Professional Documents
Culture Documents
Pegasystems 2009
Agenda
CTI
CTI What and why PegaCALL architecture Integration with PRPC Application Flow Terminology
Generic CPM HC DEMO CPM HC Class structure Enabling CPM HC Wizard CPM Wizard to create flow Show new flow in HC working Under covers of flow design and structure Changing User Interface of flow Overview of integration to external systems with CPM
Questions
Pegasystems 2009
What is CTI?
Pegasystems 2009
sLegacy
pre-fetch to drive IVR processing and call routing sRe-use rules to drive IVR decisioning sAdaptive screen pop for effective coordination of call arrival sDesktop and workflow-based telephony controls for improved call management sImplement individually or incrementally!
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CTI Functions
Call Control
Customer data pre-fetch Call routing Adaptive screen pop
Desktop Telephony
ACD/PBX Login/ Make available/ Hold/Un-hold Answer call Make call Disconnect call Conference call Blind transfer Warm transfer
Pegasystems 2009
ACD/Call Routing
Automatic Call Distributor a device that distributes large volumes of incoming calls to agents. The ACD contains logic that drives routing decisions based on multiple input parameters. Routing parameters can include a combination of data about available agents and their skills, and specific information about the call/caller Common Vendors: Avaya, Aspect, Cisco
Caller is directed to IVR and prompted for information needed to access profile PegaCALL monitors call arrival on premise and may begin customer lookup by ANI. Information is gathered to satisfy IVR data requirements from any available source (see #5) IVR, Pegasystem, or caller request opt out and IVR attaches data to the call for handling by the CTI middle ware. Call is directed to ACD or is managed by CTI middle ware to the correct ACD. CTI Middleware may optionally request final route input from PegaCALL Pegasystems uses any data available to drive rules engine to determine possible route for call PBX places call in queue and maintains update with PegaCALL via link. Call is offered to next available agent in queue PegaCALL obtains message of call offering, starts rules engine with relevant data. Pegasystem drives data needed for POP to the desktop using data obtained in step 5 based on business rules. Desktop requests CTI functions (conference, transfer, hold, etc) via PegaCALL interface methods Pegasystem rules engine instructs CTI Middleware as need via PegaCALL to perform needed functions requested by desktop application.
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Member dial 800 # and is directed to IVR for ID prompt
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CTI middle ware may request data from Pega for preroute
Rules retrieve & evaluate data & determine when/if telephony functions are required by CSR
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MQ or SQL
u s t o m
e r
e r v
SQLNet
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Telephone
Workstation 7
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T-Server
SOAP Services
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Provides seamless integration of telephony events and business processes No desktop DLLs to install Puts the right customer information in front of the agents Eliminates need for the customer to repeat to the agent what they just entered into the IVR Fully configurable can trigger different processes based on the agent and customer profiles for enhanced customer service Transfer customer and work object data with the call
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Coming soon.
Configuration Wizard should allow basic connectivity and features (screen pop) to be configured and running in 30-45 minutes, including call data mapping, custom screen pop, etc. This will be a huge help during POCs where CTI is required. Stateful telephony (Genesys only) allows state to be synchronized between PegaCALL and the phone, so that actions taken at the phone (ie put a call on hold) will be reflected in the PegaCALL UI. This also introduces the concept of a CTI Toolbar that can be embedded in CPM. CTILink Hot Failover ability to have a hot standby CTILink that will detect a failure in the primary link and take over automatically
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The CPM 6.1 release (2009) will include pre-configured voice/data transfer capability, so that when a user
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CTI
Call Center
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Market Momentum
Results - ROI
75% reduction Claims Backlog 30% increase 1st pass rate 98% reduction in group enrollment costs 20% increase issues handled per contact 20% reduction call handling time 50% reduction in training times
17 new customers in past 18 months 90% licensed our solution frameworks Significant repeat business Enterprise backbone commitments Over 95M covered lives 4 of top 5 payers 55% of BCBS Plans
Target Market
Large Payers > 2MM Members Top Pharma / LifeScience Cos Healthcare Government Selective Providers/IDNs/PBMs
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4 of top 5 Largest U . S . Payers 34 % of Blues Network Blues Members - Pegasystemsmillion covered lives 95 2009
55 % of
Servicing Backbone
Enterprise Case & Event Management
Tailored Offerings
Enrollment
Web Self-Service
Cross-Sell, Up-sell
Medical Management
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Pegasystems 2009
CRM
CPM for Healthcare
Servicing Backbone
Care Mgmt Backbone *NEW* Claims Backbone
Compliance
Membe r Service s
Provide r Service s
Care Management
Claims Repair
Claims WS+
CPM HC Foundation
Clinical Foundation
Claims Foundation
HC Enterprise Organization Structure HealthCare Object Search & Retrieval EDI Message Support HIPAA X12 Healthcare Portals HealthCare Standard SLAs HIPAA Standard Code Sets
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entry & output Intent-led data entry; automated data population for PDF and email applications Intelligent enrollment application routing Per member risk factor computation & underwriting approval recommendation based on medical underwriting
Work Parties (member, provider, broker, plan sponsor, agency, etc) HIPAA EDI x12 Support Healthcare Common Objects (claims, authorization, premium, benefits, COB,Functionality Pre-built HIPAA policy, etc) Automated file input (batch & real-time) x12 message parsing & mapping HIPAA property validation HIPAA x12 EDI samples
Multi-channel guided-intake for web, phone, email and Comprehensive member composite Pre-packaged workflows for Appeals, Grievances,
fax Requestor Party Information & service/claims information Concurrent assignments to multiple departments for research & response Secure one-time link for external parties to provide data and work cases
Member Search & Review Claim Search & Review Provider Search & Review Authorization Search & Review Policy Search & Review
Reporting
Out of the box productivity, quality & aging reports Drill-down review capabilities Custom report wizard
Correspondence Generation
Reusable standard letter templates - compiled Automated or on-demand; choose to require review or Maintained as part of inalterable audit trail for
compliance reporting allow edits dynamically when needed
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Fax & Mail Interactions Web Self-Service InteractionsCC Configuration Wizards Web Contact Center Object & Data Model
Healthcare Common Object , Data Model & Policy Structure HC Payer Enterprise Organization Structure CC Queue Management Customer SLAs CC Quality Mgt CC Productivity Analytics Customer Security
Dispute Claim Payments / Multi-member / Multi policy inquiry Denial Add Newborn Order ID Cards Add / Update PCP Manage Privacy Settings HealthCare - FAQs Schedule Activities Diagnose Problems Member Eligibility
Request Pre-certification / Prior Authorizat Mange Provider Credentialing Manage National Provider ID Manage Group Participation
Wor k Automation
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Customer Management
Smart ViewTM customer data composite (policy, member, provider, facility, claims, authorizations, contact & plan sponsor) General Information & profile Multi-channel interaction history Service history Benefit Review Claim search & review Authorization search & review Notes Add a Contact Quick Contact Add Update Contact Name & Profile* Update Contact Address & Profile
Knowledge Management
Knowledge content rules and usage statistics Knowledge inquiry & response User suggestions for content update
Reporting
Access Roles /
Access groups, privileges & user portals for*: Member, Provider & Universal CSRs Member, Provider & Universal Managers Sales Representatives Sales Managers System Administrators Operator profile, schedule & skills management Workbasket assignments Secure login Correspondence
Operator Maintenance
Interaction reports Productivity reports Quality reports Aging reports Campaign reports Pipeline & opportunity reports Quality Performance Reports Knowledge Management Reports Custom report wizard Drill-down review capabilities
System-assigned routing based on case urgency Service level goals, deadlines & escalation events User work lists System workbaskets Get Most Urgent Work functionality Work re-assignment Customer-based service level profiles Customer-based service level override
Generation Automatic & manual generation Create & modify templates Mail, email, & fax
capabilities Review, editing & verification privileges * Facilitates HIPAA 23
Compliance
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The CSR desktop is intent-driven and configured to optimize every customer interaction and overall CSR efficiency
Smart Dialog Context-sensitive, personalized dialog
Smart Scripting Dynamic scripting minimizes training and ensures service consistency
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Pegasystems 2009
Smart Views Context-sensitive, summary information enables research & review concurrent with process fulfillment
The Interaction Driver anticipates customer requests, suggests next steps & queues tasks for more effective service
Scripting guide user withAnticipates customer intent and guides CSR minimal CSR training
Interaction log Customer data available on deman where CSRs been and going
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Phone, email, fax or Web Original email/fax stored w/work item Guided data entry
Appeals Management Processes Grievance Management Processes Case Creation Requestor Party Information Service and/or claims information
Multi - Party Processing
Automatic retrieval of relevant legacy data Member Benefits Provider Contract Users access group controls information display
Reporting
Correspondence Generation
Compliance Features
Automated service levels to ensure compliance and Comprehensive audit trail documents all human and
system generated activities move cases towards timely resolution
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HC Clinical Object and Data Model HealthCare Payer Object and Data Model HC Payer Enterprise Organization Structure ICD-9 Code Lookup CPT Code Lookup HCPCS Code Lookup NDC Code Lookup Correspondence Templates
Wor k Automation
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Care Management
Wizard - Driven Program Creation
(Representative Functionality)
Comprehensive Call Management
Management programs Reusable components optimize Program creation Flexible 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 Management programs
periodic monitoring and assessment of the patients health Automated scheduling of follow up calls Powerful assessments support branching and hide logic for questions Assessments perform risk calculation and automatic creation of Care Plans based on risk
Patient 360
Patient 360 degree view provides a complete, up-todate profile of the members care and compliance with Care Plans Comprehensive view of patient demographics including contacts providers, policies, eligibility/benefit information
Single portal for Disease Management, Case Supports managing participants across the spectrum Improves the delivery of Care Management programs Automated straight-through processing of
of care by providing a complete view of the patients care Management and Utilization Management
authorizations Support for creating and routing of authorization requests Drill down views of medical claims, pharmacy claims, and authorizations
Reporting
Out of the box productivity, quality & aging reports Drill-down review capabilities Custom report wizard
Correspondence Generation
Reusable standard letter templates - compiled Automated or on-demand; choose to require review or Maintained as part of inalterable audit trail for
compliance reporting
Pegasystems 2009
Healthcare Payer Common Object & Data Model HC Payer Enterprise Organization Structure Automated Work Productivity Analytics Inventory ManagementClaim Edits and Escalation Claim Distribution
m Prioritization
Pre-Adjudication Duplicate Validation Pre-Adjudication Member Edits / Corrections Claim File Management Edits / Corrections
Pre-Adjudication Professional Service Pre-Adjudication Institutional Service Edits / Corrections Edits / Corrections
Wor k Automation
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Healthcare Claims
Anthem/Wellpoint Pre-Adjudication IBC Pre-Adjudication HealthNow Extended Adjudication XC Rules
CLAIMS REPAIR
CSC Customer Service HealthNow Post-Adjudication, Anthem/Wellpoint BPM BPM CareFirst BPM Adjudication
Adjudicati Adjudicati on on
CLAIMS REPAIR
Anthem/Wellpoint Post-Adjudication
CLAIMS WORKSTATION+
MAJOR Payer BPM
Finalized Claims
Actual Customer Results 39% improvement in first pass rate (63% to 72%) 40% increase in staff productivity 60% STP of previously manually processed work 75% reduction in training time & expense 40% throughput increase in first week 62% reduction in average inventory days on hand (7.8 to 3) 48% of duplicate claim deferrals repaired automatically
Recent Claims Automation Projects Anthem: Group-Subgroup Load CMS: Medicare Enrollment into Core Admin New Client: Enrollment COB Mgmt Anthem: Benefit Plan Mgmt and Core Admin load Great West Life Service Payment Rule load Vendor of Choice for four additional new clients
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Code Translations Member Provider Timely Filing Duplicate Claim Routing Rules Accident Claims Revenue CPT Code Validations
Surgeries Chiropractor Services Podiatry Services Anesthesia Services Inpatient Services Ambulance Services Lab Tests Prostate Screening Hemoccult Blood
837 Claim Pre-Processing (Flat File XML Conversion) 837 XML Input Process Pended Claim XML Input Process Claim Mapping & Work Object Creation Repaired Claim Output File
Benefits Emergency Room Services Benefits Cardiac Rehab Services Pricing Home Health Injectable Drugs Potential Duplicate Claim
Claim Repository Member Eligibility Provider Data DRG Agreement Data ITS Prefix Data Revenue Code CPT Code List Diagnosis & Procedure Code Data
Reporting
Authorization Data
re-adjudication Claim Repair Count Report ost-adjudication Claim Repair Count Report ustom Report Generation Wizard
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Pegasystems 2009
Secure Login Access Groups: Claims Examiner, Mgr, SysAdmin Custom Portals: Claims Examiner, Mgr, SysAdmin Role-based workflow privileges: Examiner/ Mgr Automated Routing to Workbaskets
Duplicate claim detection Routing to specified workbasket Primary routing by line-ofSecondary routing by pend code Tertiary routing: claim type &
total charge amount business
Provider Information Request Patient/Subscriber Info Request Medical Info Request Other Hold Reason
desktop w/multiple claim systems Automatic retrieval of claim from adjudication system Split-screen desktop display during claim processing
Published Claim XML DTD File-Service-Intake (Listeners) XML Parser to parse claim
elements Claim work object creation Finalized claim reconciliation (updating & resolving work objects)
claims for audit Selected claims transferred to Audit Review workbasket Auditor review of selected claims
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Pegasystems 2009
Managed Desktop
Manage the core systems
Control workflow with Pega Dashboard of the claim work
Imaging system Host claims adjudication system
object and processing options Integrate with claims adjudication system and imaging system
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Pegasystems 2009
Healthcare Portals
Proposal generation
Application Generation
Company Profile Management Agency And Broker Profile Management Large Group Management
Census Management
Renewal Management
Wor k Automation
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Company, quote opportunity, agency and broker profile management Automatic and ad hoc correspondence generation leveraging correspondence templates Activity management Rating & Pricing
Manages opportunities for multiple brokers working Creates rate card across multiple lines of business Supports both automated and manual census entry Automatically suggests products based on customer
profile & census information to reduce antiselection Packages professional proposals in multiple formats including PDF for print or e-mail to additional parties Product Configuration with the same company
Employee-based demographic rating for health and Supports actuarial and underwriting tables
dental products (effective- dated for use across multiple rating periods) Manages rating tables through an Excel interface Maintains group-specific calculations for later audits Group Enrollment
Manages complex 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
legacy systems Notifies & assigns tasks to internal & external parties Manages completion via customizable SLAs Reporting
Reusable standard letter templates - compiled Automated or on-demand; choose to require review or Maintained as part of inalterable audit trail for
compliance reporting
of the box productivity, quality & aging reports l-down review capabilities om report wizard
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Pegasystems 2009
Product Configuration
Market Segmentation essional Mandate: Medicare Part D Premium Rate Setting Preferred Broker: Large Account Individual: HSA Regulatory Filings Materials Creation Product Load
Upload Systems w/Group / Subgro Right Effort / Cost Fulfill & Activate Contract Positive Customer Experience Configure Claims System
Operationalize Sales Channels Generate Proposals Cross-Sell/ Up-Sell Manage Renewals Verify Inputs
FEATURES Sales
Streamlined Quoting & Rating for Group & Individual 1 Million Medicare Part D Members Captured Duri
Initial Open Enrollment
BENEFITS
Sales Channel & Broker Management Automated Proposal Generation Component-based Product Creation & Maintenance Group & Prospect Management
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98% Quote Delivery Time Reduction 200% Enrollment Processing Improvement 35% Cost of Sale Reduction 42% New Member Service Calls Reduction 75% Manual Steps Eliminated
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Before
After
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