Canada
Puerto Rico
USA
Belgium
France
UK
India
Client Background
The client is a leading health payer based out of the US. They were using a legacy system (Mainframe) for MA, MAPD & PDP administrative operations, and needed help in migrating the applications to a web-based platform in order to reduce existing manual operations.
Client Need
To migrate existing legacy system for Medicare advantage enrollments and billing operations
To reduce manual interventions for multiple operations for enrollments, membership and billing
System to accept claims from multiple trading partners, generate responses for all requests, accumulators, adjudication of claims and submitting EOB/Remittance advice
Need an integrated workflow system to handle errors and user requests from enrollment, billing and claim modules
Solution
Developed a rule based online channel and premium billing solution for MA, MAPD & PDP plans
Suggested and built solutions to identify delinquent members, cash transfers and refunds
Increased the resolution rate for BEQ Request and Response process by configuring rules for Election period and Effective date determination. Manual intervention was eliminated for 18 TRC’s under DTRR file processing
Built a claim system to accepts, adjudicate and send remittance advices for EDI 837P, I and D electronic claims
Streamlined the business operations by developing an integrated workflow portal
Realized Benefits
Moving from legacy solution to a web-based solution reduced the administrative costs to 10% to 15%
Configurable rule engine helped in reducing overall rule exceptions from 14% to 4%, reduced application down time by 95% and increased application availability
Automation of TRC’s helped reduce manual intervention and saved on an average 10k man hours in a reporting year
Automated workflow assignment system helped in streamline the flow, identifying the aged tickets and improved business operations efficiency
Tools & Technologies
Microsoft SQL Server
Bootstrap
Angular JS
Microsoft ASP .Net MVC4
JQuery
Microsoft SQL Server Integration Services
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