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Healthcare capabilities

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This section provides an overview of Pega Customer Service for Healthcare and shows the application stack.

Pega Customer Service for Healthcare

Pega Customer Service for Healthcare helps reduce service costs and improve customer satisfaction through a process-driven approach that resolves customer issues with context, immediacy, and relevance at the initial point-of-contact.

Pega Customer Service for Healthcare automates common service requests through intent-driven processing and anticipates customer and operator needs so that customer service representatives (CSRs) have the necessary tools to deliver a personalized and responsive service. The application delivers new value from healthcare organizations’ back-end data and processing silos, provides agility to meet changing business requirements, and facilitates compliance with internal and external regulations.

Pega Customer Service for Healthcare is purpose-built for the following types of contact centers:

  • Member Services

    Enables healthcare organizations to service health plan members. They can access case types to update contact and member information, find a provider or update the member PCP, view member benefits, and record member information for use in coordination of benefits.

  • Provider Services

    Enables healthcare organizations to service medical providers, such as physicians, practice staff, and healthcare system personnel. They can access case types to update practitioner information and hospital admittance privileges, handle authorization requests and denials, and answer claims questions.

  • Patient Services

    Enables healthcare organizations with capabilities for patient care and engagement. They can access case types to schedule and manage medical appointments, remind patients of their medical appointments, and assist patients who are having difficulty with their medical expenses.

When you create your application by running the New Application wizard, you have the option to select one or more of three bundles based on your implementation of contact centers. You select the bundle that matches the contact center type for which you are implementing Pega Customer for Healthcare. Based on your selection, you can access different case types, display different composites, and have different default access groups. After you run the New Application wizard and select Patient Services, for example, you get operators based on the default access group that is related to Patient Services.

Pega Customer Service for Healthcare application stack

Pega Customer Service for Healthcare is built on the Pega Customer Service and Pega Foundation for Healthcare applications.

The Pega Customer Service for Healthcare media includes Pega Sales Automation for Healthcare because the two applications are designed to complement each other through the use of common case types and a unified data model. Each application requires a separate license.

Pega Care Management is built on Pega Customer Service for Healthcare but is not included in the media, and also requires a separate license. For more information about the capabilities that are available by implementing the two applications together, see the Pega Care Management product page.

All Pega healthcare applications are built on Pega Foundation for Healthcare, which contains the healthcare data model.

Pega Customer Service Relationship Management for Healthcare application stack
Application stack diagram that shows the application layers for the applications in
            the Healthcare suite
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