A Technology Firm Implements Flexible Solution to Support State Programs

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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.



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.



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


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