Change Healthcare and Pegasystems Connect Claims Payment Systems

09:00 EDT 1 Aug 2017 | Businesswire
Change Healthcare

Interoperability between ClaimsXten and Pegasystems can help payers reduce administrative costs while enhancing payment accuracy

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.”

About Pegasystems

Pegasystems develops strategic applications for marketing, sales, service, and operations. Pega’s applications streamline critical business operations, connect enterprises to their customers seamlessly in real-time across channels, and adapt to meet rapidly changing requirements. Pega’s Global 3000 customers include many of the world’s most sophisticated and successful enterprises. Pega’s applications, available in the cloud or on-premises, are built on its unified Pega® 7 platform, which uses visual tools to easily extend and change applications to meet clients’ strategic business needs. Pega’s clients report that Pega gives them the fastest time to value, extremely rapid deployment, efficient re-use, and global scale. For more information, please visit us at

About Change Healthcare

Change Healthcare is inspiring a better healthcare system. Working alongside our customers and partners, we leverage our software and analytics, network solutions and technology-enabled services to help them improve efficiency, reduce costs, increase cash flow, and more effectively manage complex workflows. Together, we are accelerating the journey toward improved lives and healthier communities. Learn more at

Change Healthcare
John Hallock, 617-615-7712
External Communications & Media Relations


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