Automated health claims processing (for hcfa) using ’s omni flow
1. Case Study
S OLUTIONS F OR B USINESS P ROCESS & C ONTENT M ANAGEMENT
Automated Health Claim Processing
(for HCFA) using Newgen’s OmniFlow
For a leading US Insurance player
Overview
The client is One of the leading BPO companies that offer services for Health
Claims Processing. They process two types of HCFA forms - HCFA -
1500(HCFA) and HCFA-1450 (Ub92).
The Challenge
The BPO space, with the advent of new ways of conducting business and the
need for understanding customer requirements in a dynamic environment,
warrants cutting-edge technology.
The main objective for the automation of Health Claim Business process for
our client was to make the transaction processing service more efficient,
productive and streamlined.
The client was looking for a unified business process workflow automation
solution to support the business needs of its health claims processing and EDI
output generation as per ANSI 837 standard guidelines. .
The requirement entailed:
! Data entry of all fields from claim images
OmniFlow, Newgen's platform- ! Quality checks
independent, scalable Workflow ! Generation of EDI output files
solution and OmniDocs Newgen's
Enterprise Document Management HCFA-1500 is used for the Professional Claims and HCFA-1450 (also known
System, have been implemented and as UB-92) is used for Institutional Claims.These claim forms contain details of
the deployment done for the client is the patient, details of the illness, diagnosis, treatment etc. and are used by the
web-based. physicians and hospitals to claim the payment for services covered by
insurance providers.
The data captured in these forms has to be transferred to financial institutions
for payment purposes in EDI format. After processing of the claim forms, the
data has to be exported in to a standard EDI 837 file format, to be transferred to
the providers for further processing.
Solution
The solution broadly has 3 components:
! Upload and introduction to Workflow
! Health Claim Workflow Process with Quality Checks
! Export in EDI format
Production Site
O O EDI
SMS M M Export
(Image N N
server) I I
D F OmniFlow
O L Process Manager
C O / Dashboard
S W
D S OmniFlow
M E Desktop
Omni (Client)
S R
Flow,
V
Omni Upload to
E
Docs Workflow
R
Databas
e
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