Pegasystems Introduces Appeals and Grievance Manager for Healthcare Payers; Speeds Resolution of Member Complaints via Smart BPM Platform

CAMBRIDGE, Mass., May 23, 2005 — The healthcare industry is serious about how health plans resolve member complaints. In response, Pegasystems Inc. (Nasdaq: PEGA), the leading provider of smart business process management (BPM) software, today announced the release of Appeals and Grievance Manager. Appeals and Grievance Manager provides packaged, best-practice complaint workflows designed to help healthcare payers manage complaint processing times, correspondence and reports. It is designed for rapid deployment and easy extension throughout healthcare organizations.

Appeals and Grievance Manager helps payer organizations address execution gaps that keep them from achieving key business objectives. These gaps are caused by:

  • Continuously changing regulatory requirements that vary by line-of-business and geography;
  • Difficulty collecting and documenting supporting information from disparate sources; and
  • Inefficient, manual complaint processing that prevents the identification of root causes and the creation of solutions.

"In rating and accrediting the nation's health plans, the National Committee for Quality Assurance (NCQA) carefully looks for evidence of fair and prompt resolution of complaints and appeals from health plan members," said Jay Sherry, Vice President of BPM Markets for Pegasystems. "NCQA standards require clear communications from health plans about reasons for denying medical treatments or services and about the process for appealing plans' denials. In addition, many states' insurance regulatory agencies include complaint-management scores in their annual health plan report cards.

"For healthcare payers, efficient management of complaints and appeals from members and providers poses a major administrative challenge. Appeals and Grievance Manager can help healthcare payers ensure compliance and productivity, in turn improving employer and member satisfaction, which leads to sustained growth."

The product is available immediately.

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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