Major Health Care Provider Automating Claims Process

Major Health Care Provider Automating Claims Process

Business Need: Client is the leading health services corporation in the state and a major regional provider of health services. Previously, client processed claims and benefit changes manually through the IBM NASCO Claims processing system. In order to improve the performance and speed up processing of the claims client decided to automate the processing of all the claims using OpenConnect.

Solution: Keshav Consulting Solutions (KCS) has been involved in requirements gathering, analysis, design and development of various transactions to automate the process of adjudicating health insurance claims. Using OpenConnect we built the robots (software applications designed and developed based on the requirements given by the respective departments). KCS has been responsible for maintaining OpenConnect Comprehend module, a distributed application that allows for horizontal scalability of all components. KCS has helped client upgrade version changes and make further system enhancements for the tools being used such as OpenConnect Configure (Terminal Emulator to connect IBM Mainframes 3270  terminal, developed using Java open source code).

KCS is responsible for scheduling daily jobs, weekly jobs for claims transactions processing and generating debriefing reports and forwarding these reports to business analysts. KCS has been involved in the maintenance of the existing projects such as Eating Disorder, Mental Parity and Mod50 and has delivered new projects such as PreEx web applications, HIPAA projects resolving edits such as E905, E917, R462, C515, L081 and 40K, B10K and membership transactions. KCS has designed and developed the Web Services in order to access the built robots through the web application to process the claims in the Nasco Claims processing system through the user-friendly web interface. KCS has designed and developed a web application to generate the daily, weekly and monthly reports of the processed claims.

Benefits:

• Improved claims processing capability-increasing revenues for the firm.
• Faster claims resulted in improved customer experience.
• Advanced Analytics helped gain prescriptive wisdom on claims overall.
• Improved compliance with regulations.