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Decision Services for EDI-based Enrollment Transactions

Industry
Insurance

Client
Leading BCBS Health Insurer

Needs addressed
Enrolment, EDI Portal, Member Portal, Group Portal

• This leading BCBS plan envisaged leveraging common process and common decision service for all electronic enrollment transactions. EDI interfaces, Member portal and Group portal, were targeted to be transformed to use a set of common business rules and plan specific rules.
• The current enrolment processes for EDI involved significant error processing by the health insurer's operations staff and it was desired that decision-making and responsibility to correct errors be pushed on the side of the customer, reducing costs and improving customer experiences

Technology Solution delivered
Business Rules Management Systems (BRMS),Portal & Collaboration

• ValueMomentum partnered with the Client by providing thought leadership on leveraging a disciplined approach to developing rules-based applications using its QUICK-VAR^TM Rules Development Methodology.
• ValueMomentum Consultants teamed up with the Client's development teams towards requirements gathering, design and development of various modules in the EDI-Redesign project.
• The responsibilities handled by ValueMomentum included:
  • ValueMomentum consultants drove requirements gathering, design and development while mentoring the Client's staff
  • The Client had selected Fair Isaac's Blaze Advisor Business Rules Engine (BRE)
  • Rules Maintenance Application (RMA) was utilized to provide easier and more upstream maintenance of business rules
  • EDI portal was developed using Websphere to enable Broker partners to correct enrollment errors in a self-serve mode.
  • Developed interfaces with several systems and transaction services to fulfill transactions initiated by Broker partners.
  • Rollout plan involved multiple releases based on products such as HMO, PPO and CDHP

Execution model
At site, T&M

Technologies used
J2EE, Websphere, Fair Isaac's Blaze Advisor

Benefits delivered

• The full potential of the underlying inference-based rules engine was utilized.
• The maintenance of the Rule base mapped closely with business processes and significantly aided in future agility of the system
• Substantial reduction in costs was achieved by the Carrier's enrolment specialists as customers drove the error correction process through an EDI portal.

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