Change Healthcare and Pegasystems Connect Claims Payment Systems

Aug 1, 2017, 1:00 AM
NASHVILLE, Tenn.--(BUSINESS WIRE)--Change Healthcare today announced that ClaimsXten™ and ClaimsXten™ Select now interoperate with Pegasystems Claims Processing, helping payers ensure fast, accurate payment in compliance with internal and CMS medical policies and guidelines—all without altering their familiar Pegasystems workflows.

“We continue to invest in interoperability strategies that make it easier for health plans to connect disparate systems to streamline processes, automate accurate payment, and reduce costs,” said Amy Larsson, Vice President, Clinical Claims Management, Change Healthcare. “This integration gives Pegasystems’ customers a seamless growth path for taming the complexity of medical and regulatory policy management as well as scaling mixed payment models to improve operational levels. Now they can take advantage of the same claims editing technology and administrative savings realized by seven out of the top ten payers.”

Paying claims in accordance with frequently updated CMS medical policies and guidelines and supporting a complex mix of alternative payment models are increasing challenges for health plans. By connecting ClaimsXten technology to their Pegasystems platform, payers gain timely, consistent, and more accurate reimbursement of claims through ClaimsXten’s clinically sourced content and claims auditing capabilities.

Health plans can then auto-adjudicate most claims in real time, knowing payment is aligned with their internal medical policies, regulatory medical policies, Medicare, and Medicaid through continuous monitoring and updates by Change Healthcare. Claims edits and policy updates once performed manually become highly automated, providing significant administrative cost savings. And from the user perspective, nothing about their daily Pegasystems workflow changes. Users continue to process claims as before, while ClaimsXten quickly and seamlessly processes each claim according to the plan’s specific terms and conditions.

For large health plans, ClaimsXten is an enterprise-class solution that automates payment and medical policy and helps simplify management of increasingly complex clinical and reimbursement rules for value-based reimbursement models, with extensive customization abilities and services. ClaimsXten Select adapts ClaimsXten’s essentials for the unique needs of small to midsize health plans. ClaimsXten Select is available both as SaaS (Software as a Service) or as an on-premise offering.

“We’re excited to bring our customers a unified solution that helps them increase operational efficiency and payment accuracy,” says Susan Taylor, Business Line Leader, Healthcare and Life Sciences, Pegasystems. “In today’s healthcare environment, it’s crucial that we help our customers eliminate information silos so they can deliver better service and better care while reducing costs. Connecting Pegasystems and ClaimsXten increases the value of both companies’ solutions for our mutual health plan customers and allows Pega products like our smart claims engine to address context-driven processing for the 21st century.”

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