Configurable health claims management for quick and accurate processing

Case Study

Problem Statement

ICICI Prudential entered into the project with a complex business challenge. It used to process health claims via a third party administrator. As volumes increased, this solution became more cumbersome and expensive. ICICI needed an externalized agile Claims application to handle claims faster and more efficiently. The system needed to be seamlessly integrated with Life Asia 400 and other systems and required configurability to improve time to market for products. ICICI also required an open and standards based system for ease of maintenance and scalability. This new system needed to reduce leakage and fraud in claims processing.

The Solution

Polaris delivered a comprehensive Claims Management system for Disability Health Claims in less than five months. The solution, which has been in production since December 2009, is based on an SOA framework. The solution included a product configuration component in which claims rules were defined by product. Based on these rules, a claim benefit amount was calculated.

  • The claims system used Java and Oracle to interface with a back end AS400 policy administration system, a document management system, CRM systems and fax servers.
  • The solution was built with a scalable architecture to add business functionality incrementally.
  • The system was extended to Life Claims and provider management.
The cost of processing claims has significantly reduced, and users are finding the web-based solution more supportive, more productive and easy to use.  

The Benefits

  • 50% cost savings compared to in-house development.
  • The decisioning turnaround time has dropped from 20 days to 7 days.
  • Built-in policy and product rules and automated claims benefit calculation.
  • Extended to Life and Hospital Claims supporting pre-Auth and Network providers.
  • Configurability of products had lead to improved time to market and servicing
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