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Virtusa Smart Claims Management - Unleash productivity with intelligent claims processing

Simplify and automate claims processing to achieve performance improvement with Pega Smart Claims Management

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Pega Smart Claims Management (SCM) is a platform that can unlock potential to reduce operational costs, improve employee experience, and meet expectations for innovation without the cost of a core system replacement. With Pega SCM, your organization benefits from enhanced straight-through processing, less fallout, enhanced transparency, and visibility combined with business flexibility and agility.

Engage with Virtusa's expert resources, who have worked with Pega to develop Pega Smart Claims critical capabilities. Leverage our robust transformation template to modernize claims using Pega SCM. Built on the leading Pega platform, you can amp up the return using ready-to-deploy accelerators such as bots and data migration utilities.

  • 100% complementary offerings with Pega SCM accelerators
  • 6+ years of SCM product engineering capabilities
  • 250+ person-years with Pega HC claims experience
  • Multiple claims SCM design patterns to lead the customer to the right fit

Key Features

  • Claims intake process:
    • Detect errors and auto-correction of missing information with smart intake
    • Streamline the communication between clearing house and payer organization
    • Remain compliant - accept only claims you need to process into your adjudication
  • 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 fully orchestrated process to automate and address the complexity of modern claims operations
    • Transparency to ensure compliance with SLAs
    • Realize real-time integration to eliminate delays within the adjudication processes
  • Post-adjudication process:
    • Minimize regulation and compliance issues with improved claims denial process
    • Reduce billing/coding error correction by eliminating manual processes
  • Claims finalization:
    • Identify possible FWA (Fraud, Waste, and Abuse)
    • Meet DOFR (Division of Financial Responsibility) requirements with business rules and finalize payment with process orchestration
    • Automate outgoing correspondence by sending the final claim decision to the initiator


Virtusa Pega Smart Claims Management Brochure

Virtusa Pega Smart Claims Management Whitepaper

Other Offerings

Virtusa Care Cohort Management Solution

Virtusa's Cognitive Pharmacovigilance (PV) Intake

Virtusa's Electronic Patient Informed Consent (e-PIC)

Virtusa's Electronic Sample Collection Schedule (e-SCS)

Virtusa Intelligent Digitization of Appeals & Grievances

Pega Enterprise Modernization powered by Virtusa's Triple R

Virtusa Pega-EPIC EHR Accelerator

Virtusa Provider Lifecycle Management (PLM)

Virtusa Vax Manager

Virtusa vCollect Financial Collections Management

Virtusa vEngage

Virtusa's WisMO (Where is My Order) - A Blockchain Enabled Command Center


Compatible with

Pega Platform, 8.1, 8.2, 8.3, 8.4, 8.5, 8.6

Last updated

June 30, 2022

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