Case StudiesA Medical TPA In Oman Completely Digitized Their Health Claims Process

March 11, 2022

The Challenge

Our client, a well-established Medical TPA, was seeking to obtain approval for the TPA license provided by the CMA (Capital Market Authority, Oman). The quality of infrastructure used to process claims was one of the key considerations to attain the TPA license. Our platform was leveraged to complete the licensing process and the client became the first company to get a TPA license in Oman.

The Solution

To equip the client with the mandated software infrastructure, iNube leveraged its state-of-the-art technology platform – ClaimsLive Health. The solution was tweaked to address the differences in TPA processes in Oman. The solution was also made to be capable of handling Outpatient Department Claims (OPD) claims automatically.

Highlights

  • Key Modules – Business Administration, Business Rule Engine, User Management, Enrolment and Member Management, Endorsement Management, Provider and Claims Management, Suspect Case Management, Payment and Settlement, Dashboards & MIS Reports
  • Dedicated portals for various stakeholders
  • Sophisticated Benefits Administration – ICD 10 based configuration of benefits
  • Business Rule Engine to tackle the complexity of data and automate decisions
  • Digitized provider tariff rates by maintaining Schedule of Charges (SOC)

Value Delivered

  • Automated rule-based adjudication
  • Reduced TAT for claims processes
  • Enabled Straight Through Processing (STP) for OPD claims
  • Quick customer on-boarding (group or an individual)
  • Realistic and objective risk management
  • Reduced grievances from customers and providers
  • Tailor-made for region-specific processes
  • Highly scalable solution
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