Vendor Buzz: Pegasystems Helps Health Organizations Meet Compliance Demands

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Solutions handle new HIPAA and International Classification of Disease (ICD-10) mandates with ease


Continuing its innovation in healthcare, Pegasystems Inc., (NASDAQ: PEGA), the leader in Business Process Management (BPM) software solutions and a leading provider of customer relationship management (CRM) solutions, today announced several enhancements that address the healthcare industry’s critical business imperatives.

  • · Consistency of electronic healthcare information: New ICD functionality in Pega includes general equivalence mapping (GEM) crosswalk tables for ICD-9 to ICD-10 conversion, plus reverse mapping capabilities for diagnosis and procedure codes. Organizations can use both code sets, critical for historical reporting as well as for on-going refinement.
  • · Increased efficiencies and standardization in healthcare payer and provider patient information: Pega technology gives full support for HIPAA 5010 message standards which impact most payer and providers’ electronic transactions, including claims, claims status and eligibility requests, and authorizations.
  • · Impending government deadlines with healthcare reform: Pega’s HIPAA 5010 solution enhancements are being used by healthcare organizations to conduct internal testing necessary to achieve Level 1 compliance, and will also be used for their external testing with the Centers of Medicare and Medicaid Services when it officially begins in January 2011.

HIPAA 5010 and ICD-10 rulings impact as much as 80 percent of a health plan’s business processes and systems. Healthcare organizations that are able to successfully address reform and improve operational agility can increase member satisfaction, reduce costs and see improved outcomes.

The new product enhancements are further supported with transactional automation and business-friendly decision management to sustain optimal straight-through-processing (STP) of claims and authorizations.

Pegasystems’ solutions are widely used by major healthcare organizations including the three largest US health plans, two of the four largest pharmacy benefit managers, several leading healthcare delivery systems, and US government agencies at the state and federal level.  Healthcare transactions for more than one of every two Americans, including members from over 60 percent of the Blues network, are processed with Pegasystems technology.

Supporting Quotes:

Janice Young, Program Director, IDC Health Insights

“Healthcare payers must view ICD-10 as a strategic disruptor and manage ICD-10 remediation to reassess business and technology strategies and future differentiation models. Viewing ICD-10 as a strategic change agent will position healthcare payers for success in the future business market after the conversion.”

Elizabeth Hart, Principal, Healthcare Solutions, Pegasystems

“Our solutions already provide healthcare companies with efficiencies foreseen by the original HIPAA standardization. In fact, multi-million dollar savings are being achieved annually by payers using our solutions to automate healthcare transactions. The benefits from moving to ICD-10 are expected to be even larger, and our enhanced solutions will help the industry move beyond the first steps of remediation and compliance to true business transformation.”

Supporting Resources:

To see more about Pegaystems’ healthcare solutions, visit: .

To hear a podcast on how Medco, a leading pharmacy benefits manager with the nation’s largest mail-order pharmacy, is achieving operational agility with Pega, visit:

To read a white paper on how Pega enables agility in healthcare, visit:

To read a blog on healthcare reform by CEO Alan Trefler, visit:

About Pegasystems

Pegasystems, the leader in business process management and a leading provider of CRM solutions, helps organizations enhance customer loyalty, generate new business, and improve productivity.  Our patented Build for Change® technology speeds the delivery of critical business solutions by directly capturing business objectives and eliminating manual programming.  Pegasystems enables clients to quickly adapt to changing business conditions in order to outperform the competition.  For more information, please visit us at

RSS Feeds for Pegasystems Press Releases, Pegasystems Media Coverage, Pegasystems Webcasts, and Pegasystems Events

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