Core Claims Administration

As the States look at making big and mission critical investment in replacing the legacy Core Claims systems, it is imperative to keep an eye on the future, 10-20-even 30 years from now. Legacy core administration systems were designed in a different era. While many legacy MMIS providers have made significant investments to modernize and integrate these systems, their architecture does not offer the flexibility and speed needed to succeed in today’s environment where delivery models and payment arrangements are rapidly evolving and there is increased focus on interoperability.

Our Claims Administration solution, built on HealthEdge’s HealthRules® platform, is designed to address the challenges of modernizing legacy claims administration systems, with the ability to evolve as future needs occur. As a scalable SaaS-based, cloud-native platform, it can significantly reduce the time and effort needed to maintain systems and enable seamless upgrades, with no custom-built components and no harvested code from legacy systems. It’s comprehensive capabilities enables Medicaid agencies to bring new efficiencies to how they handle core tasks such as:

Benefits management
Edits and adjudication
Capitation fee payments
Pricing, including value-based payment models
Authorizations
Care management
Exception processing
Correspondence management

, Our unique data model works in combination with the patented and award-winning natural language rules engine, HealthRules Language, to make it much easier for business analysts to create and update processing rules. Similarly, they can quickly and easily configure benefit plans and pricing using the solution’s user-friendly interface. Overall, it is a fully configurable tool that is easy to deploy.

Our integrated Claims Administration solution is based on a contemporary vision of the ever-changing healthcare marketplace. As it supports work queue processing and document linking, it is more than just a claims-processing system. It’s a fully functional business process management and content management system for Medicaid. Users don’t have to log in to multiple systems to complete their day-to-day activities for claims adjudication, resulting in unmatched efficiencies.

The HealthRules Care Manager component in Claims360 provides service authorization functionality. Claims360 has built-in integration with EDI gateway (TransSend) and claims editing services (ClaimsXten) to ensure the real-time adjudication of claims.

The Claims Administration module of Wipro EMaaS enables state Medicaid agencies to improve operations and outcomes by:

Supporting multiple lines of business, viz. Medicaid, dual beneficiaries, Children’s Health Insurance Program (CHIP), nursing home and behavioral services, on a single platform.
Lowering administrative costs significantly by automating critical business processes.
Enabling the real-time processing of claims.
Offering comprehensive and automated recoupment, reprocessing, and recovery options, including mass adjustments.
Helping identify and manage care to high-risk populations with high utilization.
Achieving and maintaining regulatory compliance as new rules emerge.
Tracking and reporting on critical quality compliance measures.
Delivering transparency of information for increased member engagement and superior customer experiences.
Leveraging key data sources with seamless integration using APIs and open standards, viz. EDI X.12.

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