Virtusa Smart Claims Management

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

• 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