Nationwide Health Insurance Eligibility Processing and Financial Integration Platform

The client operates a health insurance eligibility and processing platform initially designed for a single state with specific regulatory and administrative requirements. Due to independent implementation across different states, there is a need to customize and extend this platform to support nationwide operations, accommodating varying regulations, processes, and financial transaction handling requirements. Existing manual or siloed systems hinder efficiency, compliance, and real-time data management, leading to increased errors and delays in processing insurance claims and eligibility certifications.

A large government agency responsible for managing public health insurance programs across multiple states, seeking to modernize and standardize eligibility processing and financial workflows.

• Develop a flexible and scalable platform to support health insurance eligibility determination across multiple states with diverse regulations.
• Implement a comprehensive financial transaction management module enabling secure processing of refunds, account transfers, payment reversals, and transaction history viewing.
• Ensure seamless integration with external financial institutions and state-specific administrative systems to facilitate real-time data exchange.
• Achieve a reduction in processing errors and improve the timeliness of insurance eligibility and financial transactions.
• Deliver a cost-effective solution that reduces project budget overruns, targeting a project cost at or below initial estimates.
• Enable administrators and service staff to service large volumes of eligible populations efficiently, improving overall service delivery.

• Eligibility verification module tailored for multi-state variations and regulatory compliance.
• Financial transaction processing interface to handle refunds, reversals, ACH inactivations, and account transfers.
• Integration layer for secure communication with external financial institutions and state agencies.
• Real-time transaction processing with high throughput capability for handling millions of records.
• Comprehensive user interface for service staff to view transaction histories, financial summaries, and initiate refunds or adjustments.
• Reporting and approval workflows for refunds and financial adjustments.
• Audit logs and security features to ensure data integrity and compliance with financial and privacy regulations.

• Financial institutions for transaction processing and verification.
• State government information systems for eligibility data exchange.
• Payment gateways for ACH transactions and refunds.
• Regulatory compliance systems for audits and reporting.

• System scalability to support increasing user and transaction volumes across multiple states.
• High availability and reliability to ensure uninterrupted service.
• Secure data handling complying with financial and health data privacy regulations.
• Performance metrics including processing time under 2 seconds per transaction and system uptime ≥ 99.9%.
• Flexible customization options to accommodate varying state regulations without major system overhauls.

The development of a nationwide, adaptable health insurance eligibility and financial management platform is expected to reduce processing errors by up to 30%, decrease claim and eligibility processing times, and enable handling of millions of transactions efficiently. Cost savings from streamlined workflows and automation are projected to reduce operational overheads, while improved compliance and reporting capabilities support regulatory adherence. The scalable architecture will allow for future expansion and integration of additional states and programs, enhancing the client's ability to serve millions of eligible individuals more effectively.