Pega Foundation for Healthcare Common Objects API Technical Specification … · 2018-08-02 ·...

Pega Foundation for Healthcare Common

Objects API

TECHNICAL SPECIFICATION 7.4

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Pega Foundation for Healthcare

Document: Common Object APIs Technical Specifications

Software Version: 7.4

Updated: March 2018

CONTENTS

Overview ........................................................................................................... 1

How to access Pega Healthcare APIs ............................................................. 2 Published Healthcare APIs ................................................................................ 4

Business request APIs ................................................................................. 4 API integration classes ....................................................................................... 5

Business request APIs ..................................................................................... 7 Connector rule for API ....................................................................................... 7

Key rules in business request API execution ............................................ 7 Connector data page ................................................................................... 7 Connect REST rule ........................................................................................ 9 Dynamic settings end point URL management data page .................... 10 Map request data ....................................................................................... 12 Map response data .................................................................................... 12 Wrapper map rule ...................................................................................... 13 Resource map rule ..................................................................................... 14

Business service APIs ..................................................................................... 15 Healthcare API – service package rule ........................................................... 15 REST service method ....................................................................................... 16 Key rules in service execution ........................................................................ 16 Service REST rule .............................................................................................. 17 Resource and query parameters .................................................................... 17 Service activity rule .......................................................................................... 19 Mapping data transform rule ......................................................................... 19

Extending Pega Healthcare APIs .................................................................. 21 MapToEntity extension pattern ...................................................................... 21 Inbound mapping ............................................................................................ 21

HTTP status codes .......................................................................................... 25 Success codes ................................................................................................... 25 Error codes ........................................................................................................ 25

Healthcare API – key ...................................................................................... 26

Business request APIs ..................................................................................... 26 Authorizations - GET authorization details ............................................. 26

Authorizations - GET authorizations by member policy ID ......................... 26 URL format .................................................................................................. 27 Parameters ................................................................................................. 27 Key rules ...................................................................................................... 27

Benefit request – POST benefit details .......................................................... 27 URL format .................................................................................................. 27 Parameters ................................................................................................. 27 Key rules ...................................................................................................... 29

Business entities – GET business entity ......................................................... 29 URL format .................................................................................................. 29 Parameters ................................................................................................. 29 Key rules ...................................................................................................... 29

Business affiliations – GET business entity ................................................... 30 URL format .................................................................................................. 30 Parameters ................................................................................................. 30 Key rules ...................................................................................................... 30

Policy – GET policy details ............................................................................... 31 URL format .................................................................................................. 31 Parameters ................................................................................................. 31 Key rules ...................................................................................................... 31

Member policies – GET member policies details .......................................... 31 URL format .................................................................................................. 32 Parameters ................................................................................................. 32 Key rules ...................................................................................................... 32

Provider Contracts - GET contract details ..................................................... 33 URL format .................................................................................................. 33 Parameters ................................................................................................. 33 Key rules ...................................................................................................... 33

Claims - GET claim history ............................................................................... 34 URL format .................................................................................................. 34 Parameters ................................................................................................. 34 Key rules ...................................................................................................... 34

Claims - POST claim ......................................................................................... 34 URL format .................................................................................................. 34

Output ......................................................................................................... 34 Key rules ...................................................................................................... 35

Employer group contract – GET employer group contract details ............. 35 URL format .................................................................................................. 35 Parameters ................................................................................................. 35 Key rules ...................................................................................................... 35

Member APIs .................................................................................................... 35 Members - GET member details ..................................................................... 36

URL format .................................................................................................. 36 Parameters ................................................................................................. 36 Key rules ...................................................................................................... 36

Members - GET member’s policy networks .................................................. 37 URL format .................................................................................................. 37 Parameters ................................................................................................. 37 Key rules ...................................................................................................... 37

Networks - GET network details ..................................................................... 37 URL format .................................................................................................. 37 Parameters ................................................................................................. 38 Key rules ...................................................................................................... 38

Payers - GET payer details ............................................................................... 38 URL format .................................................................................................. 38 Parameters ................................................................................................. 38 Key rules ...................................................................................................... 39

Plan details - GET plan details ......................................................................... 39 URL format .................................................................................................. 39 Parameters ................................................................................................. 39 Key rules ...................................................................................................... 39

Plan networks - GET plan networks ............................................................... 40 URL format .................................................................................................. 40 Parameters ................................................................................................. 40 Key rules ...................................................................................................... 40

Provider APIs .................................................................................................... 41 Providers - GET provider details ..................................................................... 41


Providers – GET provider networks ............................................................... 42 URL format .................................................................................................. 42 Parameters ................................................................................................. 43 Key rules ...................................................................................................... 43

Rate sheets - GET rate sheet details .............................................................. 43 URL format .................................................................................................. 43 Parameters ................................................................................................. 43 Key rules ...................................................................................................... 44

Business service API ...................................................................................... 45 Claims – GET claim ........................................................................................... 45


Claims – POST (create) claim ........................................................................... 45 URL format .................................................................................................. 45 Output ......................................................................................................... 45 Key rules ...................................................................................................... 46

Claims – PUT (update) claim ........................................................................... 46 URL format .................................................................................................. 46 Output ......................................................................................................... 46 Key rules ...................................................................................................... 46

Pega Foundation for Healthcare Common Objects API Technical Specification Guide 1

The Pega Healthcare API enables you to leverage built-in REST/JSON services to integrate your Pega applications with external systems to request, receive, and send data. You can call any of the Pega Healthcare API services by using standard HTTP methods (for example: GET, POST, or PUT). The supported APIs provides a standard set of services and requests that include access to data pages for commonly referenced objects in healthcare applications e.g. Member, Provider, Claim and so on. These APIs enable rapid deployment of your Pega’s healthcare applications.

Overview


Pega offers online help documentation on the Healthcare APIs. You can access the Pega Healthcare API help documentation from the Designer Studio menu.

The API information is organized as Business Request API methods to GET (request) data from third party applications based on parameters passed in the request.

How to access Pega Healthcare APIs


TITLE of INTERNAL DOCUMENT – Arial Bold 12 pt

Using the above links, you can:

• View the JSON data model for each published resource

• List the parameters used for each resource

• Directly test the API by clicking the Try it out! and viewing the actual request URL, response body, response code, and response headers.



KNOWN ISSUE: Swagger rendering in Pega does not support embedded definitions – When a given definition is reused more than once in the API e.g. ‘Address’, it is displayed as Null. To overcome this issue, these attributes are repeated with a slightly different name e.g. Address and AddressEntity as shown in the Payer model above.

Published Healthcare APIs Business request APIs • Authorizations

− Get Authorization by ID

− Get Authorizations by Member Policy ID

• Benefits

− Get Benefit Coverage (in the context of member’s claim line)

• Business Entities (Provider)

− Get Provider Business Entity

• Business Affiliations (Provider)

− Get Provider Business Affiliation

• Provider Contracts

− Get Provider Contract

• Claims



− Get Claims History (for member)

• Employer Group Contracts

− Get Employer Group Contract

• Members

− Get Member

− Get Member Policies

− Get Member Networks

• Networks

− Get Network

• Payers

− Get Payer

• Plan Networks

− Get Plan Network

• Policies

− Get Policy

• Providers

− Get Provider

− Get Provider Networks

• Rate Sheets

− Get Rate Sheets

API integration classes The Healthcare API infrastructure provides an integration class for each published API resource. This class defines the data model used in mapping the response data returned via API call. The classes are configured as PegaHC-Int-xxxxx as shown below.



Note: The sample rules shown in the next two chapters are shown using the Payer resource as an example. Each published resource API has similar rules associated with it.


Connector rule for API The Healthcare API infrastructure contains pre-configured specified endpoint URL and populates the returned result in data pages. The following diagram illustrates the flow of execution:

Key rules in business request API execution Rule Name Rule Type Usage D_Connect e.g. D_ConnectPayer

Data Page Calls the connector and identifies the request and response mapping rules

Get

Connect REST Calls the REST Service using endpoint URL MapRequestData Data Transform Maps the request data MapResponseData Data Transform Maps the results data to data page MapToEntity Data Transform Maps the results to the Payer object

Connector data page The Connector data page for each Resource provides the configuration for the data page definition and the data source(s) that are used to fetch the data. It also identifies the request and response data mapping rules. The following Connect Data pages are configured for the APIs.

Business request APIs


As shown below, the Source for the data is configured as a Connector which invokes the external system REST service using the endpoint URL. The Endpoint URLs for all configured services in Healthcare API are fetched through a dynamic settings data page called D_HCSettings as explained later in this document.


Connect REST rule The Connect REST rule supports the interaction between Pega and other systems over the Hypertext Transfer Protocol (HTTP). It identifies the resource path endpoint URL of the source system to which this rule connects, and the parameters used to pass in the request. Refer to Pega online Help for additional information on configuring Authentication, Security Settings, and Error Handling.


Dynamic settings end point URL management data page You cannot modify the End Point URL resource path configured on a Connect REST rule once you finalize and lock the rule. To be able to maintain different end point system URLs and reference them dynamically, the Healthcare API configuration provide a pre-configured node level dynamic settings data page called D_HCSettings. As shown above, this page is referenced as a parameter to retrieve the EndPointURL for the given resource.


The data source configured to fetch the end point URL is a Data Transform rule called LoadHCSettings. The rule is configured with URLs for a test reference system used internally for testing the Healthcare APIs. The rule is marked for Extension and is expected to be updated in your application with URLs for your own source systems for the different resources.


Map request data The MapRequestData data transform rule provides the parameter(s) passed in the request API.

Map response data The MapResponseData data transform maps the response received from the source system. The data received as JSON format is stored in Param.Response which is then mapped to appropriate object class in your application. In this example, the returned payer information is mapped to payer class using the MapToEntityWrapper data transform rule.


Wrapper map rule A wrapper rule envelops each mapping rule for every resource API published in the Healthcare APIs. The wrapper rule contains the Pre and Post extension points to extend the mapping in your implementation. These rules are marked for Extension and you should extend as per your need. The expectation is that the you maintain the main mapping rule included in the wrapper rule as is to allow Pega to maintain backward compatibility with the Pega-provided mapping rules. See the “Extending your APIs” section defined later.



Resource map rule The configured mapping of the expected response for each Resource is configured in this data transform rule.


Healthcare API – service package rule The key service package rule is called Healthcare API. It lists all the REST services published in this release.

Business service APIs



Note: The key Business Service API is for the Claim resource. The list of service rules shown above also includes additional service rules for other resources that are configured to test the corresponding Business Request APIs with the sample data provided in Pega Foundation for Healthcare.

REST service method The Healthcare API provides a mechanism for an external system to call the Pega Healthcare API REST services. The schematic shown below illustrates the flow of the REST service execution using ‘Payer’ as an example.

Key rules in service execution

Rule Name Rule Type Usage

Service REST REST service rule that identifies the path, parameters, and methods

GetAPI

Activity Method in REST service to get Payer details

MapFrom

Data Transform Map results from HCIF Payer to API Integration object



Service REST rule Each Resource published in the Healthcare API has a pre-configured REST Service rule that identifies the key properties including the path and parameters as well as all the methods configured for the Resource. Let’s look at an example below for the Payers API.

Resource and query parameters The Resource and Query parameters configured on the REST Service rule are used to form and call the appropriate endpoint system URL. In this example, the payer ID is passed as resource parameter, which will convert endpoint URL as shown below:

http://vfwiapppgr063:8080/prweb/PRRestService/healthcareapi/v1/payers/{ID}

The Methods tab of the rule defines any of the methods - GET, PUT, POST defined for the Resource along with the parameters for each method.



Service activity rule Each method defined on the Resource REST Service rule has an activity rule that kicks-off the process when the Service Method is executed. The requested data is retrieved using the endpoint URL of the source system using the parameters that were passed in the Method.

The data that is returned from the source system is mapped to the Integration class for the Resource as shown earlier. Results of this request will be stored in Param.Response and passed to data page.

Mapping data transform rule The Activity defined in the Service Method calls a mapping Data Transform rule to map the returned data to the appropriate data page.


The Healthcare APIs provide a mechanism for your application to extend the wrapper rule of every resource. A wrapper rule envelops each mapping rule for every resource API published in the Healthcare APIs. The wrapper rule is provided as a placeholder for extending the mapping in your implementation.

These rules are marked for Extension and you should extend them as per your need. It is expected that the main mapping rule included in the wrapper rule is maintained as is to allow Pega to maintain backward compatibility with the Pega-provided mapping rules.

MapToEntity extension pattern This method describes the new API mapping paradigm. In this method, the pattern is described using the Authorization API as an example.

Inbound mapping The mapping begins at the connect Data page i.e. D_ConnectAuthorization. The Connector data page for each Resource provides the configuration for the data page definition and the data source(s) that are used to fetch the data. It calls the connector and identifies the request and response data mapping rules.

Extending Pega Healthcare APIs



MapRequestData: The MapRequestData data transform rule provides the parameter(s) passed in the request API.

MapResponseData: The MapResponseData data transform maps the response received from the source system. The data received as JSON format is stored in Param.Response which is then mapped to appropriate object class in your application. In this example, the returned authorization information is mapped to Authorization data class using the MapToEntityWrapper data transform rule.

MapToEntityWrapper: MapToEntityWrapper accepts a single Page Name parameter called Integration Page. In this case the parameter will be the ‘Authorization’ page of type ‘PegaHC- Data-Authorization.

The data transform serves as a control point for making calls out to a series of three additional Data Transform rules that provide the core mapping functionality as well as the appropriate extensibility needed by customers:



MapToEntity: a single MapToEntity rule exists in @baseclass and this rule is overridden in each of the classes that need to supply their own definitions. In the new implementation

‘MapToEntity’ would exist in the ‘Int’ classes and have the corresponding mappings. In the current example, we have the ‘MapToEntity’ data transform in the ‘PegaHC-Int-Authorization’ class. It contains the mappings related the authorization object.

The ’MapToEntityWrapper’ paradigm will be extended to all the embedded pages/objects as well. In the example, the authorization JSON response has a ‘requester’ page with page definition ‘PegaHC-Int-AuthorizationRequester’. We intend to map this page to the ‘Requester’ page on the HCIF Authorization object. The ‘Requester’ page is set as the parameter to the ‘MapToEntityWrapper’, which in turn invokes the ‘MapToEntity’ in the ‘PegaHC-Int-AuthorizationRequester’ class.


Success codes

HTTP Status Code Description 200 Success(OK) 201 Created 204 No content

Error codes

HTTP Status Code Description 400 Bad request 401 Unauthorized 403 Forbidden 404 Not found 412 Precondition failed 500 Internal Error

HTTP status codes


Business request APIs Authorizations - GET authorization details This connector rule takes Authorization ID (certification number) as input parameter and returns the authorization details in data page.

URL format

GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/authorizations/{ID}

Parameters

Key rules


Class: PegaHC-Int-Authorization

authorizations Service REST GetAuthorizations Activity Method in REST service to get authorization

MapFromAuthorization Data Transform Map results from HCIF Authorization to API Integration object

D_ConnectAuthorization Data Page To call connector and map request and GetAuthorization Connect REST Call REST Service using endpoint URL

MapRequestData Data Transform To map service request data MapResponseData Data Transform To map result data to data page MapToEntity Data Transform To map the results to HCIF Authorization object

Authorizations - GET authorizations by member policy ID This connector rule takes Authorization ID (certification number) as input parameter and returns the authorization details in data page.

Healthcare API – key

https://%5Bhostname:port%5D/prweb/PRRestService/healthcareapi/v1/authorizations/%7bID%7d



URL format

GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/memberAuthorizations/{Member PolicyID}

Parameters

Key rules


Class: PegaHC-Int-Authorization

memberAuthorizations Service REST GetMemberAuthorizations Activity Method in REST service to get authorization

MapFromAuthorization Data Transform Map results from HCIF Authorization to API Integration object

D_ConnectMemberAuthorizations Data Page To call connector and map request and GetMemberAuthorizations Connect REST Call REST Service using endpoint URL

MapRequestData Data Transform To map service request data MapMemberAuthorizationsRespo

Data Transform To map result data to data page

MapToEntity Data Transform To map the results to HCIF Authorization

Benefit request – POST benefit details URL format POST https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/Benefits

Parameters This connector rule takes PlanBenefitRequest as a parameter which is claimLine details for a claim to fetch the coverage for particular line item.



PlanBenefitRequest {

claimLineNumber (string,

optional), planID (string,

optional), serviceFromDate

(date, optional), serviceToDate

(date, optional), revenueCode

(string, optional),

procedureCode (A00.1, optional),

placeOfService (string,

optional), diagnosis (string,

optional),

age (string, optional),

gender (string, optional),

DateOfBirth (date,

optional), billType

(string, optional),

networkRelationship (string,

optional), AdmissionType (string,

optional),

IRC (string, optional),

Modifier (string,

optional), Providerype

(string, optional)

}



Key rules Rule Name Rule Type Usage

Class: PegaHC-Int-Benefit

D_ConnectPlanBenefitCoverage Data Page To call connector and map request and PlanBenefitCoverage Connect REST Call REST Service using endpoint URL

MapBenefitCoverageFilters Data Transform To map service request data MapResponseData Data Transform To map result data to data page MapToPlanBenefitCoverageWrapper

Data Transform Wrapper DT which calls ‘MapToPlanBenefitCoverage’ and can be

MapToPlanBenefitCoverage Data Transform Map results to HCIF Plan Benefit object

Business entities – GET business entity Business Entity API takes TIN or Tax ID as required field to fetch details and effective, end dates are optional parameters. Foundation provides OOTB connector data page which invokes the external system REST service using endpoint URL. Below are key rules:

URL format GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/businessentities/{TIN}

Parameters


Class: PegaHC-Int-BusinessEntity

businessEntities Service REST GetBusinessEntities Activity Method in REST service to get Business Entity

MapFromBusinessEntity Data Transform Map results from HCIF Business Entity to API Integration object



D_ConnectBusinessEntities Data Page To call connector and map request and BusinessEntities Connect REST Call REST Service using endpoint URL

MapRequestData Data Transform To map service request data MapResponseData Data Transform To map result data to data page MapToEntity Data Transform Map results to HCIF Business Entity object

Business affiliations – GET business entity Business Affiliations API takes ID which is a comma delimited string of ProviderID, BusinessEntityID and EffectiveDate (in the same order) as parameters to fetch business affiliation details.

Foundation provides OOTB connector data page which invokes the external system REST service using endpoint URL. Below are key rules:

URL format GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/businessaffiliations/{ID}

Parameters


Class: PegaHC-Int-BusinessAffiliation

businessaffiliations Service REST GetBusinessAffliations Activity Method in REST service to get business

MapFromBusinessAffiliation Data Transform Map results from HCIF Business Affiliation to API Integration object

D_ConnectBusinessAffiliation Data Page To call connector and map request and GetBusinessAffiliation Connect REST Call REST Service using endpoint URL

MapRequestData Data Transform To map service request data MapResponseData Data Transform To map result data to data page MapToEntity Data Transform Map results to HCIF Business Affiliation object

https://%5Bhostname:port%5D/prweb/PRRestService/healthcareapi/v1/businessaffiliations/%7bID%7d



Policy – GET policy details Policy API takes ID which is Policy ID as the parameter to fetch policy details.

Foundation provides OOTB connector data page which invokes the external system REST service using endpoint URL. Below are key rules:

URL format GET

https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/policies/{ID}

Parameters


Class: PegaHC-Int-Policy

policies Service REST GetPolicyAPI Activity Method in REST service to get policy details MapFromPolicyObject Data Transform Map results from HCIF Policy to API Integration

D_ConnectPolicy Data Page To call connector and map request and GetPolicy Connect REST Call REST Service using endpoint URL

MapRequestData Data Transform To map service request data MapResponseData Data Transform To map result data to data page MapToEntity Data Transform Map results to HCIF Policy object

Member policies – GET member policies details Member Policies API takes Member ID as required, PolicyID. Effective and End date as optional parameters to fetch policy details. Based on parameters passed to request – it will return results.



• If MemberID and PolicyID both are passed, then request will return details of requested policy

• If only MemberID is passed, then it will get details of all policies Member has

Foundation provides OOTB connector data pages which invoke the external system REST service using endpoint URL. Below are key rules:

URL format https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/members/{memberID}/memberPolicies/{PolicyID}

Parameters


Class: PegaHC-Int-Policy

memberPolicies Service REST GetMemberPolicies Activity Method in REST service to get policy details MapFromPolicy Data Transform Map results from HCIF Policy to API Integration



D_ConnectMemberPolicies D_ConnectMemberPoliciesByID

Data Page To call connector and map request and response

MemberPolicies MemberPoliciesByID

Connect REST Call REST Service using endpoint URL

MapRequestData Data Transform To map service request data MapResponseData Data Transform To map result data to data page MapToEntity Data Transform Map results to HCIF Policy object

Provider Contracts - GET contract details This connector rule takes Provider Contract ID as required and Effective, End date as optional parameters. Based on Provider Contract ID match – it will return the contract details including Network and rate sheet IDs.

URL format GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/providercontracts /{ID}

Parameters

Key rules Rule Name Rule Type Usage providercontracts Service REST REST service rule that identifies the path, parameters, and

GetProviderContracts Activity Method in REST service to get Provider Contract details MapFromProviderContract

Data Transform Map results from HCIF Provider Contract to API Integration object

D_ConnectProviderContract

Data Page To call connector and map request and response

ProviderContracts Connect REST Call REST Service using endpoint URL MapRequestData Data Transform To map service request data



MapResponseData Data Transform To map result data to data page MapToEntity Data Transform Map results to HCIF Provider Contract object

Claims - GET claim history Get Claim History request returns the set of claims based on matching attributes in query string parameter. Foundation provides OOTB connect rule which invokes the external system REST service using endpoint URL. Below are key rules:

URL format GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/GetClaims

Parameters This request takes ‘QueryString’ as parameter in format as

[patient.firstName='BOB' AND provider.name='Ian' AND claim.diagnosisType=55 OR (policy.type = 'EMP')]

Key rules Rule Name Rule Type Usage GetClaims Service REST REST service rule that identifies the path, parameters,

and methods GetClaims Activity Method in REST service to get array of claims for the

matched criteria MapRequestClaimHistoryDa

Data Transform Map results from HCIF Provider Contract to API

GetClaimsHistoryBasedOnQ

Connect REST Call REST Service using endpoint URL MapResponseClaimHistory

Data Transform To map service request data

Claims - POST claim This connector rule takes claim JSON data as a required parameter and returns a claim ID in JSON. HCIF provides a Pega-provided connect rule, which invokes the external system REST service using an endpoint URL. Below are key rules:

URL format POST https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/Claims

Output {

"claimID": "CML-123"

}



Key rules Rule Name Rule Type Usage PostClaim Connect

Call REST Service using endpoint URL

MapFromClaimWorkWrapper Data

Map results from HCIF claims object to API Integration

Employer group contract – GET employer group contract details Employer Group Contract API takes ID as required field to fetch details. Foundation provides OOTB connector data page which invokes the external system REST service using endpoint URL. Below are key rules:

URL format GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/Contracts/{ID}

Parameters


Class: PegaHC-Int-Contract

Contracts Service REST GetContracts Activity Method in REST service to get Employer Group

Contracts details MapContractData Data Transform Map results from HCIF Contract to API

D_ConnectContract Data Page To call connector and map request and GetContract Connect REST Call REST Service using endpoint URL

MapRequestData Data Transform To map service request data MapResponseData Data Transform To map result data to data page MapToEntity Data Transform Map results to HCIF Contract object

Member APIs There are two resources for Member API:



• Get Member Details

• Get Member Networks

Both of these services takes Member ID as parameter and returns relative details in data page. Foundation provides OOTB connector data pages which invokes the external system REST service using endpoint URL. Below are key rules:

Members - GET member details URL format GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/members/{ID}

Parameters


Class: PegaHC-Int-Member

members Service REST GetMember Activity Method in REST service to get Member details MapFromMember Data Transform Map results from HCIF Member to API

D_ConnectMember Data Page To call connector and map request and GetMember Connect REST Call REST Service using endpoint URL

MapRequestData Data Transform To map service request data MapResponseData Data Transform To map result data to data page MapToEntity Data Transform Map results to HCIF Member object

https://%5Bhostname:port%5D/prweb/PRRestService/healthcareapi/v1/members/%7bID%7d



Members - GET member’s policy networks URL format GET

https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/members/{ID}/memberPolicies/{ policyID}/networks

Parameters


Class: PegaHC-Int-Network

members Service REST GetMember Activity Method in REST service to get Member details GetMemberNetworks Activity Method in REST service to get Member’s

MapFromNetwork Data Transform Map results from HCIF Network to API D_ConnectMemberNetworks Data Page To call connector and map request and

MemberNetworks Connect REST Call REST Service using endpoint URL MapRequestData Data Transform To map service request data MapNetworkResponseData Data Transform To map result data to data page MapToEntity Data Transform Map results to HCIF Network object

Networks - GET network details URL format GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/networks/{ID}



Parameters


Class: PegaHC-Int-Network

networks Service REST GetNetworkAPI Activity Method in REST service to get Network details MapFromNetwork Data Transform Map results from HCIF Network to API

D_ConnectNetwork Data Page To call connector and map request and GetNetwork Connect REST Call REST Service using endpoint URL

MapRequestData Data Transform To map service request data MapResponseData Data Transform To map result data to data page MapToEntity Data Transform Map results to HCIF Network object

Payers - GET payer details URL format GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/payers/{ID}

Parameters

https://%5Bhostname:port%5D/prweb/PRRestService/healthcareapi/v1/payers/%7bID%7d




Class: PegaHC-Int-Payer

payers Service REST GetPayerAPI Activity Method in REST service to get Payer details MapFromPayer Data Transform Map results from HCIF Payer to API Integration

D_ConnectPayer Data Page To call connector and map request and GetPayer Connect REST Call REST Service using endpoint URL

MapRequestData Data Transform To map service request data MapResponseData Data Transform To map result data to data page MapToEntity Data Transform Map results to HCIF Payer object

Plan details - GET plan details URL format GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/plans

Parameters


Class: PegaHC-Int-Plan

plans Service REST GetPlanDetailsAPI Activity Method in REST service to get Plan details MapFromPlan Data Transform Map results from HCIF Plan to API Integration

MapFromBenefitDefinition Data Transform Map results from HCIF Benefit Definition to API Integration object

https://%5Bhostname:port%5D/prweb/PRRestService/healthcareapi/v1/plans



MapFromBenefitCoverage Data Transform Map results from HCIF Benefit Coverage to API Integration object

D_ConnectGetPlanDetails Data Page To call connector and map request and

Rule Name Rule Type Usage GetPlanDetails Connect REST Call REST Service using endpoint URL MapPlanRequestData Data Transform To map service request data MapResponseData Data Transform To map result data to data page MapToEntity Data Transform Map results to HCIF Plan object MapToEntity (PegaHC-Int-Benefit- Definition)

Data Transform Map results to HCIF Benefit Definition object

MapToEntity(PegaHC-Int-Benefit- Coverage)

Data Transform Map results to HCIF Benefit Coverage object

Plan networks - GET plan networks This connector rule takes Plan ID as required and Effective, End date as optional parameters. Based on plan’s network – it will return the network details.

URL format GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/plans/{ID}/{ Resource}

Note: Here Resource is passed as ‘Networks’ for End point URL.

Parameters

Key rules Rule Name Rule Type Usage plans Service REST REST service rule that identifies the path,

parameters, and methods GetPlanAPI Activity Method in REST service to get Plan’s Network



MapFromNetwork Data Transform Map results from HCIF Network to API D_ConnectPlanNetworks Data Page To call connector and map request and

PlanNetworks Connect REST Call REST Service using endpoint URL MapRequestData Data Transform To map service request data

Rule Name Rule Type Usage MapNetworkResponseData Data Transform To map result data to data page MapToEntity Data Transform Map results to HCIF Network object

Provider APIs The following are the resources provided for Provider API:

• Get Provider Details

• Get Provider Networks

Pega Foundation for Healthcare provides connector data pages which invoke the external system REST service using endpoint URL. Below are key rules:

Providers - GET provider details This connector rule takes NPI ID as required and TIN, Effective, End date as optional parameters to fetch provider details. For Provider – all details including Provider demographic, Provider Affiliations will be returned to data page.

If TIN is passed, then it will return only matching TIN details in Provider Affiliations.

URL format GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/Provider/{ID}

Parameters



Key rules Rule Name Rule Type Usage Provider Service REST REST service rule that identifies the path, parameters, and

GetProvider Activity Method in REST service to Provider details MapFromProvider Data Transform Map results from HCIF Provider to API Integration object D_ConnectProvider Data Page To call connector and map request and response GetProvider Connect REST Call REST Service using endpoint URL

Rule Name Rule Type Usage MapRequestData Data Transform To map service request data MapResponseData Data Transform To map result data to data page MapToEntity Data Transform Map results to HCIF Provider object

Providers – GET provider networks This connector rule takes NPI ID as required and TIN, Effective, End date as optional parameters to fetch provider details. For Provider – all details including Provider demographic, Provider Affiliations will be returned to data page.

URL format GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/provider/{ID}/{Resource}

Note: Here Resource is passed as ‘Networks’ for End point URL.



Parameters

Key rules

Rule Name Rule Type Usage Provider Service REST REST service rule that identifies the path, parameters,

GetProvider Activity Method in REST service to get Provider details GetProviderNetworks Activity Method in REST service to get Provider’s Network

MapFromNetwork Data

Map results from HCIF Network to API Integration D_ConnectProviderNetworks Data Page To call connector and map request and response

ProviderNetworks Connect

Call REST Service using endpoint URL MapRequestData Data

To map service request data

MapNetworkResponseData Data

To map result data to data page MapToEntity Data

Map results to HCIF Network object

Rate sheets - GET rate sheet details This connector rule takes Rate Sheet ID as required and Effective, End date as optional parameters and returns the Rate sheet details in data page.

URL format GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/ratesheets/{ID}

Parameters




Class: PegaHC-Int-RateSheet

D_ConnectRateSheet Data Page To call connector and map request and response RateSheet Connect REST Call REST Service using endpoint URL MapRequestData Data

To map service request data

MapResponseData Data

To map result data to data page MapToEntity Data

Map results to HCIF Rate Sheet object


Claims – GET claim Get Claim service takes Claim ID as input path parameter and returns the claim object in JSON format.

URL format Get https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/Claims/{ID}

Parameters This service rule takes claims id as path parameter and then returns claim object in the form of json.

Key rules


Class: PegaHC-Int-Claim

GetClaimAPI Service activity Method in REST service to create claim and return claimed created as response

Claims Service REST REST service rule that identifies the path, parameters, and methods

Claims – POST (create) claim Post Claim service rule takes claim JSON as parameter and returns the created Claim ID in JSON format

URL format POST https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/Claims

Output {


}

Business service API



Key rules Rule Name Rule Type Usage Class: PegaHC-Int-Claim PostClaimAPI Service activity Method in REST service to create claim and return

claimed created as response Claims Service REST REST service rule that identifies the path,

parameters, and methods

Claims – PUT (update) claim PUT claim service rule takes claim json as parameter and then returns updated claim ID in the form of json.

URL format PUT https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/Claims

Output {


}


Class: PegaHC-Int-Claim

PutClaimAPI Service activity Method in REST service to create claim and return claimed created as response

Claims Service REST REST service rule that identifies the path, parameters, and methods

HTTP status codesBusiness service APIHealthcare API – keyExtending Pega Healthcare APIsBusiness service APIsBusiness request APIsHow to access Pega Healthcare APIsOverviewPublished Healthcare APIsBusiness request APIs

API integration classesConnector rule for APIKey rules in business request API executionConnector data pageConnect REST ruleDynamic settings end point URL management data pageMap request dataMap response dataWrapper map ruleResource map rule

Healthcare API – service package ruleREST service methodKey rules in service executionService REST ruleResource and query parametersService activity ruleMapping data transform ruleMapToEntity extension patternInbound mappingSuccess codesError codesBusiness request APIsAuthorizations - GET authorization detailsURL formatParametersKey rules

Authorizations - GET authorizations by member policy IDParametersKey rules

Benefit request – POST benefit detailsURL formatParametersKey rules

Business entities – GET business entityURL formatParametersKey rules

Business affiliations – GET business entityURL formatParametersKey rules

Policy – GET policy detailsURL formatParametersKey rules

Member policies – GET member policies detailsURL formatParametersKey rules

Provider Contracts - GET contract detailsURL formatParametersKey rules

Claims - GET claim historyURL formatParametersKey rules

Claims - POST claimURL formatOutputKey rules

Employer group contract – GET employer group contract detailsURL formatParametersKey rules

Member APIsMembers - GET member detailsURL formatParametersKey rules

Members - GET member’s policy networksURL formatParametersKey rules

Networks - GET network detailsURL formatParametersKey rules

Payers - GET payer detailsURL formatParametersKey rules

Plan details - GET plan detailsURL formatParametersKey rules

Plan networks - GET plan networksURL formatParametersKey rules

Provider APIsProviders - GET provider detailsURL formatKey rules

Providers – GET provider networksURL formatParametersKey rules

Rate sheets - GET rate sheet detailsURL formatParametersKey rules

Claims – GET claimURL formatParametersKey rules

Claims – POST (create) claimURL formatOutputKey rules

Claims – PUT (update) claimURL formatOutputKey rules

Pega Foundation for Healthcare Common Objects API Technical Specification … · 2018-08-02 ·...

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