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Case Study


ELEVANCE HEALTH TRANSFORMS CLAIMS OPERATIONS WITH PEGA AI

 * Created a single, unified view of claims processing across the organization

 * Handles 40 million claims monthly

 * Skills-based routing gets the right work to the right people

> “With automated adjudication through the digital clinic examiner and
> integration with various tools, CIW has truly brought a transformational
> experience to our associates.”
> 
> Ashwini Gupta
> Senior Director of Digital Ops, Elevance Health


THE BUSINESS ISSUE

Elevance Health is on a mission to improve the health of humanity and become a
trusted lifetime health partner for its members. Traditionally focused on
selling health benefit plans, Elevance Health now has almost 100,000 associates
serving 118 million members at every stage of health.

Part of delivering the right member experience includes processing claims in a
timely manner. Yet with close to 5,000 claim examiners handling approximately 40
million claims monthly, the immense volume of claims has exposed inefficiencies
in the process. Claims examiners needed to navigate through multiple legacy
systems and green screens to access relevant information, resulting in high
training times and suboptimal customer experiences. Elevance knew that it needed
to reimagine the claims examiner experience to create an industry-leading
customer experience.


THE SOLUTION

The company had a vision to empower its associates with a digital tool that
would integrate the latest technologies and provide access to all relevant data
in one place. Elevance Health used Pega to create a unified, end-to-end claims
processing platform, named Claim Intake Workflow (CIW), that would eliminate
manual processes and streamline claim examiner workflows.

Leveraging Pega Smart Claims Engine™, CIW brought together all required
functionalities in a single user-friendly interface, eliminating the need for
context switching between disparate systems. Claim examiners can now access
member benefits, provider information, and claim lines seamlessly. With
end-to-end claims processing and smart assistance driven by Pega AI, the
platform reduced manual validation tasks, streamlining and simplifying the
claims process while reducing processing times and improving accuracy.

Smart Claims Engine integrates seamlessly with Elevance Health's existing
systems, providing real-time insights, analytics, and guided resolutions for
claims examiners. Through intelligent automation, the engine automates manual
tasks, ensuring swift, accurate claim adjudication and reducing the need for
associates to swivel between multiple systems.


THE RESULTS

With CIW, Elevance Health has achieved greater efficiency, accuracy, and user
satisfaction, elevating the customer experience to new heights. The streamlined
claims processing has resulted in faster reimbursement and improved customer
satisfaction. With fewer errors and timely payments, Elevance Health has
strengthened its relationships with healthcare providers and members alike,
solidifying its position as a trusted health partner.

In addition, AI-driven forecasting and simulations have revolutionized
decision-making at Elevance Health. The Smart Claims Engine predicts claim
processing times, allowing workforce managers to make data-driven decisions on
resource allocation and process optimization. Simulations help identify the
impact of different scenarios, enabling the company to prioritize claims
strategically and meet service level agreements more effectively. 

With Pega Smart Claims Engine, Elevance Health has achieved: 

 * A single, unified user interface across multiple legacy platforms
 * Skills-based routing that gets the right work to the right people
 * Real-time automation that aligns the enterprise to business outcomes
 * Reduced training time, allowing associates to focus on the moments that
   matter
 * Improved accuracy and speed to resolution

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TAGS

Industry: Healthcare Product Area: Platform Solution Area: Operational
Excellence
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ABOUT PEGASYSTEMS

Pega provides a powerful platform that empowers the world’s leading
organizations to unlock business-transforming outcomes with real-time
optimization. Clients use our enterprise AI decisioning and workflow automation
to solve their most pressing business challenges – from personalizing engagement
to automating service to streamlining operations. Since 1983, we’ve built our
scalable and flexible architecture to help enterprises meet today’s customer
demands while continuously transforming for tomorrow.


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