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New Healthcare Framework Releases

Suggest edit Updated on September 10, 2021

Pegasystems announced the general availability of three new healthcare frameworks releases in April, 2007. This completes major claims related upgrade work especially in the area processing capabilities for EDI X12 837 claims formats. All the frameworks are released on PRPC 5.1 SP2.

Highlights of Healthcare Payer Industry Framework v 6.1

  1. Foundation for all other healthcare framework offerings
  2. Extensive healthcare object model
  3. HIPAA EDI X12 Message support
  4. Complete maps for healthcare claim (X12 837) format intake and output (Professional as well as Institutional Claims)
  5. Sample Solution Layer for Authorization (Referrals) Management
  6. Sample Solution Layer for New Member Enrollment
  7. Sample organizational model (org structure, access groups, users)
  8. Common object starter kit (sample data, search & display functions)

Highlights of Claims Repair v 6.1

  1. Fully integrated with Healthcare Payer Framework v 6. 1
  2. Fully integrated with Claims Workstation + Framework v 6.1 to manage entire life-cycle of claim (BRE + BPM)
  3. X12 837 claim message straight-through processing (X12 claim intake - work object creation - repair edits - X12 claim output)
  4. XML claim message straight-through processing (XML claim intake - work object creation - repair edits - XML claim output)
  5. Library of pre-configured claims repair edits (pre-adjudication mode as well as pended claim mode)
  6. Modular claim repair edit design (individual flows and sub-flows) for better visibility and customization
  7. Improved sample claims data maintenance model for demo / POC purposes (no need to mess with database scripts / tables)
  8. Extensive documentation of the features and customization options in the Implementation Guide
Highlights of Claims Workstation+ v 6.1
  1. Fully integrated with Healthcare Payer Framework v 6. 1
  2. Fully integrated with Claims Repair Framework v 6.1 to manage entire life-cycle of claim (BRE + BPM)
  3. Intelligent claim inventory skill-based routing, urgency escalation, and service level compliance
  4. Comprehensive claims desktop with claim image integration
  5. Management efficiencies for real-time claim inventory monitoring and re-distribution
  6. Management efficiencies for work force monitoring (operator skill and profile maintenance, operator performance statistics)
  7. Claim Processor efficiencies preventing cherry-picking of work
  8. Pre-configured Claims Reports
  9. Improved sample claims data maintenance model for demo / POC purposes (no need to mess with database scripts / tables)
  10. Extensive documentation of the features and customization options in the Implementation Guide
For more information or to schedule a consultation to discuss the applicability of this release update for your organization, please contact Salil Shinde, Pegasystems Product Manager, Healthcare.
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