Canada
Puerto Rico
USA
Belgium
France
UK
India
Client Background
Our client is a leading health payer based in the US.
Client Need
Our client sought to modernize existing systems for Medicare Advantage enrollments and billing operations. Key challenges included:
Reducing manual intervention across enrollment, membership, and billing operations
Accepting claims from multiple trading partners, generating responses, managing accumulators, adjudicating claims, and delivering EOB/Remittance advice
Implementing an integrated workflow system to handle errors and user requests across enrollment, billing, and claims modules
Solution
We developed a comprehensive rule-based online channel and premium billing solution for MA, MAPD, and PDP plans. Key solutions included:
BEQ Processing: Configured business rules to automate election period and effective date determination
Integrated Workflow Portal: Streamlined business operations by developing an integrated workflow portal
Refund Solutions: Designed and implemented solutions to identify delinquent members, cash transfers, and refunds
Automated DTRR Processing: Eliminated manual intervention for 18 Transaction Reply Codes (TRCs) under DTRR file processing
Comprehensive Claims System: Built a claims system to accept, adjudicate, and send remittance advice for EDI 837P, I, and D electronic claims
Realized Benefits
The solution provided the following benefits:
Significantly increased resolution rates for benefit enrollment and change requests
Migration reduced administrative costs by 10-15%
The configurable rule engine lowered rule exceptions from 14% to 4%, application downtime by 95%, and increased application availability
Automating Transaction Reply Codes (TRCs) decreased manual intervention, saving an average of 10,000 man-hours annually
An automated workflow assignment system streamlined processes, identified aged tickets, and improved business operational efficiency
Trending Success Stories
Accelerating Claims Adjudication Through Gen AI–Enabled Pend Code Automation
Optimized QE Time Up to 40% Using an Intelligent, AI-Powered Test Automation Approach
Redefining Payments with Azure-Powered Intelligence
Driving Innovation in Generating Evidence Using Real-World Data
Ready to Innovate with Us?
Let’s Talk!
Connect with us on social media
Write to us at
[email protected]