Health Insurance Project

Organisation Name-Alere

Application name-PAS(Prior Authoroization system)

Operators and access groups for below.

Developer

Admin

CSR

Pharmacist

MD

Create a new application

Login as Administrator@[Link] / install and

Name application as PAS. Which means Prior authorization system.

In advance window name organization as Alere.

Create a new operator as urname@[Link]

Later logoff n login with new operator.

Configuring stages in PAS application

Go to cases explorer and create a new case type named as PA.

Create primary stages as below

Provider search
Member search
Drug search
Questionnaire
Pharmacist Approval
Medical director Approval
Resolve

Alternate Stages:
Rejected

Provider search:
Under provider search stage configure view with below fields

 Provider ID
 Provider name
 Provider address
 Provider email
 Provider Phno

Member Search:

For member search configure below fields

 Member ID
 Member name
 Member email
 Member address
 Member Phoneno

Drug search:

Drug search stage fields

 Drug name
 Dosage
 Taken through
 NO of days to be taken
 Formulary alternatives

Data classes creation:

Create data classes in PAS application.

Go to data explorer->Click on Add new data type and create a new data class as Members

 Add below fields

 Memberid (Primary Key)
 Member Name
 Member email
  Member phone number
 Member address

Add another new data type and create a new data class as Drugs

Fields as Below

 Gpc(Primary Key)
 Ndc
 Drug name
 Dosage
 Formulary alternative

Follow the above instructions and create another data class for providers

Add below fields

 Providerid(Primary Key)
 ProviderName
 Provideremail
 Providerphonenumber
 Provider address

Pharmacist Approval stage:

Create a section and flow action named PharmacistApproval with read only fields to display selected
provider, member, drug details in read only mode. Hint (In section drag controls and map existing
properties and in cell settings under presentation make them read only)

Create a section and flow action named PharmacistRejected to capture Reject reason. Create property
“Reason for rejection” and map in section.

Create flow as Pharmacist approval and on assignment shape add 2 connectors and on each connector
map above 2 flow actions and give livelihood as 80 for approve and 20 for Reject so that by default
approval screen appears 1st and Reject appears under actions tab of work object as optional screen.

Medical Director Approval stage:

Create a section and flow action named MDApproval with read only fields to display selected provider,
member, drug details in read only mode. Hint (In section drag controls and map existing properties and
in cell settings under presentation make them read only)
Create a section and flow action named MDRejected to capture Reject reason. Create property “Reason
for rejection” and map in section.

Create flow as MD approval and on assignment shape add 2 connectors and on each connector map
above 2 flow actions and give livelihood as 80 for approve and 20 for Reject so that by default approval
screen appears 1st and Reject appears under actions tab of work object as optional screen.

Validation:

Provider Id : It should start with “P-“ example “P-12345678“ . Hint :Use starts with function in validate
rule.

Note:Make sure in Providers data table you have data as shown in example.

It should contain only integers after “P-“ Hint : use substr and is integer functions
combination.

Member Id: It should start with “M-“ example “M-12345678“ . Hint :Use starts with function in validate
rule.

Note:Make sure in Members data table you have data as shown in example.

It should contain only integers after “M-“ Hint : use substr and is integer functions
combination.

Provider Name: It should not contain integers or special characters.

Length should not be greater than 35 characters.

Member Name: It should not contain integers or special characters.

Length should not be greater than 35 characters.

Provider PhoneNo: Should be integers and length =10 or length = 13 characters. Example : 8019256326
(length 10 chars) or +9180192564326(length 13 chars).

Can have special character + in it. Hint: Look for allowed spl character functions

Member PhoneNo: Should be integers and length =10 or length = 13 characters. Example : 8019256326
(length 10 chars) or +9180192564326(length 13 chars). Can have special character + in it.

Provider Email: Should have @ and .com.

Member Email: Should have @ and .com.

Edit Input rule: Convert member Id to upper case

Convert Provider id to upper case

1. Provider Search Requirement:

User should enter provider id and hit on search button, then provider details like provider
name , address, email , phone number should display in repeating grid or table layout

Code Configuration:

In provider search section add a text box for entering provider id and a search button.

Add Repeating grid(Table Layout) to display all provider details

Create a datapage of type list and source as activity which can hit the database and get the
provider details based on provider id.

Add “on click” Refresh action on Search button. On click of search the table layout should
refresh and display provider details.

In the repeating grid add a select button and name it as “Select Provider”.

Onclick of “Select Provider” button trigger a datatransform name it as copyproviderdetails and

copy the data from primary page to pyWorkPage as below.

[Link] = [Link]

Trigger the data transform from the “select Provider” button using onclick event.

Copied details will be displayed in Approve section.

2. Member search:

Follow the same steps above for member search

3. Drug search:

Follow the same steps above for Drug search

4. Task on questionnaire stage:

Create paragraph rules for each question (Right click on class 🡪 Create 🡪 User Interface 🡪
Paragraph (write your question here and save it))

Q1. Is this a formulary drug?

Q2. What is the intake of this drug?

Q3. Number of drugs required

Q4. What dosage of drug was required?

 Q5. What is the duration of the drug to be issued?

Once the paragraph rules are created, open questionnaire question and drag paragraph control
and map paragraph rule in it , then the question will display.

5. Create Answers for above questions.

A1. Create a property and give local list values, Yes NO (Refer network property in banking
project)

A2. Create a property with local list values with Mouth or Intraveinal

A3. Create a property of type text and no local list values

A4. Create a local list values with 25 Mg, 50 Mg , 75 Mg and 100 Mg

A5. Create a date property with name as duration

Map the above created answer properties to the questionnaire section below the corresponding
Question

6. Logic to auto approve or reject the case.

Create a decision table with below conditions

If the drug Mg is less than or equal to 50 Mg and if taken by Mouth 🡪 Approve the case

If the drug Mg is greater than 50 Mg and taken either by mouth or Intraveinal 🡪 Pend the case

7. Add a decision shape in the questionnaire flow and trigger the above created decision table

8. The outgoing connector from the decision table with the result as approve should be connected
to end shape and the other connector with result pend should be connected to “ChangetoStage
“ Smart shape to route to Pharmacist approval stage

9. In pharmacist approval stage we have approve and reject screens.

10. Upon case approval end the flow by connecting it to end shape.

11. If case is rejected add change to a stage smart shape and route to Medical director approval
stage.

12. Upon approve or reject in Medical director approval flow connect to end shape.
 13. Add status as Resolved approved on approve connector and status as resolved rejected on
reject connector.

Configuring Routing:

14. Create a new workbasket named as PharmacistPendingCases.

15. Create a new work group as HealthCareTeam.
16. Add work group name in Work basket and vice versa.
17. Now create a new operator named as Pharmacist and map the work group and work basket in
that operator instance.
18. In the pharmacist approval flow on assignment shape configure work basket routing to route to
PharmacistPendingCases basket.
19. Create a case and testing routing.
20. Configure similar routing in Medical director Flow by creating a basket named as
MDPendingCases and an operator named as MedicalDirector. Use same old work group
HealthCareTeam in work basket MDPendingCases and in operator record.

Reporting:

Create a report definition rule in work class to display Resolved –Rejected cases and plug it in
manager portal under Reports category using category and shortcut rules.

SLA

Create a SLA rule named as “PharmacistApprovalSLA” , with goal as 2 days and deadline as 4 days.
When deadline time expires resume flow on approve flow action, which means it should auto
approve.

Create a SLA rule named as MDApprovalSLA with goal as 1 day and deadline 2 days when goal
expires send reminder email, when deadline expires auto approve case.

Agents

Create a advanced agent which triggers an activity which identified the cases whose pystatuswork is
“Resolved Approved” sends email to all the approved cases with subject holding case id approved and
body of mail holding all details.