Pega Smart Claims Engine

Pega’s Smart Claims Engine™ for Healthcare is an application designed to facilitate the adjudication of healthcare claims. You can leverage or edit the out of the box orchestration layers or easily build custom orchestration layers to implement specific features as part of your claims processing lifecycle.

This flexibility in orchestration allows you to manage complexity, create transparency, and increase auto-adjudication rates.

Smart Claims Engine is also packaged with an intuitive, modern user interface and workflow tools to manage claims with issues that require manual resolution. Smart Claims Engine delivers highly automated consumer-centric transactional functionality for health plans.

Pega Smart Claims Engine for Healthcare processes both institutional and professional medical claims, as well as dental claims and dental predeterminations. Smart Claims Engine also supports adjustments, splitting of claims and claim lines, routing for suspended claims, claim status updates, claim balancing, and application of surcharges for all claim types.

Smart Claims Engine is designed to integrate seamlessly within a healthcare payer’s technology and existing application environment. This functionality is supported by:

• Standards-based integrations that unite Pega processes with enterprise systems to maximize existing investments and reduce data inconsistencies and replication.
• Stand-alone, modular, or cloud implementations that provide the flexibility to fit an implementation within an organization’s technology infrastructure.
• Rules-driven controls define how each processing step is managed.

Smart Claims Engine provides a rich set of features which are designed to enhance your experience, improve your productivity and increase your satisfaction.

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