Built on Pegasystems’ industry-leading SmartBPM® platform, CMF gives healthcare organizations the flexibility to manage an unlimited number of population groups with high-touch care programs for those with chronic, acute-episodic and acute-complex needs. CMF was designed to ease the burden of managing changes, such as new clinical protocols or government regulations, without interrupting on-going and highly customized care programs.

“Differentiation among payers is shifting to how well they care for members, and many are just not able to meet the growing demands in care management because not only are their processes are broken -- they have inflexible technology,” said Joanne Galimi, Research vice president of Gartner Inc. “Payers need flexible, user-friendly systems that provide workflow and rules-engine capabilities. BPM technology helps automate and manage all the key processes within the care management continuum.”

Key benefits of CMF include:

• 360 degree view of patient – a dynamic patient record that provides real-time information across pertinent care plans and data sources including demographic, clinical, claims, authorizations, correspondences and notes;
• Visual timeline for care management – gives care managers at-a-glance view of progress and status, displaying all scheduled patient care management events including phone calls, assessments, outgoing correspondence, materials, and processing steps across all active care plans;
• Automated care plans – guides and automates the creation and customization of care plans;

• Intelligent alerts – searches through relevant data sources and systems to see if warnings are needed and determines whether necessary conditions have been met (lab values, weight targets, and treatment adherence). It automatically triggers next-steps, sending tasks, correspondence, literature or notifications to all parties;
• Industry standards – comes with pre-configured database support for lab results, medications, and risk assessments; includes typical roles (member, provider, etc) and typical work (claims, authorization and clinical codes including ICD-9, CPT, HCPCS and NDC). Also includes HIPAA x12 EDI support for multiple message including 278 (authorizations) and decision support for straight-through-processing of utilization requests.

“Traditional care management technologies provide clinical content, but do not always help the care team and patients work effectively together,” said Elizabeth Hart, senior director of Healthcare Solutions at Pegasystems. “This adds cost, wastes time, degrades the quality of care, and makes it impossible to offer customized programs. CMF fixes this problem at a time when payers anticipate an ever-increasing influx of aging baby boomers needing care.”

Pegasystems’ CMF solution maximizes the efficiency of care management professionals through its intelligent decisioning and patient-centric workflow. CMF automates high-volume transactions such as pre-authorizations and pre-certifications for healthcare services, allowing skilled staff to focus on higher value-added and personal care management functions. Well-suited for complex cases, CMF drives collaboration through the coordination and sharing of information across communication channels throughout the care management team and the patient’s support network.

Pegasystems’ healthcare solutions are widely-used by major healthcare organizations including three of the top five US health plans and more than 50 percent of the Blues network, representing over 100 million covered lives. To find out more about Pegasystems healthcare offerings visit www.pega.com.

About Pegasystems

Pegasystems (NASDAQ: PEGA), the leader in Business Process Management, provides software to drive revenue growth, productivity and agility for the world's most sophisticated organizations. Customers use our award-winning SmartBPM^® suite to improve customer service, reach new markets and boost operational effectiveness.

Our patented SmartBPM technology makes enterprise applications easy to build and change by directly capturing business objectives and eliminating manual programming. SmartBPM unifies business rules and processes into composite applications that leverage existing systems -- empowering businesspeople and IT staff to Build for Change^®, deliver value quickly and outperform their competitors.

Pegasystems’ suite is complemented by best-practice frameworks designed for leaders in financial services, insurance, healthcare, government, life sciences, communications, manufacturing and other industries.

Headquartered in Cambridge, MA, Pegasystems has offices in North America, Europe and Asia. Visit us at www.pega.com.

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