agents s&ill set

+D1Application 2 +ector Directory 1umber (Avaya) 2 an e4tension that directs incoming

calls to a specific vector or application- Calls are trac&ed by vector, the vector drives a
specific message and Bueues- The +D1 or App can indicate to the agent (and the
software) the type of call

Availability 2 Agent driven indication that they are available to receive calls, usually
entered into the phone set or the soft phone, but can be software controlled

Auto-*nAuto-,eady 2 An indication of the agent state that is automatically established

upon release of a phone call- An <auto-ready: agent will become available as soon as a
call is released, versus having to manually indicate availability

)hisper 2a message from the ACD that is whispered to the agents headset 9ust prior to
the call being established, typically indicates the call type to the agent
CTI

*+,+,( 2 *nteractive +oice ,esponse +oice ,esponse (nit

0creen !op 2 0creen !opulation

CT* 0erver%iddleware 2 0erver component that provides a layer of abstraction between

the ACD and client software- !ega supports 3nvo4, Cisco *C%, /enesys and Aspect
Contact 0erver

CT*$in& 2 !ega component that sits between !,!C and the CT* 0erver

0oft !hone 2 0oftware based phone that allows agents to control telephony functions from
their computer

Call Center

)rap (p 2 Agent state after release of a call that allows them to finali=e any wor&, enter
notes, etc- Auto-,eady call centers will have no wrap-up period

*dle 2 Agent state where they indicate that they are (navailable to ta&e phone calls- %any
call centers measure idle time and force agents to indicate idle reason prior to going
idle (ie "athroom, etc)

Call DispositionCall Coding 2 ;eature of many ACD:s that allow the agent to indicate the
disposition of a call during the wrap up using either the phone set or the soft phone-
%any ACD:s provide Call Center dashboards that leverage this data in real time

'andle TimeA'T 2 Average 'andle Time is the time it ta&es to handle an interaction-
This typically includes wrap and any after call wor&-

0ervice $evels 2 usually measured as the E of calls that actually ma&e it to an agent
without abandoning- A @6E service level means half the calls never get to an agent-

1*
Pegasystems 2009
CPM for Healthcare
14
Pegasystems 2009
Pegasystems 'he !ealthcare
9PM 0ea#er
Target Mar$et
0arge Payers G 2MM Members
'op Pharma ; 0ife3cience &os
!ealthcare Ho-ernment
3electi-e Pro-i#ers;(,As;P9Ms

Mar$et Mo%e&t'%
16 new customers in past 17 months
90I license# our solution framewors
3ignificant repeat business
2nterprise bacbone commitments
8-er 94M co-ere# li-es
* of top 4 payers
44I of 9&93 Plans
HC Practice Overview
*0I of Pega 9usiness
,eep #omain eCpertise
(e)'lt) * (OI
64I re#uction &laims 9aclog
$0I increase 1st pass rate
97I re#uction in group enrollment costs
20I increase issues han#le# per contact
20I re#uction call han#ling time
40I re#uction in training times
15
Pegasystems 2009


. . ! of top " Largest # $ Payers - % %! of &lues 'etwork - % "" of
&lues (embers - )" million covered lives
(ar*uee +ealthcare Clients
,ransforming +ealthcare
Across ,he lobe
16
Pegasystems 2009
+,ec'tio& -a.) Clo)e/ 01 O'r C')to%er)
Medical Management
FDA & OIG
Compliance
HIPAA, CMS & Blues
Compliance
Su!ogation,
Collections &
"eco#e!$
Inte!nal Se!#icing
Bac%one
Claims and
Ad&ustments
Se!#ice '(ceptions
P!ocessing
'nte!p!ise Case &
'#ent Management
C!oss)Sell, *p)sell
+e Sel,)Se!#ice
-./ Deg!ee 0iew o,
the Custome!
CS" Des%top
Sales P!ocess
Management
'n!ollment
1ailo!ed O,,e!ings
1ime to Ma!%et
(i)$2 3ra'/2 &
Co%.lia&ce
Ma&age%e&t
4ervici&g
Bac$0o&e
C')to%er
(elatio&)hi.
Ma&age%e&t
5ew B')i&e))
17
Pegasystems 2009
2ew Business
Bac%one
Pega"*3'S P!ocess Commande! 4P"PC5
Healthca!e Indust!$ Foundation
Healthcare Co%%o& O06ect Mo/el
X12 +DI Me))age 4'..ort
4a%.le 4i%'late/ Data
4a%.le Orga&i7atio&al Mo/el
New Business New Business CRM CRM
Servicing Backbone Servicing Backbone
Risk Risk
Fraud & Fraud &
Compliance Compliance
CPM ,o! Healthca!e
Me%0e
r
4ervice
)
Provi/e
r
4ervice
)
$ales Process
(anager
HC P!oduct HC P!oduct
Con,igu!ation Con,igu!ation
62'+6 62'+6
Claims Bac%one
Clai%)
(e.air
Clai%)
849
Build Build
"is% "is%
F!aud F!aud
& &
Complia Complia
nce nce
"ules "ules
In In
Indust!$ Indust!$
Bac%on Bac%on
es es
CPM HC Foundation CPM HC Foundation Claims Foundation Claims Foundation
$mart&P( for +ealthcare
Ca!e Mgmt Bac%one
62'+6
Care
Ma&age%e&t
Clinical Foundation Clinical Foundation
5ew Me%0er
+&roll%e&t
A'thori7atio&
Ma&age%e&t
A..eal) & -rieva&ce)
Ma&ager
19
Pegasystems 2009
Healthcare I&/')tr1 3o'&/atio&
Healthcare Co%%o& O06ect & Data Mo/el
HC +&ter.ri)e Orga&i7atio& 4tr'ct're
HIPAA X12 +DI Me))age 4'..ort Healthcare Portal) HealthCare O06ect 4earch & (etrieval HealthCare 4ta&/ar/ 4LA)
HIPAA 4ta&/ar/
Co/e 4et)
5ew B')i&e))
Me%0er +&roll%e&t
C ( M
A'thori7atio& Ma&age%e&t
4ervici&g Bac$0o&e
A..eal) a&/ -rieva&ce)
(i)$ a&/ 3ra'/ Mg%t
A'thori7atio& Ma&age%e&t
Interaction Management
Case Management & Control
20
Pegasystems 2009
HC I&/')tr1 3ra%ewor$ (Representative Functionality)
( , , , -ork Parties member provider broker plan
, , ) sponsor agency etc
+IPAA .DI /01 $upport
( , , +ealthcare Common 2b3ects claims authori4ation
, , , , ) premium benefits C2& policy etc
- Pre configured +ealthcare Components
Reusable -ork ,emplates
& (ember $earch Review
& Claim $earch Review
& Provider $earch Review
& Authori4ation $earch Review
& Policy $earch Review
- Pre built +IPAA 5unctionality
Correspondence eneration
- Reusable standard letter templates compiled
dynamically when needed
- ; Automated or on demand choose to re*uire review or
allow edits
(aintained as part of inalterable audit trail for
compliance reporting
( & - ) Automated file input batch real time
& /01 message parsing mapping
+IPAA property validation
+IPAA /01 .DI samples
Reporting
, & 2ut of the bo/ productivity *uality aging reports
- Drill down review capabilities
Custom report wi4ard
Automated Authori4ation Re*uest (anagement
Provides -eb $ervice $2AP (essage for providers to
- submit /01 167 transactions through $elf service
portal
- - 5acilitates straight through processing of /01 167
based on easily customi4ed sample business rules
& Routes prioriti4es pending transactions for
manual processing
& (ember Application .nrollment Processing
, $ample enrollment workflows driving intake data
& entry output
- ; Intent led data entry automated data population for
PD5 and email applications
Intelligent enrollment application routing
& Per member risk factor computation underwriting
approval recommendation based on medical
underwriting
& Appeals rievances (anagement
- - , , (ulti channel guided intake for web phone email and
fa/
Comprehensive member composite
- , , Pre packaged workflows for Appeals rievances
& / Re*uestor Party Information service claims
information
Concurrent assignments to multiple departments for
& research response
- $ecure one time link for e/ternal parties to provide
data and work cases
21
Pegasystems 2009
)eb
C')to%er Proce)) Ma&ager for Healthcare
Co&tact Ce&ter O06ect & Data Mo/el
Pho&e I&teractio&) CTI I&teractio& Driver
Dialog
Ma&age%e&t
I&teractio& Trac$i&g
HC C')to%er ID & :erificatio& HC !"; Degree :iew
C')to%er Profile
Ma&age%e&t
I&teractio& Coachi&g <&owle/ge Ma&age%e&t
C')to%er Li&$i&g C')to%er Alert) I&teractio& A&al1tic) C')to%er 4'rve1) Ca%.aig& Ma&age%e&t
Co&tact Ce&ter Portal) +%ail (e).o&)e 3a, & Mail I&teractio&) 8e0 4elf*4ervice I&teractio&)CC Co&fig'ratio& 8i7ar/)
CC ='e'e Ma&age%e&t C')to%er 4LA) CC ='alit1 Mgt CC Pro/'ctivit1 A&al1tic) C')to%er 4ec'rit1
Di).'te Clai% Pa1%e&t) /
De&ial
HealthCare * 3A=)
Diag&o)e Pro0le%)
Prior A'thori7atio& (eview
Material) 3'lfill%e&t
4e&/ Corre).o&/e&ce
4che/'le Activitie)
Co%.lai&t / Co%.li%e&t
-e&eral 4ervice (e>'e)t)
Clai% 4tat') (eview
A// 5ew0or&
Or/er ID Car/)
A// / ?./ate PCP
Ma&age Privac1 4etti&g)
A..eal Prior A'th De&ial
(e>'e)t Pre*certificatio& / Prior A'thori7atio&
Ma&age -ro'. Partici.atio&
Ma&age Provi/er Partici.atio&
Ma&ge Provi/er Cre/e&tiali&g
Ma&age 5atio&al
Provi/er ID
Healthcare Co%%o& O06ect 2 Data Mo/el & Polic1 4tr'ct're
HC Pa1er +&ter.ri)e Orga&i7atio& 4tr'ct're
Me%0er +ligi0ilit1
Interaction Management
Case Management & Control
Wor !"tomation
#ot$ Mem%er & &ro'i(er Ser 'ice Mem%er Ser 'ice &ro'i(er Ser 'ice
M'lti*%e%0er / M'lti @ .olic1 i&>'ir1
Me%0er Healthcare /iag&o)tic
22
Pegasystems 2009
CPM*HC (Representative Functionality)
Inbound Customer Call
& Automated email receipt case
creation
(anual inbound correspondence
case creation
Customer verification *
Interaction Driver
,(
with
& suggested customer processes
offers
$mart Dialog
,(
interaction
scripting
& Interaction log audit trail *
- Automated interaction wrap up
Communication workflow
Contact Priority 'ote
- (ulti policy servicing including
inactivity logic
Designee management *
- Role based authority management *
Reference #tilities for Reference
, (aterials Location 5inder and 5ind
Provider
$mart View
,(
customer data composite
( , , , , policy member provider facility
, , claims authori4ations
& ) contact plan sponsor
& eneral Information
profile
- (ulti channel interaction
history
$ervice history
&enefit Review
& Claim search review
& Authori4ation search
review
'otes
Add a Contact
8uick Contact Add
& #pdate Contact 'ame Profile*
& #pdate Contact Address Profile
Add Attachment
/ Complaint Compliment
Dispute Claim
5re*uently Asked 8uestions
eneral $ervice Case
(aterials 5ulfillment
(ember .ligibility
(ember $earch
( , $chedule Activity call
, ) appointment task
$end Correspondence
* 5acilitates +IPAA
Compliance
Interaction (anagement
Customer (anagement
eneral $ervice
Re*uest Processing
(ember $ervice Re*uest
Processing
Add a 'ewborn
2rder ID Card
, #pdate (ember Address &irth
, date 'ame
#pdate Primary Care Physician *
#pdate Privacy $ettings*
- / (ulti member (ulti policy
in*uiry facilities
Provider $ervice Re*uest
Processing
Appeal Prior Auth Denial
.nroll in a Provider 'etwork
(anage 'ational Provider ID
Re*uest Prior Authori4ation
#pdate Provider Credentials
#pdate Provider Profile
C,I 5acilities
& C,I Login Availability
- $creen pop with data collection
from IVR
Desktop telephony controls
2$
Pegasystems 2009
- $ystem assigned routing based on
case urgency
, & $ervice level goals deadlines
escalation
events
#ser work lists
$ystem workbaskets
et (ost #rgent -ork functionality
- -ork re assignment
- Customer based service level
profiles
- Customer based service level
override

Interaction reports
Productivity reports
8uality reports
Aging reports
Campaign reports
& Pipeline opportunity reports
8uality Performance Reports
9nowledge (anagement Reports
Custom report wi4ard
- Drill down review capabilities
& Automatic manual
generation
& Create modify templates
, , & (ail email fa/
capabilities
, & Review editing
verification privileges
, & Access groups privileges user
portals for*:
, & (ember Provider #niversal
C$Rs
, & (ember Provider #niversal
(anagers
$ales Representatives
$ales (anagers
$ystem Administrators
, & 2perator profile schedule skills
management
-orkbasket assignments
$ecure login
& Random manual work selection
, & .mployee review rating scoring
& - Coaching sessions real time
coaching tips
Reporting
& -ork Assignment
$ervice Level (anagement
Correspondence
eneration
8uality Performance
(anagement
/ Access Roles
2perator
(aintenance
CPM*HC (Representative Functionality)
9nowledge (anagement
9nowledge content rules and usage
statistics
& 9nowledge in*uiry response
#ser suggestions for content
update
* 5acilitates +IPAA
Compliance
, & 2ffer 2pportunity
,erritory (anagement
- , , Cross sell retention
, & restitution reward
wellness campaigns
- & Campaign set up wi4ard script
definition
$uggested offer processing
, 2pportunity creation assignment
& resolution
& 'amed customer territory
assignments
2*
Pegasystems 2009
1he CS" des%top is intent)d!i#en and 1he CS" des%top is intent)d!i#en and
con,igu!ed to optimi7e e#e!$ custome! con,igu!ed to optimi7e e#e!$ custome!
inte!action and o#e!all CS" e,,icienc$ inte!action and o#e!all CS" e,,icienc$
Sma!t Dialog8
Co&te,t*)e&)itive2 Co&te,t*)e&)itive2
.er)o&ali7e/ /ialog .er)o&ali7e/ /ialog
Inte!action D!i#e!8
Co&te,t*)e&)itive2 Co&te,t*)e&)itive2
.er)o&ali7e/ ta)$) .er)o&ali7e/ ta)$)
Sma!t 0iews8
Co&te,t*)e&)itive2 Co&te,t*)e&)itive2
)'%%ar1 i&for%atio& )'%%ar1 i&for%atio&
e&a0le) re)earch & e&a0le) re)earch &
review review
co&c'rre&t with co&c'rre&t with
.roce)) .roce))
f'lfill%e&t f'lfill%e&t
Sma!t Sc!ipting8
D1&a%ic )cri.ti&g D1&a%ic )cri.ti&g
%i&i%i7e) trai&i&g a&/ %i&i%i7e) trai&i&g a&/
e&)'re) )ervice e&)'re) )ervice
co&)i)te&c1 co&)i)te&c1
Me%0er
4.ecific
Proce))e
)
Me%0er
4.ecific
:iew)
24
Pegasystems 2009
1he Inte!action D!i#e!8 anticipates 1he Inte!action D!i#e!8 anticipates
custome! !e9uests, suggests ne(t steps custome! !e9uests, suggests ne(t steps
& 9ueues tas%s ,o! mo!e e,,ecti#e se!#ice & 9ueues tas%s ,o! mo!e e,,ecti#e se!#ice
PegaH+ALTHA PegaH+ALTHA
Me%0er Me%0er
4ervice) 4ervice)
C')to%er /ata availa0le o& /e%a&/ C')to%er /ata availa0le o& /e%a&/
I&teractio& log I&teractio& log
where C4(B) 0ee& a&/ goi&g where C4(B) 0ee& a&/ goi&g
4cri.ti&g g'i/e 4cri.ti&g g'i/e
')er with %i&i%al ')er with %i&i%al
C4( trai&i&g C4( trai&i&g
A&tici.ate) c')to%er i&te&t a&/ g'i/e) C4( A&tici.ate) c')to%er i&te&t a&/ g'i/e) C4(
25
Pegasystems 2009
-rieva&ce) & A..eal) (Representative Functionality)
, , Phone email fa/ or -eb
/ / 2riginal email fa/ stored w work item
uided data entry

- (ulti Channel Intake

+istorical Composite (ember View
Automatic retrieval of relevant legacy data
(ember &enefits
Provider Contract
#ser s access group controls information display
- Pre Packaged -orkflows
Correspondence eneration
- Reusable standard letter templates compiled
dynamically when needed
- ; Automated or on demand choose to re*uire review or
allow edits
(aintained as part of inalterable audit trail for
compliance reporting
Appeals (anagement Processes
rievance (anagement Processes
Case Creation
Re*uestor Party Information
/ $ervice and or claims information
- (ulti Party Processing
Concurrent assignments to multiple departments for
& research response
- $ecure one time link for e/ternal parties to provide
data and work cases
.asily attach supporting documents including
medical notes

Reporting
, & 2ut of the bo/ productivity *uality aging reports
- Drill down review capabilities
Custom report wi4ard
Compliance 5eatures
Automated service levels to ensure compliance and
move cases towards timely resolution
Comprehensive audit trail documents all human and
system generated activities
26
Pegasystems 2009
Co%.rehe&)ive Care Ma&age%e&t
Care Pla& Ma&age%e&t
-oal Ma&age%e&t
Alert Ma&age%e&t
Ta)$ Ma&age%e&t
HealthCare Pa1er O06ect a&/ Data Mo/el
Patie&t !"; Portal
A'thori7atio& 41)te% I&terface
ICD*C Co/e Loo$'. CPT Co/e Loo$'. HCPC4 Co/e Loo$'. 5DC Co/e Loo$'.
HC Pa1er +&ter.ri)e Orga&i7atio& 4tr'ct're
HC Cli&ical O06ect a&/ Data Mo/el
X12 2D 4TP Patie&t +ve&t :i)'ali7er
Ca%.aig& Ma&age%e&t
A'thori7atio& Ma&age%e&t
Care Pla& Te%.late Ma&age%e&t
-oal Te%.late 8i7ar/
Alert Te%.late 8i7ar/
Ta)$ Te%.late 8i7ar/
Co/e -ro'. Ma&age%e&t
A))e))%e&t Ma&age%e&t
Phar%ac1 Clai% 41)te% I&terface Me/ical Clai% 41)te% I&terface
Corre).o&/e&ce Te%.late)
Case Management & Control
Wor !"tomation
Interaction Management
27
Pegasystems 2009
4"ep!esentati#e Functionalit$5
Comprehensive Call (anagement
Patient %:;
Correspondence eneration
- Reusable standard letter templates compiled
dynamically when needed
- ; Automated or on demand choose to re*uire review or
allow edits
(aintained as part of inalterable audit trail for
compliance reporting
, - - Patient %:; degree view provides a complete up to
date profile of the member s care and compliance
with Care Plans
Comprehensive view of patient demographics
, , including contacts providers policies
/ eligibility benefit information
Reporting
, & 2ut of the bo/ productivity *uality aging reports
- Drill down review capabilities
Custom report wi4ard
Automated (onitoring of Care Plans
, Automated monitoring of complications e/ceptions to
, - optimal care avoidable utili4ations of high cost
( , services emergency department care
, ) hospitali4ations etc
Alerts notify Care (anagers of a patient s lack of
compliance with a Care Plan
, Automated creation of correspondence to patients
, providers and case managers
- -i4ard Driven Program Creation
, $tructured wi4ard driven creation of Care
(anagement programs
Reusable components optimi4e Program creation
5le/ible design allows for Programs to be created
and deployed rapidly by business users
Automated documentation of Care Plans help ensure
consistency and support meeting operational goals
of Care (anagement programs
#nified Care (anagement
, $ingle portal for Disease (anagement Case
(anagement and #tili4ation (anagement
$upports managing participants across the spectrum
of care
Improves the delivery of Care (anagement programs
by providing a complete view of the patient s care
- Automated straight through processing of
authori4ations
$upport for creating and routing of authori4ation
re*uests
, , Drill down views of medical claims pharmacy claims
and authori4ations
$chedule Call tasks support fle/ible scheduling of
periodic monitoring and assessment of the patient s
health
Automated scheduling of follow up calls
Powerful assessments support branching and hide
logic for *uestions
Assessments perform risk calculation and automatic
creation of Care Plans based on risk
Automated Case Creation
2ut of the bo/ support for automated case creation
with automatic assignment of Programs and Care
Plans
29
Pegasystems 2009
& +ealthcare Payer Common 2b3ect Data (odel
+C Payer .nterprise 2rgani4ation $tructure
+ealthcare Portals
Claim Prioriti4ation and .scalation
Claims %:; degree
Dashboard
Claim .dits Claim Inventory (anagement
Automated -ork
Distribution
Productivity Analytics
<(L Inbound Claims
Image Viewer
Integration
Legacy Claim $ystem
Connectors
+IPAA <01 7%6
2utbound
+IPAA <01 7%6
Inbound
Clai% 3ile Ma&age%e&t
A'to%ate/ Pe&/e/ Clai% Correctio&)
I&te&t Lea/ @ De)$to.
Clai% Correctio&)
Pre*A/6'/icatio& Me%0er +/it) / Correctio&)
Pre*A/6'/icatio& *Provi/er +/it) / Correctio&)
Pre*A/6'/icatio& @Profe))io&al 4ervice
+/it) / Correctio&)
Pre*A/6'/icatio& @I&)tit'tio&al 4ervice
+/it) / Correctio&)
Pre*A/6'/icatio& @ D'.licate :ali/atio&
+/it) / Correctio&)
Interaction Management
Case Management & Control
Wor !"tomation
#ot$
claims re)air
& *orstation +
Claims ,e)air Claims ,e)air
$0
Pegasystems 2009
Finalized Claims
New
Claim
Files
New
Claim
Files
PreProcess
ing
PreProcess
ing
Adjudicati
on
Adjudicati
on
Pend
ed
Claim
Files
Pend
ed
Claim
Files
!ealthcare &laimsE
Actual Customer Results
!" impro#ement in $irst pass rate %&" to '(")
*+" increase in sta$$ producti#ity
&+" ,TP o$ pre#iously manually processed work
'-" reduction in training time . e/pense
*+" throughput increase in $irst week
&(" reduction in a#erage in#entory days on hand %'01 to )
*1" o$ duplicate claim de$errals repaired automatically
CLAIM4 (+PAI( CLAIM4 (+PAI(
CLAIM4 (+PAI( CLAIM4 (+PAI( CLAIM4 8O(<4TATIO59 CLAIM4 8O(<4TATIO59
Anthem/Wellpoint
Post-Adjudication
BCBSNC
Post-Adjudication
Duplicates
HealthNow
Post-Adjudication,
BPM
BCBSXX
Coe Adjudication
!ules
NASC"
Post !epai
NASC"
Adjudication !ules
#n Data $nt% &B'(
Anthem/Wellpoint
Pe-Adjudication
BCBSMN
Pe ) !X
HealthNow
$*tended Adjudication
XC !ules
#BC
Pe-Adjudication
Cae+ist
Pe-Adjudication
Anthem/Wellpoint
BPM
MA,"! Pa%e
BPM
Cae+ist
BPM
Adjudication
Recent Claims Automation Projects
Anthem2 3roup4,u5group 6oad
C7,2 7edicare 8nrollment into Core Admin
New Client2 8nrollment C9: 7gmt
Anthem2 :ene$it Plan 7gmt and Core Admin load
3reat ;est 6i$e < ,er#ice Payment Rule load
=endor o$ Choice $or $our additional new clients
Anthem/Wellpoint
-oup-Su./oup
-eat West 0i1e
Se2ice Pa%ment !ules
S$P3/BSBS
CSC
Custome Se2ice
$1
Pegasystems 2009
Clai%) (e.air (Representative Functionality)
Code ,ranslations
(ember
Provider
,imely 5iling
Duplicate Claim
Routing Rules
Accident Claims
Revenue CP, Code
Validations
Pre*A/6'/icatio& B')i&e)) +/it)
Routine .ye ./ams
Common .ye
$urgeries
Chiropractor
$ervices
Podiatry $ervices
Anesthesia $ervices
Inpatient $ervices
Ambulance $ervices
Lab ,ests
Prostate $creening
+emoccult &lood
Po)t*A/6'/icatio& B')i&e)) +/it)
Pending &enefits .mergency Room $ervices
Pending &enefits Cardiac Rehab $ervices
Pending Pricing +ome +ealth In3ectable Drugs
Pending Potential Duplicate Claim
Clai%) I&.'t & O't.'t Proce))
Corre).o&/e&ce -e&eratio&
Critical .rror Claims (ember 'ot 5ound
- ( ) 7%6 Claim Pre Processing 5lat 5ile <(L Conversion
7%6 <(L Input Process
Pended Claim <(L Input Process
& Claim (apping -ork 2b3ect Creation
Repaired Claim 2utput 5ile
Pre*B'ilt I&terface Ca.a0ilit1
Claim Repository
(ember .ligibility
Provider Data
DR Agreement Data
I,$ Prefi/ Data
Revenue Code CP, Code List
& Diagnosis Procedure Code Data
A'thori7atio& Data
& Referral Authori4ation Data Retrieval
(e.orti&g
- Pre ad3udication Claim Repair Count Report
- Post ad3udication Claim Repair Count Report
Custom Report eneration -i4ard
$2
Pegasystems 2009
Clai%) 8or$)tatio&9 ERepresentative Functionality)
$ecure Login
: Access roups Claims
, , ./aminer (gr $ysAdmin
: Custom Portals Claims
, , ./aminer (gr $ysAdmin
- Role based workflow
: / privileges ./aminer (gr
4ig&*O& / 4ig&*Off & 4ec'rit1
A'to%ate/ (o'ti&g to
8or$0a)$et)
Duplicate claim detection
Routing to specified workbasket
- - Primary routing by line of
business
$econdary routing by pend code
: & ,ertiary routing claim type
total charge amount
Corre).o&/e&ce -e&eratio&
- Auto correspondence for re3ected
( & ) claims $ubscriber Provider
- Auto correspondence option for
re*uesting additional info
( / / ) patient provider medical
- Pre configured templates for
info re*uests
Published Claim <(L D,D
- - ( ) 5ile $ervice Intake Listeners
<(L Parser to parse claim
elements
Claim work ob3ect creation
5inali4ed claim reconciliation
( & updating resolving work
) ob3ects
Prioriti4ation for select pend
( & - ) codes header line level
Primary points by claim age
Additional points by Provider
, roups Preferred $ubscriber
& roups dollar total charge
thresholds
4ervice Level Ma&age%e&t
Clai% 3ile 3ee/ I&ta$e
Clai% Prioriti7atio&
: 2verall pended claim assignment
Provider Information Re*uest
/ Patient $ubscriber Info Re*uest
(edical Info Re*uest
2ther +old Reason
A'to%ate/ 8or$ A))ig&%e&t
Primary determination by user s
personal worklist assignments
$econdary determination by
workbasket assignments on
user s profile
,ertiary determination by
thresholds set on workbaskets
Clai%) A/6'/icatio& 41)te%
I&tegratio& Tool)
$ysAdmin tools for managing
/ desktop w multiple claim
systems
Automatic retrieval of claim
from ad3udication system
- $plit screen desktop display
during claim processing
(a&/o% Clai%) A'/it
Random selection of completed
claims for audit
$elected claims transferred to
Audit Review workbasket
Auditor review of selected
claims
$$
Pegasystems 2009
Manage# ,estop
Manage! t"e core systems
Co&trol wor$flow with
Pega Da)h0oar/ of
the clai% wor$
o06ect a&/
.roce))i&g o.tio&)
Ho)t clai%)
a/6'/icatio&
)1)te%
I%agi&g )1)te%
Pega)1)te%
clai% wor$ o06ect
I&tegrate with clai%)
a/6'/icatio& )1)te%
a&/ i%agi&g )1)te%
?)e PegaIMA-+ :iewer
or thir/ .art1 tool to
view the clai% i%age
$*
Pegasystems 2009
O..ort'&it1 Ma&age%e&t
Ce&)') Ma&age%e&t
Large -ro'. Ma&age%e&t
Age&c1 A&/ Bro$er
Profile Ma&age%e&t
Co%.a&1 Profile Ma&age%e&t
4%all -ro'. ='ote Ma&age%e&t
4%all a&/ Large -ro'. (ati&g
(e&ewal Ma&age%e&t
4ale) Ta)$ Ma&age%e&t
Pro.o)al ge&eratio& -ro'. a&/ 4'0gro'. A..licatio& -e&eratio&
Healthcare Pa1er Co%%o& O06ect & Data Mo/el
HIPAA X12 +DI Me))age 4'..ort Healthcare Portal)
HealthCare O06ect 4earch & (etrieval HealthCare Pa1er 4ta&/ar/ 4LA)
HIPAA 4ta&/ar/
Co/e 4et)
HC Pa1er +&ter.ri)e Orga&i7atio& 4tr'ct're
Pro/'ct
Co&fig'ratio&
Interaction Management
Case Management & Control
Wor !"tomation
$4
Pegasystems 2009
4ale) Proce)) Ma&ager 4"ep!esentati#e Functionalit$5
, , Company *uote opportunity agency and broker
profile management
Automatic and ad hoc correspondence generation
leveraging correspondence templates
Activity management
Profile Ma&age%e&t
(ati&g & Prici&g
- .mployee based demographic rating for health and
dental products
$upports actuarial and underwriting tables
( - effective dated for use across multiple rating
) periods
(anages rating tables through an ./cel interface
- (aintains group specific calculations for later
audits
='oti&g & Pro.o)al Ma&age%e&t
Corre).o&/e&ce -e&eratio&
- Reusable standard letter templates compiled
dynamically when needed
- ; Automated or on demand choose to re*uire review or
allow edits
(aintained as part of inalterable audit trail for
compliance reporting
(anages opportunities for multiple brokers working
with the same company
Creates rate card across multiple lines of business
$upports both automated and manual census entry
Automatically suggests products based on customer
& - profile census information to reduce anti
selection
Packages professional proposals in multiple formats
- including PD5 for print or e mail to additional
parties

(e.orti&g
, & 2ut of the bo/ productivity *uality aging reports
- Drill down review capabilities
Custom report wi4ard
-ro'. +&roll%e&t
Packaged enrollment workflows
.lectronic submission of group application to
legacy systems
& & 'otifies assigns tasks to internal e/ternal
parties
(anages completion via customi4able $LAs
Pro/'ct Co&fig'ratio&
(anages comple/ product hierarchies
Assembles data entry screens and validation rules
for each product based on the included
components
Allows easy definition and modification of the
- product structure through custom purposed rule
forms

$5
Pegasystems 2009
$mart&P( +ealthcare $ales
$olutions Driving
& (embership rowth Retention
>uoting . Rating 7anage ,ales 9pportunities
Prospecting
6ead 7anagement
9perationalize ,ales Channels
,elect :ene$its
3enerate >uotes
3enerate Proposals
=eri$y Inputs
Calculate Rates
Appro#e Rates and Riders
De#elop ,olutions
Product De#elopment
7arket ,egmentation
Premium Rate ,etting
7anage Renewals
Cross4,ell?
@p4,ell
Campaign 7anagement
Identi$y 7arket 9pportunities
Regulatory Filings
7aterials Creation
Product 6oad
RFPs2 National Acct
Congressional 7andate2 7edicare Part D
Pre$erred :roker2
6arge Account
Indi#idual2 A,A
Close ? 9ptimize ,ale
Right Products
Right Price
Right 8$$ort ? Cost
Positi#e Customer 8/perience
8nrollment
Collect 8nrollment Data
=eri$y 8ligi5ility . Contract Terms
@pload ,ystems w?3roup ? ,u5group
Ful$ill . Acti#ate Contract
+$A4&!$S +$A4&!$S
,treamlined >uoting . Rating $or 3roup . Indi#idual
,ales
,ales Channel . :roker 7anagement
Automated Proposal 3eneration
Component45ased Product Creation . 7aintenance
3roup . Prospect 7anagement
B$N$+#4S B$N$+#4S
B 7illion 7edicare Part D 7em5ers Captured During
Initial 9pen 8nrollment
!1" >uote Deli#ery Time Reduction
(++" 8nrollment Processing Impro#ement
-" Cost o$ ,ale Reduction
*(" New 7em5er ,er#ice Calls Reduction
'-" 7anual ,teps 8liminated
Pro/'ct
Co&fig'ratio&
4ale)
Proce))
Ma&ager
Con$igure Claims ,ystem
$6
Pegasystems 2009
CPM for Healthcare I& Actio&
$7
Pegasystems 2009
&PM &onfiguration 3etup
Create a r'le )et a&/ ver)io&
$9
Pegasystems 2009
&PM ruleset for new a##itions
*0
Pegasystems 2009
&PM 3etup up#ate application
Be )'re to a// 0oth r'le)et)
*1
Pegasystems 2009
3ample PRP& &onfiguration
Be )'re Profile reflect) cha&ge)
*2
Pegasystems 2009
&PM setup %or Pools
8or$ Pool './ate &ee/e/
*$
Pegasystems 2009
&PM %iJar# setup
After
Before
**
Pegasystems 2009
&PM setup %iJar# is now a-ailable
*4
Pegasystems 2009
&PM setup 3er-ice Process "ccelerator
*5
Pegasystems 2009
&PM wiJar# 3elect ruleset an# -ersion
*6
Pegasystems 2009
&PM %iJar# name the new process
*7
Pegasystems 2009
&PM %iJar# %hen an# where woul# you lie it)
Thi) will /irect where 1o'r &ew
.roce)) will 0e .lace/
*9
Pegasystems 2009
&PM %iJar# something special nee#e#)
Thi) will %a$e it ea)1 to cha&ge
)cree& co&te&t later
40
Pegasystems 2009
&PM %iJar# start enhancing
Fo' are rea/1 to te)t & refi&eGG
41
Pegasystems 2009
3tan#ar# PRP& up#ate the 1(
42
Pegasystems 2009
&PM %iJar# Flow "ction #efaults
4$
Pegasystems 2009
&PM %iJar# Flow "ction #efaults
4*
Pegasystems 2009
&PM Aew process in action
44
Pegasystems 2009
&PM a##;up#ate #ialog #efaults
45
Pegasystems 2009
&PM up#ate new flow