The customer had legacy IT infrastructure with multiple system integrations. Lack of validations during insurance claims processing led to claims leakage. Manual processing of claims consumed more time. The customer was heavily dependent on TPAs for claims processing. health insurer was seeking a system which could give them more control over the TPA and enable transparency. The customer wanted to bring in-house part of the insurance claims processing.
The Solution – Automated Insurance Claims Processing to Reduce Claims Leakage
- End to End Health Claims Management Solution from enrolment of members to settlement of claims was implemented
- Exhaustive product configuration module to enable customer to introduce product offerings
- Custom built workflows to incorporate TPAs using own system to upload data at strategic points during claims processing via a front-end interface (TPA Portal)
- Capability to map Provider SOC and tariff against unique Service Codes was done to enable digital validation of claims
- Business Rule Engine to flag duplicate claims, insufficient BSI, package mismatch etc.
- ICD 10 based configuration of benefits, covers to enable auto adjudication of claims