Manage Pre- and Post-Adjudication Issues with New-Found Agility

For today's healthcare payer, the relentless pace of change has made claims processing an expensive, complex, and resource-intensive process. These changes come from everywhere: The requirements of consumer-driven health plans, new federal and state mandates, and increasingly complex payer-provider risk-sharing agreements. All are pushing traditional claims-adjudication systems — and payers' IT budgets — to their limits. With the rules continually changing, payers require an automation solution that can repair select conditions which would otherwise lead to pended claims and require costly manual intervention.

Pegasystems' Claims Repair™ is a solution framework that combines payer-specific business rules with claims processing best-practice templates — from pre-adjudication through post-adjudication. Its SmartBPM® platform enables the inevitable changes quickly. With this increased level of agility, payers can improve their first-pass rates, eliminate claims backlog, and dramatically reduce operational and IT expenses. Productivity soars. Compliance improves.

Claims Repair Key Features

• Automated claims repair, from pre-adjudication through post-adjudication
  • Applies best-practice rules and processes to check, correct, and translate common claims errors involving pre- and post-adjudication edits. These include member eligibility, time filing, duplicate claims, and specific deferral codes.
  • Interfaces with core processing systems and databases to extract required data such as provider, referral, and claims history
  • Accepts 837 format through an internalized claims loader
• Real-time process change and robust reporting, analytics, and monitoring
  • Provides a 100% Java- and XML-based platform
  • Uses familiar Microsoft Visio diagrams for quick and easy deployment of claims policies and practices
  • Graphically measures the productivity and historical performance of critical claim processes through monitoring dashboards
• Integrated rules and BPM platform
  • Applies the right business rules at the right time — all based on healthcare-specific factors such as employer group, provider group, mandated turnaround times, member-specific needs, and more
  • Integrates with and augments core processing systems or other software applications, without duplicating functionality
  • Offers HTML integration forms for one-click integration
• Reduced operational costs and improved member/provider satisfaction through increased first-pass claims resolution
  • Reduces dependency on external clearinghouses and eliminates the need for operator intervention
  • Lowers the rate of errors and provides increased consistency through higher levels of automation
  • Enables immediate, actionable decisions for mission-critical processes — improving efficiency and shortening cycle time
• Maximized value of existing technical infrastructure
  • Provides greater control over the claims process, eliminating the need to rely on outside vendors for changes
  • Speeds product implementation for rapid ROI
  • Enables innovative benefit designs that expand product offering and increase competitive advantage

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