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Reducing Claims identification and processing time by 30% for a leading US-based healthcare payer

Reducing Claims identification and processing time by 30% for a leading US-based healthcare payer

The Client

Healthcare payer for prepaid medical, hospital and related comprehensive health care services through various popular health plans like HMO, PPO and POS.

Area of Engagement

Provider and Pricing Configuration, Re-adjudication of claims in AMISYS and ASM of Membership and Billing Application

Business Challenges

With a 40% year on year growth, client was facing many challenges including:

  • Immediate need to configure and re-adjudication of claims
  • Additional identification and termination of membership
  • Increasing business resulting into improper documentation
  • Non-availability of skilled IT resources to support the automation

 

HCL Approach: Transition through ASSETTM

Assessment Phase

  • Customer-HCL communication plan set up
  • Application Landscape of customer was understood
  • Plan for Skill Needs
  • Support Needs identified


Start up & Planning

  • A detailed Knowledge Assimilation plan based on application master list was prepared


Knowledge Absorption

  • Project Details & Knowledge Gap identified


Knowledge Replication

  • Onsite Transition
  • Offshore Transition Planning
  • Offshore Parallel Run


Provider's Data Management

  • The configuration of Provider's information to process Provider's Claims and maintain the updated information of existing and new Providers contracted with Client


Pricing Management

  • Loading the Pricing logic into Client's Tool called AMISYS to ensure defects free Provider's information and processing of Claims


Claims Adjudication/ Re-adjudication

  • Ensuring correct Provider loaded in AMISYS before final processing of claims


Application Support and Maintenance

  • ASM of Providers and Billing applications - Completed a Proof Of Concept on Membership and Billing Applications

 

Technologies Used

  • HP3000
  • Amisys
  • Cobol 85
  • Turbo Image

 

Value delivered

  • Re-adjudication time reduced by 10%
  • Provider Configuration time reduced by 30%
  • Smooth knowledge transition through HCL's ASSETTM
  • Ensured Optimum availability and utilization of skilled resources
  • Quick Ramp-up on AMISYS skills
  • Introduced QA audit for the claims processed to ensure data integrity and consistency
  • HIPAA Compliance for Physical Safeguards, Administrative Safeguards, Technical Safeguards

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