Executing the Benefits Eligibility Solution Scenario using Business Space

The Benefits Eligibility is used to view the data associated with the benefit and eligibility information of a patient; based on the patient name, date of birth, and so on, information that is supplied. This Benefits Eligibility can be invoked in Business Space using the procedure provided here.

The Provider Customer Service Representative can invoke the Benefits Eligibility Solution Scenario in Business Space by logging on to Business Space, initiating a request, providing details using forms, and submitting the data for processing. The data specified in the form is processed and the inquiry is closed or transferred to a specialist. The specialist can retrieve the form and update the data for the tasks transferred. A supervisor can then use Business Space to view and analyze information using the various graphs and diagrams displayed in the reports generated.

Note: Some of the fields, used in the forms, for this Solution Scenario are programmed using basic validations. You can verify the validation for the field by moving the mouse pointer over the field.

The fields in which data is required are labeled with a * and have a different color. The Submit button in the form is disabled until you provide a value in all such fields in a form.

You can start the Solution Scenario in Business Space to view the Getting Started Widget. The Getting Started Widget lists the assets and the steps for using the Solution Scenario.

Table 1. Widgets to roles mapping
Roles Create Task Task Definition List All dashboard Process Instance / Process Check
Provider Yes Yes N/A N/A
EPO / HMO / Other Specialist N/A Yes N/A N/A
LOB Manager N/A N/A Yes N/A
Provider Administrator N/A N/A N/A Yes
Before you begin
Ensure that the following prerequisites are complete before you invoke the Solution Scenario.
  • Add and configure users and groups.
  • Verify that the Benefits Eligibility Solution Scenario artifacts are successfully installed in WebSphere® Process Server.
About this task
Invoke the Benefits Eligibility Solution Scenario in the Business Space using the following steps.

Accessing the Benefits Eligibility Business Space

When using Business Space to view the Solution Scenario execution, you need to log in to the Business Space. This involves providing login details and viewing various pages that are part of the Benefits Eligibility Space.

Procedure
  1. Open the Business Space portal.

  2. Log on to Business Space with the User ID as Adam.
  3. Open the Benefit Eligibility Space and verify that the following pages are displayed.
    • Getting Started
    • My Tasks
    • Benefit Eligibility Process
    • Benefit Eligibility Process Check
    • Benefit Eligibility Dashboard
    • Benefit Eligibility Analysis
    • Benefit Eligibility Performance
    • Benefit Eligibility Reports
    Note: This Solution Scenario is configured to display the Benefit Eligibility Space by default.

Accepting patient details

After logging to the Benefit Eligibility space, a Benefit Eligibility Inquiry request can be created for a patient. The patient details are provided in the Submit Eligibility Request form.

Procedure
  1. Open the My Tasks page.
    Note: The My Tasks page is displayed by default the first time you log on to the Business Space.
  2. In the Task Definitions List widget, select the Benefit Eligibility Inquiry check box and click the Create an instance from this task template icon Create an instance from this task template icon. The Submit Eligibility Request form is displayed in the Task Information widget.

  3. Provide the required information in the form and click Submit. The Display Benefit Eligibility Details Task is displayed in the Tasks Lists widget.
    Note:

    Select the All - Assess and work on tasks option from the list that is displayed in the Tasks List widget to view the task.

    The scope of this Solution Scenario is limited and you must use the following Patient ID.
    Table 2. Sample data for the Benefit Eligibility Solution Scenario
    Patient ID Description
    AMX123456, BMX123456, BMX654321, or AMX654321 Co-pay and deductible amount available
    AMX135790 or BMX135790 Co-pay and deductible information is not available
    AAA123456 or AAA73 Patient name not available
    AAA43 Patient contract not available
    AAA64 Invalid patient
    YTH6, YTH7, or YTH8 Inactive patients
    The inquiry is closed if the Co-Pay Amount and the Deductible Amount are available. If the Co-Pay Amount and the Deductible Amount are not specified, then the first three characters of the Patient ID are processed and, the response is transferred to the specialist displayed in the following table.
    Table 3. Relationship between the Patient ID and Specialist
    Patient ID Specialist
    AMX EPO Specialist
    BMX HMO Specialist
    AAA Other Specialist

Reviewing the patient details

Depending on the Co-Pay Amount and the Deductible Amount, the inquiry request initiated is routed to the concerned specialist. The specialist can log in to the Business Space to review and accept the request.

Procedure
  1. Log on to Business Space using the login details of an HMO specialist agent.
    Table 4. Agent login information
    Agent type User ID
    EPO Specialist Jay
    HMO Specialist Peter
    Other Specialist Susan
  2. Select the Display Benefit Eligibility Details Task check box from the Tasks List widget, and select Accept from the Actions list. The Member Eligibility Information form is displayed in the Task Information widget.
    Note: Select the All - Assess and work on tasks option from the list that is displayed in the Tasks List widget to view the task.
  3. Review the information displayed on the Member Eligibility Information form and click Submit. The HMO Specialist HT task is displayed in the Tasks List widget.

Updating the patient details

After the specialist accepts the request, he can update the Member Eligibility Information form with the Co-Pay Amount and the Deductible Amount.

Procedure
  1. Select the HMO Specialist HT check box from the Tasks List widget, and select Accept from the Actions list. The Member Eligibility Information form is displayed in the Task Information widget.
    Note:

    Select the All - Assess and work on tasks option from the list that is displayed in the Tasks List widget to view the task.

    The task displayed in the My Tasks widget varied according to the User ID, of the specialist, used to log on to Business Space. The specialist information and the task displayed in the My Task widget is given in the following table.
    Table 5. Task displayed in the My Task widget
    Specialist Task
    EPO Specialist EPO Specialist HT
    HMO Specialist HMO Specialist HT
    Other Specialist Other Specialist HT
  2. Review the information displayed in the Member Eligibility Information form, enter the Co-Pay Amount, enter the Deductible Amount, and then click Update Details.
    Note: The scope of this Solution Scenario is limited and you must click Submit. The details specified in the form are not saved in any database.

Viewing reports

The Solution Scenario provided with the WebSphere Healthcare Content Pack includes different pages that are customized to display reports. These reports can be used for further analysis.

After you submit the request, the information can be viewed for analysis on the following pages.

Benefit Eligibility Dashboard

The Benefit Eligibility Dashboard page contains widgets that provide information about alerts, request summary, request overview, and so on, related to the benefits eligibility request raised.

The details for the widgets displayed on the Benefit Eligibility Dashboard page are given in the following table.

Table 6. Benefit Eligibility Dashboard page - widgets
Widget Description
Nationwide Distribution of Requests The map displays the total submitted claim requests for 50 states.
Request Summary - Current Month The total number of accepted and rejected requests, for the current month is displayed here.
Nationwide Distribution of Requests The graph displays the request statistic for each state.
Request Overview - Current Month The full gauge diagram displays an overview of the requests received for the current month.
Alerts The widget displays the business measure alerts.
Note: You can drill down to view and further analyze the attributes of report values. To drill down, double-click a drillable field on the graph or diagram that you want to analyze. To return to the previous level, right-click a value and click Drill Up. You can also click Display menu icon from the Instances widget title bar, and click Refresh.

Benefit Eligibility Performance

The Benefit Eligibility Performance page contains widgets that provide information about request overview, inactive patients overview, and rejected request overview related to the benefits eligibility request raised.

The details for the widgets displayed on the Benefit Eligibility Performance page are given in the following table.

Table 7. Benefit Eligibility Performance page - widgets
Widget Description
Request Overview by State The full gauge diagram displays the percentage of requests received for a given state.
Inactive Patients Overview by State The half gauge diagram displays the percentage of inactive patients for a given state.
Rejected Request Overview by State The half gauge diagram displays a percentage of the number of rejected requests grouped using the reason for rejection for a given state.
Note: You can drill down to view and further analyze the attributes of report values. To drill down, double-click a drillable field on the graph or diagram that you want to analyze. To return to the previous level, right-click a value and click Drill Up. You can also click Display menu icon from the Instances widget title bar, and click Refresh.

Benefit Eligibility Analysis

The Benefit Eligibility Analysis page contains widgets that provide information about Distribution of Reasons for Rejection and Reason for Rejection related to the benefits eligibility request raised.

The details for the widgets displayed on the Benefit Eligibility Analysis page are given in the following table.

Table 8. Benefit Eligibility Analysis page - widgets
Widget Description
Distribution of Reasons for Rejection The pie chart displays the number of requests received. You can select the month or the year, for the data that you want to analyze, from the list.
Reason for Rejection Overview The full gauge diagram displays an overview of the number of rejected requests grouped using the reason for rejection.
Note: You can drill down to view and further analyze the attributes of report values. To drill down, double-click a drillable field on the graph or diagram that you want to analyze. To return to the previous level, right-click a value and click Drill Up. You can also click Display menu icon from the Instances widget title bar, and click Refresh.

Benefit Eligibility Report

The Benefit Eligibility Report page contains widgets that provide information about monthly rejected requests and monthly reject reasons related to the benefits eligibility request raised.

The details for the widgets displayed on the Benefit Eligibility Report page are given in the following table.

Table 9. Benefit Eligibility Report page - widgets
Widget Description
Monthly Rejected Requests Report The graph displays the number of requests rejected in the current month.
Monthly Reject Reasons Report The bar graph displays the number of requests rejected grouped by the reason for rejection in the current month.
Note: You can drill down to view and further analyze the attributes of report values. To drill down, double-click a drillable field on the graph or diagram that you want to analyze. To return to the previous level, right-click a value and click Drill Up. You can also click Display menu icon from the Instances widget title bar, and click Refresh.

Viewing the Benefit Eligibility process flow

The Benefit Eligibility process flow can be viewed as published using WebSphere Business Compass or as an inflight process that displays the services used and the sequence in which they are executed.

View the Benefit Eligibility Process on the following pages.

Benefit Eligibility Process

The artifacts, users, and roles used in the Solution Scenario can be viewed in the Benefit Eligibility Process page.

The details for the widgets displayed on the Benefit Eligibility Process page are given in the following table.

Table 10. Benefit Eligibility Process page - widgets
Widget Description
Draft Artifacts Navigate and view the artifacts used in the Solution Scenario.
Publishing Server Access Control Navigate and view the users and roles provided for the Solution Scenario.

Benefit Eligibility Process Check

The Benefit Eligibility Process Check page contains a process flow that shows the sequence of the services invoked for every eligibility inquiry request raised using the Solution Scenario. The human tasks that display the order flow for this process are displayed in green on this page.

The details for the widgets displayed on the Benefit Eligibility Process Check page are given in the following table.

Table 11. Benefit Eligibility Process Check page - widgets
Widget Description
Instances The instances of the requests and responses created can be viewed in this widget.
Diagrams This dynamic process flow diagram displays the state of the transaction. Select an item from the Instances widget to view the run time transaction flow in this widget.