UC-503
Improve Insurance Eligibility and Claims to reduce cost, risk and delay
Checks insurance eligibility and claim requirements before service to reduce rework and rejected claims.
TBDBuild Duration
XXXXIndicative ROI
XXXXBuild Cost
XXXXValue
The Challenge
The opportunity is to eliminate eligibility discovered only after the customer reaches the store, coverage discovered at the till, and claims keyed into a spreadsheet. The proposed workflow is source-linked, but the current operating baseline and financial value remain illustrative until validated with the client.
How It Works
- Reads insurer rules, member eligibility, service codes, claim requirements and submission status.
- Links the records and ranks exceptions against the agreed business rules.
- Routes the source-linked result to the named owner for review and action.
What It Removes
- Eligibility discovered only after the customer reaches the store
- Coverage discovered at the till
- Claims keyed into a spreadsheet
Input Data RequirementsRelevant operational records, contracts, transactions, schedules, documents and outcome history named in the source proposal
Output FormatEligibility and claims dashboard showing coverage, missing evidence and submission status
“The customer knows what they pay before they leave the house.”