Healthcare Insurance Solutions for a Digital World

Smarter Health Insurance. Stronger Business Outcomes.
RULESWARE

Healthcare insurance operations get more complex every year.

Rulesware reduces the cost and complexity – and elevates your performance with personalized service and digital efficiencies. From automating enrollment and managing unruly claims, simplifying authorizations and superior customer service, to easy appeals, provider management and more, our solutions empower payers to streamline back-end processes while providing a superior customer journey.
Insurance Operations

Streamline the flow of content, reduce costs, and enhance service quality:

Operational Excellence

Processes take minutes instead of days, while Rulesware automation reduces operating and production costs.

Best in Class TCO

Easily maintained solutions with minimal custom development and a proven enablement model means clients are self-sufficient after deployment.

Business Agility

Solutions can easily adapt to changing requirements and support new programs, thanks to features that dynamically add, create, and modify complex business rules.

Higher Customer Lifetime Value

Personalized, relevant communications and offers boost engagement, while faster processes – from enrollment to one and done customer service and claim processing – increase customer loyalty.

"Our milestones could not have been achieved without Rulesware’s significant contributions.”

Health Insurance Client

Healthcare Solutions

Enrollment

Smarter data management improves the precision of your quotes, while automation accelerates enrollment processes across all channels and prevents improper claims payments and denials.

Authorizations

Your business rules are consistently applied to every customer the proper way every time. The decisioning capabilities should reside in the Pega rules logic, not on sticky notes or knowledge management systems that support typical authorization applications. Approve or deny authorizations in minutes, do it consistently and do it right every time, the first time.

Claims Automation

Expedite the automated repair of claims during the pre-adjudication and post-adjudication process while always having clear insight to your claims inventory and management processes. Pega’s natural adaptability helps you continually sync your rules to pay all your claims right the first time – reducing the administrative burden of reprocessing or incorrectly paying claims.

Customer Decision Hub

Expedite the automated repair of claims during the pre-adjudication and post-adjudication process while always having clear insight to your claims inventory and management processes. Pega’s natural adaptability helps you continually sync your rules to pay all your claims right the first time – reducing the administrative burden of reprocessing or incorrectly paying claims.

Customer Service

Pega’s AI-driven engagement engine simplifies operating and regulatory requirements. By automatically selecting the best action to take, Rulesware optimizes the relevance and value of each interaction. The result: seamless customer service across all transactions and channels.

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Success Story

Health insurer that connects the underserved community in NYC responds and absorbs rapid pandemic growth

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