Client Background
The client is a multi-line managed care enterprise that serves as a major intermediary for both government-sponsored and privately insured health care programs.
Client Need
- In the business end, there was no process to split the amounts into Medicare and Medicaid responsibilities for dual claims
- Previously, client had to alter their claims processing in order to capture this information
- In the technical end, the client was facing strict go live timeline of OSDS from state and with ongoing APD submissions
- The enhancements needed to be appropriately designed and implemented without affecting each other’s timelines
Our Solution
- Integrated dual claims split and minimum wages information into replication process for their claim submissions
- APD and OSDS claim submissions processes are enhanced with implementation of logic using split amounts and minimum wages information with correction of dollar amounts at claim and claim line levels
- Created processes to report errors (State rejections and submissions errors) and to notify business teams
- Created workload automation for monthly resubmissions of claims based on new split amounts and minimum wages
Tools & Technologies
Greenplum, Microsoft SQL Server 2016, IBM, Datastage, Automic
Key Benefits
- Added value by reducing business analysis efforts through query based automated approach of notifying business team with appropriate State responses information
- Manual effort of frequent analysis of state responses and resubmissions are reduced through automated reporting and resubmission processes
- Code has been reused at most of the places for APD and OSDS, causing reduced development and code maintenance efforts to 50%
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