Pharmacy Claims Processing

A pharmacy client whose primary business was processing claims for health insurers, employers, individuals and seniors on Medicaid needed a more efficient intake process. Rulesware was tasked with automating an entirely manual intake process.

The Problem

The client had several manual intake processes that would dump the corresponding requests into an enterprise email folder. Then certain personnel had to be present in order for the request to be properly processed or the end client’s care would be delayed.

The Solution

Beginning with a simple intake process, Rulesware led the Pega-platform implementation to automate the application and claim processes. By moving manual intakes to digital and multi-channel intakes, the resulting solution could consume and automatically direct the request to its proper destination in order for timely fulfillment.

The Result

This single intake application has not only automated the patient’s applications and claims processes but also automated eligibility checks to ensure the requestor’s membership and corresponding benefits. The system also conducts checks on prescriptions and providers, when needed. This simplified and automated process has increased the client’s efficiency and timeliness in processing claims and care requests for those it insures.

For more information on how Rulesware and how we can help your company achieve its goals, please contact us.

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