Pelica Health
Pelica Health provides an AI operating system for value-based care organizations, unifying fragmented claims, EHR, pharmacy, and lab data into a single canonical record. The platform deploys role-specific AI copilots for risk adjustment, quality, pharmacy, provider network, and care management that automatically identify gaps and generate evidence-cited recommendations. The system includes an AI Data Analyst that answers plain-English questions, replacing traditional BI ticket queues.
- Healthcare Technology
- AI Agents
- Artificial Intelligence
- Digital Health
- Insurance Technology
- Software Only
- Data & Analytics
Funding
Raised to date
$500KRaised to date based on public sources. This may differ from the amount the company actually raised and is based only on what is publicly available on the internet.
Founders
Founder details are not available yet.
Product
Problem
Value-based care organizations face fragmented data across claims, EHRs, pharmacy, labs, and payer feeds, forcing care teams into manual coordination to close quality gaps, capture risk-adjustment diagnoses, and manage care transitions. This manual work limits the number of members a team can effectively manage and often results in missed revenue opportunities and avoidable utilization.
Solution
Pelica provides an AI operating system for quality, risk, and care operations that unifies live data from multiple sources into a single canonical record. The platform deploys a workforce of role-specific AI copilots—covering risk adjustment, quality and Stars, pharmacy, provider network, and care management—that automatically identify gaps, generate evidence-cited recommendations, and coordinate workflows across teams. Every recommendation cites its source evidence, with trumping logic, RADV-defensibility, and submission-window awareness built in. The system also includes an AI Data Analyst that answers plain-English questions, replacing the traditional BI ticket queue. The platform includes an action layer with outbound voice (TCPA-compliant, multilingual), EMR overlays (Epic SMART-on-FHIR, Athena marketplace), and a provider and staff portal.
Target Audience
Primary customers are health plans (MA, dual-SNP, regional Blues), IPAs and MSOs with delegated risk, ACOs (MSSP, REACH, CINs), and medical groups (primary care, multi-specialty, DSOs) operating under value-based care contracts.
Features
- Live data ingestion across claims (MMR, MAO-004, MOR, 277CA), EHR (FHIR/HL7), pharmacy (PDE), labs, ADT, telephony recordings, and payer SFTP drops, built for ECDS volumes 35-75x the supplemental data of hybrid sampling
- Risk Adjustment Copilot delivering real-time HCC capture with trumping logic and RADV-defensible chain-of-custody documentation
- Quality & Stars Copilot providing unified gap closure across every payer with glide-path forecasting and year-round post-hybrid HEDIS tracking
- Pharmacy & Part D Copilot lifting PDC on the three triple-weighted measures (diabetes, RAS, statins)
- Provider Network Copilot with EMR overlay that auto-generates practice agendas, reducing meeting prep from 90 minutes to 15 minutes
- Care Management Copilot with ADT-driven transition-of-care worklists and 5-day follow-up tracking to prevent duplicate outreach
- AI Data Analyst that converts plain-English questions into SQL queries against the canonical record, with V28-aware logic and trumping rules
- Tenant-isolated, BAA-covered architecture with encryption in transit and at rest, HIPAA compliance, and SOC 2 Type I & II certification