A Technology Firm Implements Flexible Solution to Support State Programs

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CLIENT

 

The client is a technology company that provides healthcare products for various customers. The client handled multiple health plans, Third-Party Administrators (TPA), carriers, and state programs, and therefore, required a flexible enterprise solution for health plan administration.

BUSINESS CHALLENGE

 

The scope of work for the client would include streamlined development and maintenance, with ongoing product enhancements covering iterative and incremental upgrades. A key business objective was to ensure functional interoperability with real-time integrations. The final goal was to ensure end-to-end business process transparency with Pharmacy Benefits Manager (PBM) abilities, user-driven configuration parameters with workflow, compliance with the Health Insurance Portability and Accountability Act (HIPAA), as well as multilingual support. The client required a solution that addressed all core and peripheral concerns.

SOLUTION

 

Our team devised a solution using:

• Atlantes: Care management solution for care coordination, optimization of care expenditure, and development of efficient UR process

• Healthcare portals

• Healthcare payer system

BENEFITS

The solution enabled the client to:

 

• Integrate with members’ benefits, payers, and providers for improved health outcomes

• Develop and implement member, provider, and e-prescribe portals

• Implement six state programs and 11 client programs

• Interface with payer systems like Metavance and interchange

• Establish a real-time point-of-service for claims adjudication

• Create rules-driven queuing for enterprise workflows

• Integrate Altruista GuidingCare™ for care management

• Provide end-to-end functional coverage

• Enable a comprehensive rules engine and reporting functionalities

• Implement large commercial and state programs, as well as healthcare reforms