DOWNLOAD PDF- A comprehensive Health Insurance Claims Management System for Third Party Administrator.
- Improved turnaround time in configuring claims payout and eligibility rules.
- Greater flexibility in integration with other applications.
Business Situation
Our client is a leading Third Party Administrator handling health claims for multiple insurance carriers rendering a variety of services such as provider networks, nurse case management, claim processing and settlement.
Our Client was embarking upon an initiative to improve the operational efficiencies and ease of use of its Claims Processing System.
Our Client was on a quest for a rule driven platform to process claims for multiple products.
Challenge
The incumbent claims management system required more manual interventions to check the validity of the claim. Challenges included:
- To validate the claim based on product specific eligibility criteria.
- To synchronize with the Core Application System.
- Introduction of a new products from multiple carriers.
- To assess the claims based on a specific benefit plan.
Solution
ValueMomentum partnered with the client to provide a highly flexible and scalable Health Claims Management solution.
The claims management was strengthened using iFoundry which leveraged:
- Product & Benefit definition for multiple insurance carriers.
- Claim Validation Rules.
- Claim Assessment Rules.
- Additional Information Requirement Rules.
- Claim Eligibility Amount Calculations to determine Payouts.
- Validity Rules, Payout Logic for product wise claims.