Comprehensive Electronic Claims Processing System for Healthcare Insurance

The client currently relies on a manual, paper-based claims system that results in high processing costs, lengthy payout times, and increased vulnerability to fraudulent claims. Their goal is to transition to a fully electronic claims processing system to enhance operational efficiency, ensure data security, and strengthen fraud detection capabilities.

A large national healthcare agency seeking to modernize its claims processing through a fully digital, scalable, and secure eclaims platform to improve efficiency and reduce fraud.

• Automate and digitize over 95% of claims processing to increase efficiency and reduce processing time.
• Achieve a 65% faster payout cycle to healthcare providers.
• Reduce fraudulent claims incidence by at least 40% through integrated fraud detection mechanisms.
• Support secure, role-based access for various user types including healthcare providers, claim officers, and administrators.
• Implement a scalable, Web-enabled platform with integrated reporting and monitoring dashboards.

• Provider portal for claim uploads with real-time feedback and validation.
• Automated claims validation, autocorrection, and dynamic pricing updates.
• Role-based access control and privilege management for different user stages.
• Secure reporting and dashboard for real-time monitoring and quality control.
• Built-in intelligent fraud detection module utilizing business rules and technology updates.
• Customizable claim structures supporting refunds and medicine lists.
• API-driven claim submission for automation and integration with external systems.
• Support for low internet reliability scenarios with offline capabilities.
• Full compliance with device and platform standards for diverse hardware.

• Existing healthcare provider information systems
• Government health and insurance databases
• Fraud detection and analytics tools

• System scalability to handle over 21 million claims annually
• High availability and continuous support (minimum 11 years support commitment)
• Security compliance with data protection standards
• Performance: Claim processing velocity to ensure at least 40% reduction in processing time
• Usability across diverse devices and network conditions

The implementation of a comprehensive digital claims processing system is expected to process over 21 million claims annually, increasing claim processing efficiency by 95%, reducing payout times by 65%, and lowering fraudulent claim incidents by 40%. These improvements will significantly enhance operational efficiency, reduce costs, and improve service delivery to healthcare providers and beneficiaries.