Client Background
The client is a health solution provider and acts as a mediator between hospitals and medical service providers to help patients get proper Medicaid claims
Client Need
- Need a solution to collect, save and validate the claims information, from different health plan systems, received in EDI 837I/P/D format
- Need the ability to send acknowledgments for the claims received from different vendors
- Need a feature for encounter submissions to CMS – RAPS, EPDS (post adjudicated files in the form of EDI 837I/P/D files)
- Need a feature for sharing 277 CA (claim acknowledgment) and 999 electronic claim responses, received from CMS, with the vendors
Our Solution
- Built a system:
- To accept and validate adjudicated EDI 837 claims from various health plans and provide proper acknowledgement
- To read post-adjudication claims and check encounter eligibility for submission based on configured business rules
- To submit ( to CMS) and track responses of all encounters and reconcile them
- To share 277 CA and 999 responses, received from CMS, with the vendors
Tools & Technologies
Greenplum, IBM Datastage, SQL Server, Informatics, Oracle Database
Key Benefits
- Streamlined the claims intake and submission process and increased efficiency by 30%
- Improved the CMS acceptance rate to 98.5% from 96.5%
- Made the reconciliation process easy by tracking all encounter submissions and responses from CMS
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