Under pressure from competitors, consumers, and government, healthcare payers and providers are striving to remake themselves into more efficient and agile organizations. Some of the most successful organizations are using Pegasystems healthcare software to power their transformation.


CRM Evolved

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The Total Economic Impact of the Pega 7 Platform

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Healthcare Software from Pegasystems: Driving Performance, Efficiency, and Agility

Pega’s agile, intelligent Better Business Software™ systems that streamline and automate business processes and customer service functions. Organizations that use Pega software improve operational performance, reduce costs, deliver outstanding customer service and enhance their ability to adapt quickly to changes in the marketplace.

For healthcare organizations, Pega offers pre-built healthcare software solution frameworks that leverage Pega’s industry-leading BPM and CRM technology. These healthcare management solutions provide healthcare-appropriate data models, rules, workflows, and interfaces that give you a head start on creating applications for your organization’s specific business processes and objectives.

Pega healthcare solutions frameworks are available for a range of healthcare process areas, including sales and enrollment, marketing and retention, customer service, care management, and claims processing. With any of these healthcare software solutions, our innovative Build for Change® technology empowers business users to design and create new or updated applications without having to do any coding or scripting.

Pega Healthcare Software in Action: Automating Claims Processing

Claims processing automation is a good example of Pega healthcare software systems in action. For healthcare claims processing, Pega offers two solution frameworks:

  • The Pega Claims Repair Solution checks and corrects errors in claims in order to boost first-pass rates and decrease the number of claims requiring manual examination. This healthcare software solution applies HIPAA-based best practices and easily integrates with your existing claims adjudication system.
  • For claims that require manual intervention, Pega Claims Workstation automates claims routing and queueing and provides a complete view of each claim, integrating all relevant data from back-end systems. This Pega healthcare management system increases processor productivity and shortens cycle times. The system can easily be customized by claims managers to encapsulate organization-specific rules, policies, and objectives.


Progressive healthcare organizations have used these Pega healthcare software solutions to achieve measurable improvements in service delivery, performance, efficiency, and agility. For example:

  • A regional BCBS used Pega to increase its claims first-pass rate by 4.5 points and gain a more than 300% ROI in the first year of deployment.
  • A multi-state Medicaid plan boosted their first-pass rate by 3.4 points during the first year of Pega implementation despite sharp growth in their business and their claims volume.
  • A small BCBS was able to implement 45 health reform-related changes in their Pega-based claims automation system in just a week.


Pega healthcare management technology such as our claims automation solutions are available for on-premise deployment or as SaaS solutions in the Pega Cloud.

Learn more about healthcare software solutions from Pegasystems.