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Case Study

Elevance Health transforms claims operations with Pega AI

  • Created a single, unified view of claims processing across the organization
  • Handles 40 million claims monthly
  • Skills-based routing gets the right work to the right people

“With automated adjudication through the digital clinic examiner and integration with various tools, CIW has truly brought a transformational experience to our associates.”

The Business Issue

Elevance Health is on a mission to improve the health of humanity and become a trusted lifetime health partner for its members. Traditionally focused on selling health benefit plans, Elevance Health now has almost 100,000 associates serving 118 million members at every stage of health.

Part of delivering the right member experience includes processing claims in a timely manner. Yet with close to 5,000 claim examiners handling approximately 40 million claims monthly, the immense volume of claims has exposed inefficiencies in the process. Claims examiners needed to navigate through multiple legacy systems and green screens to access relevant information, resulting in high training times and suboptimal customer experiences. Elevance knew that it needed to reimagine the claims examiner experience to create an industry-leading customer experience.

The Solution

The company had a vision to empower its associates with a digital tool that would integrate the latest technologies and provide access to all relevant data in one place. Elevance Health used Pega to create a unified, end-to-end claims processing platform, named Claim Intake Workflow (CIW), that would eliminate manual processes and streamline claim examiner workflows.

Leveraging Pega Smart Claims Engine™, CIW brought together all required functionalities in a single user-friendly interface, eliminating the need for context switching between disparate systems. Claim examiners can now access member benefits, provider information, and claim lines seamlessly. With end-to-end claims processing and smart assistance driven by Pega AI, the platform reduced manual validation tasks, streamlining and simplifying the claims process while reducing processing times and improving accuracy.

Smart Claims Engine integrates seamlessly with Elevance Health's existing systems, providing real-time insights, analytics, and guided resolutions for claims examiners. Through intelligent automation, the engine automates manual tasks, ensuring swift, accurate claim adjudication and reducing the need for associates to swivel between multiple systems.

The Results

With CIW, Elevance Health has achieved greater efficiency, accuracy, and user satisfaction, elevating the customer experience to new heights. The streamlined claims processing has resulted in faster reimbursement and improved customer satisfaction. With fewer errors and timely payments, Elevance Health has strengthened its relationships with healthcare providers and members alike, solidifying its position as a trusted health partner.

In addition, AI-driven forecasting and simulations have revolutionized decision-making at Elevance Health. The Smart Claims Engine predicts claim processing times, allowing workforce managers to make data-driven decisions on resource allocation and process optimization. Simulations help identify the impact of different scenarios, enabling the company to prioritize claims strategically and meet service level agreements more effectively. 

With Pega Smart Claims Engine, Elevance Health has achieved: 

  • A single, unified user interface across multiple legacy platforms
  • Skills-based routing that gets the right work to the right people
  • Real-time automation that aligns the enterprise to business outcomes
  • Reduced training time, allowing associates to focus on the moments that matter
  • Improved accuracy and speed to resolution
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Industry: Healthcare Product Area: Platform Solution Area: Operational Excellence
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