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Pega Smart Claims Management for Healthcare

"Since going live with Pega's smart claims engine functionality last year, we've had a number of solid wins. We have created a powerful modernized foundation and ... we have started to radically re-engineer claims processing; and have a path and a plan to achieve end-to-end claims automation that is real, today."

Get to know Pega Smart Claims Management

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.

Pega Smart Claims Engine for Healthcare

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.

healthcare claims management

Improve productivity with
built-in processor training

Pega Smart Claims Engine 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.

Pega Smart Claims Engine for Healthcare

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.

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