Pegasystems Enhances Two Business-Critical BPM Frameworks for the Healthcare Industry

CAMBRIDGE, Mass., Nov. 13 — Pegasystems Inc. (Nasdaq: PEGA), the leader in unified process and rules technology, today announced significant upgrades of two business-critical frameworks for the healthcare industry — the Healthcare Payer Industry Framework and the Healthcare Claims Repair Framework, both built with Pegasystems' rules-driven SmartBPM Suite.

Used by healthcare organizations across the nation, the Healthcare Payer Industry Framework delivers pre-built foundational elements that promote rapid deployment and development of personalized solutions. Today, this framework is helping healthcare payers deliver sustainable competitive advantage across a wide range of business challenges including consolidating pharmacy transactions and addressing new claims UB-04 format requirements.

Pegasystems' Claims Repair Framework combines payer-specific business rules with claims processing best practice templates — for both pre- and post-adjudication activities — to maximize straight-through-processing, increase adjudication accuracy and decrease processing costs. This framework provides payers heightened flexibility for automating new processing requirements and is far more agile than traditional custom code or rigid macro options.

"In a market where change is constant and competition is intense, it's important to be armed with the best available technology to both adapt and capitalize on that change, whether that change be regulatory, market or consumer driven," said Elizabeth Hart, director, healthcare product management, Pegasystems. "New enhancements to these two frameworks give healthcare organizations better tools to help rapidly drive top-line growth and bottom-line savings."

Pegasystems' Healthcare Payer Industry Framework includes HIPAA EDI templates and a HIPAA-compliant healthcare data model along with market-specific best-practice work templates for rapidly creating SmartBPM solutions that deliver productivity, spur growth and ensure compliance. Several key enhancements packaged in the framework's newest release include:

  • My Showcase rules custom gadget that enhances ease-of-use for developers;
  • AJAX "Hover and See" functionality that provides immediate feedback to end-users and increased interactivity, speed and usability of Web applications;
  • Spell check feature for ad hoc correspondence;
  • Simplified creation of sample data; and
  • Simplified access to sample PDF intake functionality.

Pegasystems' Claims Repair Framework delivers a normalized claims processing infrastructure built on an industry standard object model with pre-packaged claims rules, edits and functions. The framework provides an efficient platform on which to configure, organize and maintain business edits used in processing claims. Enhancements packaged in the upcoming framework release include:

  • Improved visibility across claim edits through the flow explorer gadget;
  • Leveragability of the Healthcare Payer Industry Framework for use of and standardization from HIPAA properties and healthcare normalized common objects;
  • Inclusion of a library of pre-configured functions to be used across numerous decision points including Validate NPI rules for National Provider Identification requirements; and
  • Additional claims reports, including edits applied at line level and batch processing disposition monitoring.

About Pegasystems

Pegasystems (NASDAQ: PEGA) develops strategic applications for marketing, sales, service, and operations. Pega’s applications streamline critical business operations, connect enterprises to their customers seamlessly in real-time across channels, and adapt to meet rapidly changing requirements. Pega’s Global 3000 customers include many of the world’s most sophisticated and successful enterprises. Pega’s applications, available in the cloud or on-premises, are built on its unified Pega 7 platform, which uses visual tools to easily extend and change applications to meet clients’ strategic business needs. Pega’s clients report that Pega gives them the fastest time to value, extremely rapid deployment, efficient re-use, and global scale. For more information, please visit us at

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The information contained in this press release is not a commitment, promise, or legal obligation to deliver any material, code or functionality. The development, release and timing of any features or functionality described remains at the sole discretion of Pegasystems, Pegasystems specifically disclaims any liability with respect to this information.


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