Building a Claims processing solution on Pega Smart Claims Engine

Client: A global health services organization, with insurance subsidiaries that are major providers of dental, medical, Medicaid and Medicare plans. The organization provides health insurance plans to individuals, and through governmental and non-governmental organizations, unions and other associations

Business Problem: With the drastic and continuous changes to Healthcare in the US, antiquated claims adjudication systems in place are not able to meet the needs of today’s Healthcare Payers. In addition, a main concern in new claims systems is flexibility and configurability, it is imperative that if an issue is identified with business rules, claim edits or other processes, that the issue can be resolved without substantial time and effort. Configurability be business users without the need for dedicated IT staff is of the utmost importance.

Serendebyte Solution: Serendebyte played a key role in the definition and delivery of the Pega Smart Claims Engine, including in soliciting requirements, user story creation and grooming, sizing initiatives and leading Pega DCO sessions. With focus specifically on identifying processes and system elements that could be created in a way that would make them configurable so that future needs could be addressed. This required a delicate balance of user configurability and a strong system framework to ensure that though specialized users are able to make changes, these changes would not be able to negatively impact system performance or cause major exceptions that would cause claims to be incorrectly adjudicated.