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Health Insurer Integrates Multiple Claim Systems into One Coherent View Using Service Oriented Architecture

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      • The Challenge

        The customer service representatives of a large national health insurance company were not able to easily access the claim histories of members, which made it difficult to effectively answer questions and resolve issues in a timely manner.

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        Calling your insurance company to discuss benefits and claims can be a frustrating experience for health insurance customers. Claims processing is typically done through a variety of claims software solutions from a multitude of vendors, making difficult the task of dealing with a member’s claim records in a holistic manner. Often companies will find that their customer service representatives require complicated and lengthy training in order to discern the correct claims history from information returned by multiple claim systems.

        A government employee program managed by a large national Health Insurance company had just this problem. The customer service representatives were required to access multiple systems in order to retrieve the entire claim history for members that called in with questions. As part of an enterprise plan to continually improve customer service, the decision was made to utilize a single tool for all claim inquiries.

        Pulling together information from disparate sources into an integrated view requires very complex business rules to resolve data inconsistencies and duplications. Ideally, customer service representatives should not be aware that the information is coming from multiple sources, but rather, the needed information is presented in a coherent and effective manner from one interface. All of this has to happen in real time to maintain a high-level of customer service and to control costs.

      • The Solution

        Netsoft USA built a customer service application that provides a holistic view of a member’s claim record history.

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        The Heath Insurer chose Netsoft USA specifically for the skills and experience required to understand the intricacies of healthcare claim systems, as well as the technical prowess to integrate complex business processes. Netsoft worked with a dozen teams from end users to outside vendors, and by following their disciplined management processes, was able to bridge the gap between the various technical systems and create a coherent view. The final status of a member’s health claim information required the application of sophisticated business rules to ensure consistency. Netsoft designed and built 23 business services to connect the Health Plan’s strategic customer service applications with multiple membership and claim systems.
    • The Impact

      Customer Service Representatives are able to quickly pull up the entire claims history for members, answer questions, and resolve issues more efficiently.

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      A single customer service application can now provide a holistic view of a member’s claim record history. Customer Service Representatives are able to quickly pull up the entire claims history for members, answer questions, and resolve issues. The new program has improved customer service, decreased costs, and increased efficiency. In addition, Netsoft trained the Health Insurance Company’s team to maintain and extend the program in Netsoft’s absence.

      “Netsoft USA met the objectives in an exemplary manner. The subject matter expertise that was displayed by all of your team members whether it was the project manager, the tech lead, or a business analyst, everybody… all of the talent you brought to the table was immediately able to make a contribution to the project.” Project Lead and Sr. Technology Manager for the Health Plan.


Case Studies