Client Background
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
Our 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
Tools & Technologies
Key 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