Group

The Group record is more comprehensive and impacts how claims are processed.  Groups are associated with Accounts; one or more groups can be associated with one Account.  The Group information is important as it is the “container” for any associated plans.  Plans are where benefits are created.

 

General Information

Some basic fields need to be filled out.

• Group Name: The description you select for the Account record.  This description must be unique within the PBM.
• Eff Start:  This is the earliest date for the associated Groups.
• Eff End:  This is the last date for the associated Groups.
• Group ID:  This is the ID you create that will be associated with the Group.  This value cannot change once saved as a Draft.  This is the ID that the pharmacy/provider will submit on the claim and that would be printed on the ID Card.
• Default Plan:  Each group is allowed to have a single default plan.  This default plan is used primarily for Bypass Enrollment (ignore any member enrollment rules).  This field cannot be populated until one or more plans are associated with the Group.  

At top of the screen, the Contact Information option will bring you to a screen to enter contacts.  Entering a new contact or editing one is the same process for all levels of the System Hierarchy.

Administration

The next section of the Group has to do with the Administration data.  There are key processing elements identified here.

• Default Group ID:  This switch determines if the BIN/PCN can be used to route the claim to this specific Group record regardless of the group number on the claim.  This is typically set to on for programs where Bypass Eligibility is selected. (see below).
• BIN:  If the Default Group ID switch is on, this field will use the BIN number to route the claim to this specific Group. 
• PCN: When the BIN field is populated, the PCN, or Processor Control Number field, will be available.  This is the PCN that the Providing pharmacy should populate in the claim. When the Default Group ID switch is on and the BIN/PCN fields are populated, the inbound claim with the identified BIN/PCN combination will route claims to this Group, regardless of the Group ID on the claim.

NOTE:  If the Default Group ID is set to on and ONLY the BIN has a value, all incoming claims with this BIN will route to this Group for adjudication.  Unless you have some specific business rules, you should always enter the correct information into the BIN and PCN fields.

 

• Account Assignment:  The Account Assignment is the required relationship between the Group and the Account.  This drop-down will present all Account options available.
• Return Response Group:  The Return Response Group allows you to return the group ID as submitted by the Pharmacy on the transaction (External Group ID) or the group ID as setup in the system (Adjudicated Group ID).
• Industry Type:  This is a classification for the business represented by the Group or what supports your business’s needs.  These are industry standard values based on the NAICS or North American Industry Classification System.  These may be important for your reporting needs.  This is unique to the Group setup.
• Client:  This associates the Group to a specific client as registered in the Financial Manager module.  This association is used for Client Invoicing.
• Help Desk Phone Type:  The Phone Type is the industry qualifier reflecting whose phone number is on the claim response.
• Help Desk Phone Number:  This number is communicated to the Provider on the transaction response for Pharmacy help desk needs.

Run Out Claims Configuration

This option needs to enabled to allow the run out claims to be processed after group's effective end date. You can also set a date until which run out claim processing should be allowed

Enrollment

The Enrollment section defines the enrollment process to be used for this Group.

• Bypass Eligibility:  This option is typically selected when there is no enrollment/eligibility loaded into the platform due to the type of program (typically discount cards or programs open to any person).  If this switch is on, no member specific rules are utilized in claim processing.  When the Bypass Eligibility is selected, no further records/options can be updated as they have no impact to the Bypass Eligibility process.

Cardholder ID Management

• Cardholder ID Assignment:  Currently, the system only supports cardholder IDs as provided in enrollment.  System generated ID’s are not currently supported.
• System Cardholder ID Starting Value:  When the option to have the system generate the cardholder ID is selected, the starting number is entered. 
• Cardholder ID Prefix:  This is the prefix for the generation of a system cardholder ID.
• Cardholder ID Length: This indicates the number of characters in the cardholder ID.  This is required to identify the cardholder ID portion of the submitted cardholder ID when the person code is concatenated.
• Auto Assign Person Code:  If ON , the batch enrollment process will generate the Person Code for each member.
• Auto Terminate:  If ON , the batch enrollment process will auto terminate members.
• Medical Cardholder ID:  If ON , the
• Medical TPA ID:  This will be available when Medical Cardholder ID is enabled. Medical TPA defines the external client that will be sending the Medical Eligibility file.
• Eligibility Inbound:  This defines the TPA that will be sending Eligibility file to the PBM.
• Accumulator Inbound: This defines the TPA that will be sending Accumulator file to the PBM
• Accumulator Outbound:  The TPA to whom accumulator extract file will be sent.
• Share Accumulations: If ON , members who move plans within this group will also allow the accumulations to be shared in the new plan.

ID Card Production

ID Card Production is the same process and functionality as the other System Hierarchy levels.

 

Group Update Flows

• Each group record has an effective start and effective end date in it. 
• Whenever a group record is updated, we do not overwrite the existing data. The system creates a new version of the group record. This is because, the Procella system follows Point In Time Architecture (PTA). Please refer to this document for more details on Point In Time Architecture

Draft Records:

Activating Draft Records

When activating a draft record, the system checks for any overlapping effective dates with existing active records and provides options accordingly. There are 4 possible scenarios that could occur when activating a record.

Scenario 1: New Active Version with a New Effective Start Date

Record	Effective Start Date	Effective End Date
Existing Active Record	01/01/2024	12/31/9999
Draft record being activated	01/03/2024	12/31/9999

 

 

• When the user tries to activate the draft version, a popup will be shown. This popup contains the info of current and existing start and end dates , and allowing the user to change the end date of the already existing group version. 

• After making the date change, a confirmation dialog box is displayed to the user as a preview before updating the records.

 

• If the user clicks Back to Editing option, system returns the user to the draft screen without saving changes.
• If the user clicks on Update & Activate, then the existing active record will be updated, and the current record will be activated.

Actions	Effective Start Date	Effective End Date	Status
Effective end of the Existing Active Record will be updated	01/01/2024	01/02/2024	ACTIVE
Draft record will be activated	01/03/2024	12/31/9999	ACTIVE

Scenario 2: New Version with an Earlier Effective Start Date

Example 

Record	Effective Start Date	Effective End Date
Existing Active Record	01/02/2024	12/31/9999
Draft record that user is trying to activate	01/01/2024	12/31/9999

• When the user attempts to activate the draft version, a popup will be displayed. This popup will include the details of the effective start and end dates for both the existing and current records,

• When the user attempts to continue, a Popup with confirmation details for deactivating the existing overlapping record will be shown.

• If the user clicks the Back to Editing option, the system returns the user to the draft screen without saving any changes.
• If the user clicks on Update & Activate, then the existing active record will be inactivated, and the current record will be activated.

After Update

Actions	Effective Start Date	Effective End Date	Status
The existing record will be inactivated. It will no longer be used by the Transaction Engine	01/02/2024	12/31/9999	INACTIVE
The draft record will be activated	01/01/2024	12/31/9999	ACTIVE

Scenario 3: New Version with the Same Effective Dates

Record	Effective Start Date	Effective End Date
Existing Active Record	01/01/2024	12/31/9999
Draft record that user is trying to activate	01/01/2024	12/31/9999

• When the user attempts to activate the draft version, a popup will be displayed. This popup will include the details of the effective start and end dates for both the existing and current records.

• When the user attempts to continue, a Popup with confirmation details for deactivating the existing overlapping record will be shown.

• If the user clicks the Back to Editing option, the system returns the user to the draft screen without saving any changes.
• If the user clicks on Update & Activate, then the existing active record will be inactivated, and the current record will be activated.

After Update

Actions	Effective Start Date	Effective End Date	Status
Existing record will be inactivated. It will no longer be used by Transaction Engine	01/01/2024	12/31/9999	INACTIVE
Draft record will be activated	01/01/2024	12/31/9999	ACTIVE

Scenario 4: Multiple Overlapping Active Versions

• When the user attempts to activate the draft version, a popup will be displayed. This popup will show the effective start and end dates of the current version, and it will highlight that multiple active records have overlapping periods.
• If the user chooses to click the Save Changes option the configuration changes will be saved as a draft version.

Steps to Activate a Draft Record :

1. Review the Draft: Check all details and dates in the draft record.
2. Initiate Activation: Begin the activation process, which will automatically trigger an overlap check.
3. Handle Overlaps: Choose the appropriate action from the dialog box (Back to Editing or Update & Activate) based on the scenario.
4. Confirm Activation: If choosing to activate, confirm the details and finalize the activation.

Note:

• Always verify effective dates and ensure no overlaps. Also, ensure no gaps are created within the effective dates of different group versions.
• Check the details in the confirmation dialog to ensure all changes are as intended before finalizing the activation.

Accessing History versions of a Group Record

Navigate to Group List Screen: Click on the "Group List" option in the navigation menu to access the list of available groups.

Locate Specific Group: use the search functionality to quickly find the specific group that is to be modified/changed.

Open Group Options: Next to the group status, click on the ellipses icon to open a dropdown menu with various options related to the group.

View Group History: Select the "View Group History" option. This action will direct you to a detailed history screen for the selected group.

Group History Filter Bar

Date Selection: A date picker field to select an effective date.

Choosing an effective date will fetch the single active record that is effective for the selected service date. The effective date field has a clear option that will remove the date. Once the date is cleared, it will bring all historical records of the group record. 

Effective Date: The date picker will display the 5 most recent effective start dates of the record at the bottom of the calendar, which the user can select to find a specific active record.

Status Filter: Dropdown menu to filter by Active, All, Draft, or Inactive status.

Two actions can be performed from the History screen

1. Change Effective Dates
2. Inactivate

• The above actions can be performed only for Active records. This helps users manage when an overlapping occurs.

• Change Effective End:  When the user selects the Change Effective date option. User will be asked for a Effective End date.

 If (selected) the new effective end date overlaps with any of the existing Active records, the system will display a below popup error.

View Details:

• Users can select the View Details option to view the group configuration record.

• For Active records, Change effective date and inactivate options are also available from the View screen. This helps the user confirm the configuration before making any updates.

• If a user tries to change the effective end date from the View screen and the new effective end date overlaps with any of the existing records, the system will not allow it to be saved and will show the same popup error.

• When a user tries to inactivate an active version, a standard confirmation message is displayed for confirmation.

• If the user tries to inactivate the last active version of a record (or the only available active version), a warning message will be displayed.