Pega Marketplace
Virtusa Smart Claims Management
Pega Smart Claims Engine: Unleash productivity with intelligent claims processing
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Overview
Virtusa offers end-to-end claims transformation services to help payers achieve competitive differentiation from reduced claim-cycle times to the total cost of ownership. We help customers leverage Pega SCE solutions to transform core claims processes and address the following:
Claims intake process:
- Detect errors and auto-correction of missing information with the smart intake process
- Streamline the communication between the clearinghouse and the payer organization
Pre-adjudication process:
- Address incorrect or missing member, provider, and plan information with an automated process
- Minimize queries, appeals, or missing required documentation with the auto-adjudication process
Adjudication process:
- Deliver a fully orchestrated process to minimize communication gaps and inaccuracies
- Realize real-time integration to auto-adjudication processes
Post-adjudication process:
- Minimize regulation and compliance issues with an improved claims denial process
- Reduce billing/coding error correction by eliminating manual processes
Claims finalization:
- Identify possible FWA (Fraud, Waste, and Abuse) with AI capabilities
- DOFRize (Division of Financial Responsibility) with business rules and finalize payment with process orchestration
- Automate outgoing correspondence by sending final claim decision to the initiator
Key Features
- Detect errors and auto-correction of missing information with the smart intake process
- Streamline the communication between the clearinghouse and the payer organization
- Address incorrect or missing member, provider, and plan information with an automated process
- Realize real-time integration to auto-adjudication processes
- Identify possible FWA (Fraud, Waste, and Abuse) with AI capabilities
- Reduce billing/coding error correction by eliminating manual processes
Resources
Partner Name
Virtusa
Tags
- Pega Products: Pega Smart Claims Engine for Healthcare
- Industry: Healthcare
- Product Capability: Case Management Cloud Services Decision Management Enterprise Application Development Low-Code App Development Mobile Next Best Action Reporting Security System Administration User Experience
- Pega Version compatibility: Pega Platform 8.1 8.2 8.3 8.4 8.5 8.6 8.7 8.8
- Geography: Americas
Offering Type
Packaged Service Offering