Health Claims Management Solution

End-to-end Solution Template using Business Process Management and Rules

Business Drivers

In today’s competitive business environment, increasing government regulation and tightening market conditions are driving Health and Life Insurers to look for better ways of meeting strategic objectives. They seek to:

  • Control claims costs
  • Serve and retain agents and customers
  • Perform consistently and predictably
  • Respond quickly to changing market conditions
  • Meet regulatory requirements

Business Solution

The SoluSoft Health Claims Management Solution is built on world-class Business Process Management and Rules software from OpenText and Corticon. It provides a customizable solution that fits easily into any insurance environment. It delivers true end-to-end management of the entire process and provides much greater control and visibility to all areas of the business. The entire organization can leverage these tools to:

  • Reduce operational costs
  • Provide Business Intelligence in key performance areas
  • Provide automatic, verifiable and consistent decision-making
  • Provide a better customer experience
  • Serve customers faster and more accurately
  • Provide better claims status information to agents and customers, with fewer issues
  • Provide a better customer experience
  • Provide complete audit trail of all documents and actions related to a claim
  • Control access to information easily and comply with security regulations
  • Provide greater visibility to management for the status of applications both pending and issued
  • Control risks, while simultaneously meeting regulatory requirements
  • Streamline processing to allow a higher volume of work to be done by the same group
  • Enable knowledgeable workers to update the rules and process without programming

Claims Process Overview

The Solution Template for Health Claims Management consists of the following process components:

Capture Claims: Claims are captured using both paper methods and electronic methods. X.12 837 edi transactions are captured and populate the claims case. Capture paper HCFA 1500, CMS 1500, UB92, UB04 and any other custom claims forms. Automatic document separation for scanned documents and data entry is done for scanned forms.

Auto Adjudication: Your custom business rules for claims management are incorporated directly into the business process, so that existing policy guidelines are checked for completeness and verified for settlement actions. A certain percentage of claims may be automatically settled without interruption of your staff, so they may concentrate on the higher risk claims.

Examine: The template process provides proactive distribution and management of claims according to your business rules and risk management criteria. A certain percentage of cases may be audited and reviewed by various levels of claims supervisors. Escalation is done automatically and claims are processed consistently. Key process metrics are recorded each step of the process. Work is dynamically balanced to match the workload and staff. Work is separated and pushed to the right people according to the criteria needed. Anyone can access case files at any time. The user’s role governs the security and the view of the claim.

Settlement: Claims are settled with the least amount of interaction. Correspondence is generated using your existing systems or with optional correspondence modules.

Recovery: If appropriate, recovery and auditing of claims is automatically flagged according to your rules. Process activities and rules are executed to help personnel consistently manage higher value claims. Complete audit history is maintained for all transactions.

Straight Through and Special Processes

The Health Claims Management Solution Template provides out-of-the-box processing capability, which can be configured for your unique requirements. Straight-through processes allow quick adjudication of claims meeting certain rules and more complex cases are handled with logic that insures consistent and proper escalation. Process management insures that handoffs are minimized.

The Health Claims Management Solution Template also accommodates your special process requirements, with out-of-the-box templates for:

  • Investigation
  • Audit
  • Negotiation/Subrogation
  • Directory Synchronization
  • Archiving

SoluSoft Claims Management Solution Template works with your systems

The Claims Management Solution Template provides end-to-end business process and content management in all key areas of the Claims Management Application process. It works with your existing claims payment system, policy management system and EDI service providers. You can use your existing Correspondence system or it can be provided separately. The system is modular and can be customized to your requirements. Advanced system architecture used requires no software distribution to your user clients and process and rules can be maintained by your business operations staff.

Solution Template is Fast to Implementation

Using a solution template for your application provides the fastest time to implementation, yet still allows you to customize the solution using BPM tools and business rules.

  • Reduced development and maintenance costs
  • Faster ROI
  • Out of the Box Functionality
  • Leverage your existing legacy applications
  • Capture knowledge of key staff within business rules
  • Virtualizable and advanced system architecture requires no client software distribution
  • Future-proof your systems so they may be modified easily