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Pega Claims Automation for Healthcare

"We are able to change much more quickly in Pega. Right now, to write a modification to a rule takes just 5 hours to code, document and user test that change in Pega."
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Get to know Pega Claims Automation for Healthcare

Claims Automation for Healthcare 1

Eliminate gaps with
targeted claims processing

With Pega’s robust business rules capability and healthcare claims models, you can easily configure claims processing business rules that legacy systems can’t support, including pre- and post-adjudication rules, to improve auto-adjudication rates.

Claims Automation for Healthcare 2

Manage change with
configurable workflows

Respond quickly to changes in government regulations and the needs of your business with Pega’s configurable workflows. With familiar, business-friendly modeling tools, users can easily implement optimum claims processing workflows or customize pre-defined components.

Improve productivity with
built-in processor training

Pega Claims Automation for Healthcare intelligently guides your processors through pend investigation to the correct resolution. With Pega, you can pinpoint the areas to adjust on a claim line and bring the right information at the right time, guiding users to clear complex claim pends more efficiently.

Claims Automation for Healthcare 4

Satisfy customers with
improved claims processing

Deliver a more satisfying experience for providers, consumers, and employees. Skill-based routing enables organizations to focus improvements on the benefits, claims, and episodes of care that need highest levels of attention.

Claims Automation for Healthcare 5

Adapt and comply with
on premise or on cloud

With Pega, you can develop a claims processing capability that reflects your business while supporting HIPAA compliance. Choose traditional on-premise deployments or Pega’s cloud platform, which features a turnkey service providing immediate access to create, test, deploy, and manage applications.

Additional Product Features

Built-in Rules Bring OOTB Benefits

Best-practice rules and processes automatically check, correct, and translate common claims errors.

Rapid Implementation Boosts ROI

Included best-practice workflows, interfaces, rules, data models and more jumpstart implementation.

Purpose-Built for Healthcare Claims

Built-in Claim Loader Accepts 837 Formats.

Enable Best Practices Across Your Team

Custom, role-based views of data and automated guidance ensure examiners follow best practices.

Reporting Provides Actionable Insights

A visual management dashboard, ad-hoc and operational reports provide real-time claims status insight.

Speed Time to Market for New Products

Configure processing “outside the box” of legacy systems to rapidly implement products and benefits.

Respond to Changes in Performance

Dynamic inventory management enables you to direct claims to the most efficient and effective outcomes.

Deliver Consistent Service Experiences

Document and track claims activities to ensure consistent, accurate, and timely response to members and providers.

Related Resources

UnitedHealth/Optum: Operational Wedded Bliss PW17 Highlight

Watch highlights from the breakout session where Peg Conniff and John Silva discuss the marrying power of Robotic Automation and BPM Automation to achieve $40M in claims operations saving annually.

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Case Study

Automation Streamlines BPO Claims Processing

Learn how this BPO has accelerated provisioning of new edits, and provided enhanced visibility and audit capabilities.

See how Pega can help your business

Talk to an expert and see how Pega can transform your customer experiences with next-generation software applications and solutions.