Pega Claims Automation for Healthcare

Reduce costs while improving accuracy and customer satisfaction with
Pega Claims Automation for Healthcare


Boost first pass rates, reduce manual touch, and drive down costs with more agile automated claims processing. Pega’s pre-built edits and customized rules yield unprecedented levels of efficiency.


Empower your claims examiners to work more accurately and efficiently. Inventory management and skills-based routing send the right claims information to the right examiner to manage backlog.


Deliver on your promises to customers, partners, and regulators with automated SLA management. Configure complex benefits and reimbursement rules to service what you sell and reduce late processing.
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.
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.
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.
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

Best-practice rules and processes automatically check, correct, and translate common claims errors.
Included best-practice workflows, interfaces, rules, data models and more jumpstart implementation.
Built-in Claim Loader Accepts 837 Formats.
Custom, role-based views of data and automated guidance ensure examiners follow best practices.
A visual management dashboard, ad-hoc and operational reports provide real-time claims status insight.
Configure processing “outside the box” of legacy systems to rapidly implement products and benefits.
Dynamic inventory management enables you to direct claims to the most efficient and effective outcomes.
Document and track claims activities to ensure consistent, accurate, and timely response to members and providers.
ECM Taxonomy Terms: 
Claims Automation
Claims Automation
Industry Level Only