Health Alliance Plan

Case Study

Health Alliance Plan gives itself a health boost

  • 13% increase in timeliness

  • 33% increase in accuracy

  • 66% increase in productivity

"In an era of consumer-driven healthcare, having an effective appeals and grievance management system and processes can provide any health plan a competitive edge."

The Business Issue

Like other health plans, Health Alliance Plan (HAP) faced the challenge of a highly manual appeals and grievances process that was extremely labor-intensive and time-consuming. With the pressure to meet state and federal regulations and ever-evolving mandates, it was essential for the plan provider to accurately track appeals and grievances and ensure a low error rate.

The Solution

Pega helped HAP streamline its entire appeals and grievance lifecycle –from origination to resolution. The solution is based on a configurable process automation framework that streamlines the inflow of all appeals and grievances from multiple sources: Web, email, fax, walk-ins, etc. Pega’s smart rules engine, which prioritizes transactions based on case urgency, enables skill-based routing, resulting in faster assignment of cases.

The Results

“Our success was almost immediate,” says Garima Aggarwal, director of customer experience at HAP. When the insurer tracked productivity, timeliness, and accuracy, it discovered it had exceeded all of its metrics.

HAP doubled its productivity because of process standardization. Pega’s insights and guidance, based on its 360-degree view and simple and clear process, enabled the plan provider to improve service for members and providers alike.

Related Resources

  • Birgit König shares Allianz’s journey to change customer expectations and drive innovation.

  • See how Pega Customer Service for Healthcare delivers a unified platform for personalizing interactions.

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  • Industry: Healthcare
  • Product Area: Customer Service
  • Challenge: Customer Service