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Improve Claims Acceptance Rate Through Intelligent Automation

Increasing CMS acceptance rate (>99%) through intelligent automation in the encounter submission process

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

Challenges

  • 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

Solutions

  • 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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