End to end transformation
End-to-end claims adjudication
Various implementation scenarios exploit the deliberate modularity of Pega Smart Claims Engine™ for Healthcare, but Smart Claims Engine can also be used to adjudicate claims from intake to finalization.
Modularity is also valuable when Smart Claims Engine is used for the full adjudication cycle. You may choose to approach a full digital transformation by implementing one piece of functionality at a time. Doing so avoids, or breaks down into manageable segments, the “rip and replace” scenario that can overwhelm those who face the replacement of legacy systems.
Mid-adjudication processing
In addition to the pre-adjudication and post-adjudication scenarios, you can add mid-adjudication, which includes the determination and application of benefits (and benefit limits), authorizations, Coordination of Benefits (COB) or Medicaid reclamation processing, and application of pricing. This functionality completes the full cycle of claims adjudication, from intake to finalization.
Summary
The cost savings, business agility, flexibility, and digital transformation capabilities supported by Smart Claims Engine make it an ideal solution for health plans as they contend with the evolution of claims processing solutions. Smart Claims Engine positions healthcare payers for transformation now and in the future.
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