Rulesware is extremely proud to have recently worked with a not-for-profit health insurance provider on two successful releases that contribute directly to the organization’s business transformation goals.
Business Transformation Claims Intake
The first release delivered a new Pega pre-processor solution designed to improve the client’s claims intake process. The new solution is now able to process between 100K and 150K claims per day–all within a 4- to 6-hour window.
Rulesware used Pega’s ‘Claims Repair’ Framework to meet the client’s requirements . And the client is thrilled with the effectiveness of the solution, especially in terms of its complex business logic and data/input validation. One of the product owners on the client side noted specifically that the Pega preprocessor would provide the organization with “greater transparency, accuracy, and efficiency in processing claims,” and that “it has significantly improved our provider ID selection process compared to the retired legacy preprocessor.”
The release went in with one production defect, which was fixed during the implementation, exemplifying our team’s hard work and thorough testing of the application. The new Pega pre-processor solution replaces an older application (legacy claims pre-processor) which required a significant amount of development and time to maintain, and was limited in its scalability.
Our second successful release for the same health insurance provider, for an authorizations intake project, included high-value usability and regulatory enhancements, advanced reporting capabilities, and administrative functions. And we’re pleased to report that the release went in with ZERO production defects: a testament to Rulesware’s ongoing commitment to delivering high-quality solutions, done right the first time.
The Online Authorization Request Intake application is the first Pega solution in our client’s clinical business function, as well as their first Pega solution to be exposed outside of their network for use by healthcare providers. The solution uses Pega’s Care Management Framework and Internet Application Composer (IAC) to deliver a state-of-the-art user experience for providers.
Early feedback from providers shows that they love the tool, and they love how easy it makes the process of submitting authorization requests – especially the features that help them choose diagnosis and procedure codes out of a list of ~80,000 codes!
Our client is excited about the solution and grateful to Rulesware for the positive experience. The project sponsor commented that “It was a really great job by all involved to implement such a critical endeavor.” Best of all, the project sponsor also observed that the joint team involved in developing the release was “named as an example for best practices” within their organization, and that this release was another example of that.
We couldn’t be more proud.