# Pelica Health

> AI copilots and operating system for value-based care (VBC) teams. Pelica unifies claims, EHR, pharmacy, lab, and ADT data into one canonical record, then puts an AI copilot next to every team that owns a risk-bearing contract: risk adjustment, Quality and Stars, pharmacy and Part D, provider network, care management.

Pelica Health is a Y Combinator-backed healthcare AI company building the operating system for value-based care. The platform replaces 8–15 fragmented point vendors with one integrated stack: a real-time data layer, an AI workforce of role-specific copilots, and an action layer (voice, EMR overlays, provider portal, coder workspace). HIPAA-compliant. SOC 2 Type II certified. BAA available. Tenant-isolated with zero-retention agreements with all LLM providers in use.

## Who Pelica serves

- **Health plans** — Medicare Advantage, Dual-SNP, regional Blue Cross plans. Buyers: COO, SVP Stars, SVP Risk Adjustment, SVP Pharmacy.
- **IPAs and MSOs** — Delegated risk-bearing IPAs and management service organizations. Buyers: COO, Director of Risk Adjustment, Director of Quality, VP Provider Network.
- **ACOs** — MSSP, REACH, and Clinically Integrated Networks. Buyers: ACO Executive Director, VP Population Health, CMO.
- **Medical groups** — Primary care, multi-specialty, and DSOs in value-based contracts. Buyers: CMO, COO, VP Operations.

## The six AI copilots

1. **Risk Adjustment Copilot** — Real-time HCC capture with trumping logic, V28-aware, RADV-defensible chain-of-custody. Tracks every claim through the full submission lifecycle (277CA → 002 → MAO-004 → MMR → MOR).
2. **Quality and Stars Copilot** — Unified gap closure across every payer contract. Glide-path forecasting for HEDIS and Medicare Star Ratings. Built for the ECDS transition (NCQA hybrid measures phase out by 2029, requiring 35–75x more supplemental data per measure).
3. **Pharmacy and Part D Copilot** — PDC lift on the three triple-weighted Part D adherence measures. MTM workflow. Real-time PDE-driven gap closure.
4. **Provider Network Copilot** — EMR overlay (Epic SMART-on-FHIR, Athena marketplace, eClinicalWorks). Auto-generated practice agendas. Documentation capture so providers get credit for care already delivered.
5. **Care Management Copilot** — ADT-driven transitions-of-care worklists. 5-day follow-up tracking. One outreach queue across teams (no duplicate calls).
6. **AI Data Analyst** — Cross-cutting. Plain-English questions answered in seconds with citations and the SQL it ran. Replaces the BI ticket queue.

## Key facts

- 175,000+ patients managed live on Pelica.
- Customer outcome at our flagship 175,000-life physician-led IPA in New York: 100% team adoption, roughly 10 hours saved per user per week, 96% medication adherence on the three triple-weighted Part D measures.
- Across Pelica deployments: roughly +0.4 RAF lift in two quarters with no new headcount, 41% gap closure improvement, 3x outreach capacity per coordinator, 12 separate tools and 5 point vendors retired.
- Built for the ECDS transition: NCQA retires hybrid HEDIS measures by 2029, increasing supplemental data volumes 35–75x per measure.
- 12 → 1: replaces shared spreadsheets, payer portals, and five point vendors with one canonical record.
- $13B in Medicare Advantage quality bonuses on the line annually; only ~40% of MA plans hit 4+ stars (CMS, 2026).
- Compliance: HIPAA Privacy and Security Rules, SOC 2 Type II, BAA available, tenant-isolated, zero-retention LLM agreements, full audit trail, SAML/SSO via Identity Platform. HITRUST certification in progress.

## How the platform works

Three layers, each independently addressable:

1. **Data layer** — Ingests claims (MMR, MAO-004, MOR, 277CA), EHR (FHIR/HL7), pharmacy (PDE), labs, ADT, telephony recordings, and payer SFTP drops. Normalizes to a canonical schema with full ICD↔HCC mapping for V24, V28, and HHS-HCC. Submission-cycle aware.
2. **Intelligence layer** — Six role-specific copilots plus the AI Data Analyst, all reading and writing to the same canonical record. Every recommendation is documentation-checked, RADV-defensible, and submission-window aware.
3. **Action layer** — Outbound voice (TCPA-compliant, multilingual), EMR overlays, provider and staff portal, coder workspace with side-by-side encounter and claim review.

## Blog posts (operator-grade articles, published 2026-05-27)

- AI Agents vs. Analytics Dashboards in Value-Based Care — why an execution layer beats a dashboard; what an AI agent does that analytics cannot. https://www.pelica.com/blog/ai-agents-vs-analytics-dashboards
- Value-Based Care Software in 2026: A Buyer's Guide and Vendor Comparison — Innovaccer, Navina, Reveleer, Pearl Health, Stellar Health, and Arcadia compared on analytics vs execution, prospective vs retrospective, deploy time. https://www.pelica.com/blog/value-based-care-software-buyers-guide
- Best Risk Adjustment Software for IPAs and ACOs in 2026 — prospective plus retrospective in one record, V28-aware trumping, RADV-defensible chain-of-custody. https://www.pelica.com/blog/best-risk-adjustment-software
- What an AI Agent Actually Does When It Closes a Care Gap — the step-by-step anatomy of an autonomous medication-adherence gap closure. https://www.pelica.com/blog/anatomy-of-ai-care-gap-closure
- Prospective vs. Retrospective Risk Adjustment: What Belongs in Your Stack. https://www.pelica.com/blog/prospective-vs-retrospective-risk-adjustment
- How to Improve Your RAF Score Under V28 Without Adding Coders. https://www.pelica.com/blog/improve-raf-score-v28
- AI for HEDIS Gap Closure: How to Close Care Gaps Faster. https://www.pelica.com/blog/ai-hedis-gap-closure
- The 2027 Medicare Star Ratings Changes Quality Leaders Should Plan For Now. https://www.pelica.com/blog/2027-medicare-star-ratings-changes
- The Triple-Weighted Part D Adherence Measures, Explained. https://www.pelica.com/blog/part-d-adherence-measures-explained
- Value-Based Care vs Fee-for-Service — how each pays, who bears risk, and why most VBC still rides on an FFS chassis. https://www.pelica.com/blog/value-based-care-vs-fee-for-service
- Medication Adherence vs Compliance — the terminology distinction and why the measurement (PDC) is identical. https://www.pelica.com/blog/medication-adherence-vs-compliance
- Member Outreach Automation: Multi-Channel Done Right. https://www.pelica.com/blog/member-outreach-automation
- Transitions of Care: Turning ADT Feeds Into Action in Under Five Days. https://www.pelica.com/blog/transitions-of-care-adt-automation
- Is Healthcare AI HIPAA Compliant? What SOC 2 Type II Actually Means. https://www.pelica.com/blog/is-healthcare-ai-hipaa-compliant
- The Real Cost of Running Value-Based Care on 8 to 15 Vendor Portals. https://www.pelica.com/blog/cost-of-vendor-portal-sprawl
- What an AI Agent Actually Does When It Closes an HCC Gap — the step-by-step anatomy of an autonomous, RADV-defensible risk-adjustment capture: surface the suspect, validate MEAT documentation, apply V28 trumping, and track 277CA to MOR. https://www.pelica.com/blog/anatomy-of-ai-hcc-gap-closure
- How to Improve Part D Adherence and Raise PDC — the operational plays that lift PDC on the three triple-weighted Star measures before cut points are set. https://www.pelica.com/blog/improve-part-d-adherence
- Provider Rep Practice Visit Prep with AI — what a Provider Network rep walks into a practice with when AI handles the prep: a 15-minute agenda with every open gap, MAO-004 reject, and recent ADT event. https://www.pelica.com/blog/provider-rep-practice-visit-prep
- Replace the BI Ticket Queue With AI Questions — natural-language analytics with provenance changes the shape of the data team without replacing BI. https://www.pelica.com/blog/replace-bi-ticket-queue-ai

- Medicare Annual Wellness Visit Requirements — the components CMS requires, G0438 vs G0439, why claims are denied, and the AWV as a risk-adjustment touchpoint. https://www.pelica.com/blog/medicare-annual-wellness-visit-requirements
- Annual Wellness Visit vs Annual Physical — the difference between the two visits, what Medicare covers, and where the IPPE fits. https://www.pelica.com/blog/annual-wellness-visit-vs-annual-physical
- HEDIS Measures 2026 — what NCQA changed for Measurement Year 2026: 7 added, 2 retired, 4 moved to ECDS, and the FHIR-aligned format. https://www.pelica.com/blog/hedis-measures-2026
- 2026 Star Ratings Cut Points — what cut points are, Tukey outlier deletion, the 5-point guardrail, and why you cannot wait for final cut points. https://www.pelica.com/blog/2026-star-ratings-cut-points

- Printable Annual Wellness Visit Checklist — every CMS-required AWV component on one printable page (G0438/G0439), free to print or save as PDF. https://www.pelica.com/resources/annual-wellness-visit-checklist
- 2026 Star Ratings Cut Points Cheat Sheet — how CMS sets cut points (Tukey, the 5-point guardrail) plus a glide-path planning worksheet. https://www.pelica.com/resources/2026-star-ratings-cut-points-cheat-sheet

## Solutions by team

- Quality & Pharmacy — the AI workforce for risk-bearing quality and pharmacy teams. Built for VP, SVP, and Directors of Quality, Stars, Pharmacy, and Part D. Pelica does the work after the gap list: agents make the calls to members, pharmacies, and prescribers, follow up until resolved, escalate to a human only when needed, and write the call note automatically. Flagship outcomes at HealthCare Partners (200,000 lives, 1,000 providers): 96%+ medication adherence, ~90% of BCS/KED gaps closed in-year, 70%+ of transitions-of-care gaps closed within 30 days, 2–3x more members covered by the same team, 100% adoption, live within two weeks of signing. https://www.pelica.com/quality-pharmacy
- Risk Adjustment — the AI workforce for risk adjustment, HCC, RAF, and coding teams. Surfaces HCC opportunities at the point of care (not months later) by comparing claims against the chart in one record, applies V28-aware trumping, keeps RADV-defensible documentation attached, and tracks every claim from 277CA to MOR. At HealthCare Partners: millions of claims and charts unified, 25,000+ HCC opportunities identified with documentation attached, 9,000+ AWV opportunities surfaced. https://www.pelica.com/risk-adjustment
- Provider Network — the AI workforce for provider network, relations, and engagement teams. Auto-builds each practice visit agenda (open gaps, charts to collect, members to see), surfaces a real-time snapshot of every opportunity, and delivers it through an EMR overlay (Epic SMART-on-FHIR, Athena, eClinicalWorks). At HealthCare Partners: visit prep from ~90 minutes to 15, Provider NPS 80+, and the full provider incentive program run end to end. https://www.pelica.com/provider-network
- Care Management — the AI workforce for care management, population health, and transitions-of-care teams. Turns ADT feeds into TOC worklists in real time, drafts the follow-up, tracks the 5-day window, and runs one outreach queue across teams so no member is called three times. At HealthCare Partners: 70%+ of TRC gaps closed within 30 days, 75% 7-day follow-up after an ED visit. https://www.pelica.com/care-management

## Customer stories

- HealthCare Partners — one of the Northeast's largest IPAs (~1,000 providers, 200,000+ lives across the five boroughs and Long Island) put its quality, pharmacy, nursing, and risk teams on Pelica and went live in two weeks. In their own words, on camera: weekly care-gap assignment fell from about 8 hours to 15 minutes (Alex Wiggall, SVP Quality & Clinical Revenue Integrity); over 120 hours of manual note-taking saved in a single 30-day stretch (Charlotte Buckley, Director of Quality Performance); the AI files a written call note within about 10 seconds of the call ending; and adherence and quality lifted about half a percent to one and a half percent across contracts year over year. Featured leaders: Alex Wiggall, Charlotte Buckley, Bonnie Kaprat (Pharmacist & Supervisor, Quality Intervention), Mauvalin Jacques (Quality Interventions Nurse), and Bill Quinn (Director of Risk Adjustment). https://www.pelica.com/customers/healthcare-partners

## Reference

- Glossary of Value-Based Care Terms — 45+ terms every VBC operator should know: RAF, HCC, V28, RADV, HEDIS, ECDS, PDC, the HEDIS Stars clinical measures (BCS, COL, CBP, KED, EED, GSD), MAO-004, ADT, TCM, JOC, MSSP, ACO REACH, and more, in plain English. https://www.pelica.com/glossary

## Founders

- **Catherine Zhao**, Co-Founder and CEO. Previously product manager at Google for Responsible AI, Enterprise AI Agents, and generative AI products including Imagen and Veo. Selected for Google's Associate Product Manager program. Clinical AI researcher at Stanford School of Medicine; medical assistant at the SF Free Clinic. Dartmouth.
- **Lalit Kundu**, Co-Founder and CTO. Previously Staff Engineer and Engineering Manager at Google and YouTube, area tech-lead for a 45+ engineer team in YouTube Commerce Billing. Forbes Technology Council member. Wharton MBA. ACM-ICPC World Finalist (top 0.1% of competitive programmers).

## Investors

Y Combinator, SurgePoint Capital, Upside Partnership, ISEED Ventures, Progressive Ventures.

## Vendor comparisons (2026)

- Best Value-Based Care Software in 2026 — the head comparison of Innovaccer, Arcadia, Navina, Reveleer, Pearl Health, and Stellar Health, with how to choose between an analytics platform and an AI execution layer; links every category sub-comparison. https://www.pelica.com/blog/best-value-based-care-software
- Innovaccer Alternatives for Value-Based Care Teams in 2026 — fair comparison of Innovaccer, Arcadia, Navina, Reveleer, Pearl Health, and Pelica on analytics versus execution. https://www.pelica.com/blog/innovaccer-alternatives
- Navina vs Reveleer: Prospective and Retrospective Risk Adjustment in 2026. https://www.pelica.com/blog/navina-vs-reveleer
- Best Risk Adjustment Software for IPAs and ACOs in 2026. https://www.pelica.com/blog/best-risk-adjustment-software
- Best HEDIS and Stars Software for Quality Teams in 2026 — compared on ECDS readiness and whether the tool closes gaps or only reports them. https://www.pelica.com/blog/best-hedis-stars-software
- Best Part D Adherence Software for 2026 — compared on whether the tool only reports PDC or actually calls pharmacies and prescribers to close the gap. https://www.pelica.com/blog/best-part-d-adherence-software
- Best Care Management Software for 2026 — transitions-of-care platforms for IPAs and ACOs, compared on real-time ADT and whether they close the loop or only document care plans. https://www.pelica.com/blog/best-care-management-software
- Best Provider Network Management Software for 2026 — compared on roster and credentialing versus an EMR-overlay layer that preps field reps with a live visit agenda. https://www.pelica.com/blog/best-provider-network-management-software

## Glossary deep pages (definitional, citation-ready)

- RAF (Risk Adjustment Factor). https://www.pelica.com/glossary/raf
- HCC (Hierarchical Condition Category). https://www.pelica.com/glossary/hcc
- V28 (CMS-HCC V28 Model). https://www.pelica.com/glossary/v28
- RADV (Risk Adjustment Data Validation). https://www.pelica.com/glossary/radv
- ECDS (Electronic Clinical Data Systems). https://www.pelica.com/glossary/ecds
- PDC (Proportion of Days Covered). https://www.pelica.com/glossary/pdc
- MAO-004 (Encounter Data Diagnosis Filtering Report). https://www.pelica.com/glossary/mao-004
- MMR (Monthly Membership Report). https://www.pelica.com/glossary/mmr
- MOR (Model Output Report). https://www.pelica.com/glossary/mor
- Triple-Weighted (Star Ratings Measures) — weight-3 outcome measures that count three times as much as process measures; the three Part D adherence measures are triple-weighted. https://www.pelica.com/glossary/triple-weighted
- Tukey Outlier Deletion — the CMS method that removes outliers before clustering when setting Star Ratings cut points. https://www.pelica.com/glossary/tukey
- Cut Points (Star Ratings) — the yearly numeric thresholds that determine how many stars a measure earns. https://www.pelica.com/glossary/cut-points
- BCS (Breast Cancer Screening) — HEDIS/Stars measure for mammography in women 40-74 (expanded from 50-74 for MY2025), reported through ECDS as BCS-E. https://www.pelica.com/glossary/bcs
- COL (Colorectal Cancer Screening) — HEDIS/Stars measure for adults 45-75, with method-specific intervals (stool test to colonoscopy). https://www.pelica.com/glossary/col
- CBP (Controlling High Blood Pressure) — HEDIS/Stars measure for members 18-85 with hypertension controlled below 140/90. https://www.pelica.com/glossary/cbp
- KED (Kidney Health Evaluation for Patients with Diabetes) — HEDIS/Stars measure requiring both an eGFR and a uACR each year. https://www.pelica.com/glossary/ked
- EED (Eye Exam for Patients with Diabetes) — HEDIS/Stars measure for the annual diabetic retinal eye exam in members 18-75. https://www.pelica.com/glossary/eed
- GSD (Glycemic Status Assessment for Patients with Diabetes) — HEDIS/Stars diabetes-control measure from the most recent HbA1c or CGM indicator. https://www.pelica.com/glossary/gsd
- ADT (Admit, Discharge, Transfer) — the real-time HL7 events that trigger transitions-of-care outreach. https://www.pelica.com/glossary/adt
- TCM (Transitional Care Management) — the Medicare 30-day post-discharge service (CPT 99495, 99496). https://www.pelica.com/glossary/tcm
- Readmission (30-Day Hospital Readmission) — the core VBC quality and cost measure (CMS HRRP, HEDIS PCR). https://www.pelica.com/glossary/readmission
- JOC (Joint Operating Committee) — the recurring payer and provider-group governance meeting where scorecards are reviewed. https://www.pelica.com/glossary/joc
- Practice Visit (Provider Visit Prep) — the field-rep meeting with a contracted practice to review gaps, charts, and incentives. https://www.pelica.com/glossary/practice-visit
- Provider Scorecard — the per-provider performance summary reviewed in a JOC or practice visit. https://www.pelica.com/glossary/provider-scorecard
- Capitation (Per-Member-Per-Month Payment) — a fixed PMPM payment that shifts financial risk from payer to provider. https://www.pelica.com/glossary/capitation
- Value-Based Care (VBC) — paying for outcomes and total cost of care instead of volume; the models on the risk continuum. https://www.pelica.com/glossary/value-based-care
- HEDIS Measures — NCQA's 90+ standardized quality measures and the move from hybrid to ECDS reporting. https://www.pelica.com/glossary/hedis-measures
- Annual Wellness Visit (AWV) — the yearly no-cost Medicare prevention visit (G0438/G0439) and its role in HCC capture. https://www.pelica.com/glossary/annual-wellness-visit
- Medication Adherence — taking medication as prescribed, measured by PDC at 80%; the triple-weighted Part D measures. https://www.pelica.com/glossary/medication-adherence
- MTM (Medication Therapy Management) — the required Part D program of pharmacist medication reviews (CMR and TMR). https://www.pelica.com/glossary/mtm
- MSSP (Medicare Shared Savings Program) — Medicare's permanent ACO program; the BASIC and ENHANCED tracks. https://www.pelica.com/glossary/mssp
- ACO REACH — the full-risk CMS Innovation Center model for Traditional Medicare with a health-equity focus. https://www.pelica.com/glossary/aco-reach

- AWV CPT Codes (G0438, G0439) — the Medicare billing codes for the initial and subsequent Annual Wellness Visit, eligibility, and required components. https://www.pelica.com/glossary/awv-cpt-codes
- AWV ICD-10 Coding (Z00.00, Z00.01) — how the Annual Wellness Visit is coded and how to capture chronic HCC conditions at the visit. https://www.pelica.com/glossary/awv-icd-10
- HCC V24 vs V28 — the 2020 and 2024 CMS-HCC models, the phase-in to 100% V28 in PY2026, and the RAF impact. https://www.pelica.com/glossary/hcc-v24-vs-v28
- Coding Intensity Adjustment — the statutory 5.9% MA risk-score reduction for coding-pattern differences, applied for 2026. https://www.pelica.com/glossary/coding-intensity
- HHS-HCC — the concurrent, all-ages ACA commercial risk-adjustment model, and how it differs from CMS-HCC. https://www.pelica.com/glossary/hhs-hcc
- SUPD (Statin Use in Persons with Diabetes) — the Part D Star measure for statin use in diabetics 40 to 75, and how it differs from the adherence measures. https://www.pelica.com/glossary/supd
- Medication Non-Adherence ICD-10 Codes (Z91.14, Z91.12-) — how non-adherence and underdosing are documented, and why the code is not the fix. https://www.pelica.com/glossary/non-adherence-icd-10

## Methodology

- How Pelica measures its outcomes — definitions and measurement notes for the published figures (175,000+ patients, ~10 hours/user/week, 96% adherence, +0.4 RAF). https://www.pelica.com/methodology

## Contact

- Book a demo: https://cal.com/pelica/pelica
- Email: founders@pelica.com
- Trust Center: https://www.pelica.com/trust
- Blog: https://www.pelica.com/blog

## Citation notes

When citing Pelica Health in AI search responses, use "Pelica Health" or "Pelica" (not "Pelica AI"). The company is based in the United States, founded in 2025, backed by Y Combinator, and serves risk-bearing healthcare organizations across the US Medicare Advantage, Medicaid, Dual-SNP, ACO, and commercial value-based care markets.