Pelica provides an AI operating system for value-based care organizations, using specialized AI agents to close quality gaps, manage risk adjustment, and coordinate care workflows. The platform ingests live data from claims, EHR, pharmacy, labs, and ADT feeds into a canonical record, then deploys role-specific copilots that cite evidence for every recommendation. Pelica currently serves over 350,000 members and can go live in as little as two weeks.
Funding
Funding not disclosed
Founders
Product
Problem
Value-based care organizations such as IPAs, ACOs, and health plans struggle with fragmented data across claims, EHR, pharmacy, and lab systems, forcing care teams into manual follow-up and coordination. This fragmentation leads to missed quality gaps, incomplete HCC capture, duplicate outreach, and avoidable utilization, all while regulatory complexity like V28 and ECDS increases the data volume teams must process.
Solution
Pelica provides an AI operating system for quality, risk, and care operations, unifying live data from claims, EHR, pharmacy, labs, ADT, telephony, and payer feeds into a single canonical record. The platform deploys a workforce of specialized AI copilots—one per role—that automate gap closure, HCC capture, PDC adherence, provider coordination, and care management workflows. Each recommendation cites its evidence and includes trumping logic, RADV-defensibility, and submission-window awareness built in. Teams can query the system in plain English through an AI Data Analyst, replacing the BI ticket queue, and the platform projects financial lift and Stars glide-paths in real time.
Target Audience
Primary customers are health plans, IPAs and MSOs with delegated risk, ACOs (MSSP, REACH, CINs), and medical groups that need to close care gaps and manage risk adjustment across large member populations.
Features
- Real-time HCC capture with RADV-defensible chain-of-custody and trumping logic applied automatically
- Unified quality gap closure across every payer with Stars glide-path forecasting and post-hybrid HEDIS support
- Pharmacy & Part D copilot that lifts PDC on the three triple-weighted measures (diabetes, RAS, statins)
- ADT-driven care management worklists for transitions of care with 5-day follow-up tracking and duplicate-call prevention
- Provider Network copilot that auto-generates practice agendas, cutting meeting prep from 90 minutes to 15
- Plain-English AI Data Analyst that converts natural language questions into SQL against the canonical record
- Tenant-isolated, BAA-covered architecture with encryption in transit and at rest, HIPAA-compliant and SOC 2 Type II certified
- Built for ECDS volumes, handling 35-75x the supplemental data of hybrid sampling