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Use Case - Healthcare Payer Systems

Automating Mission-critical Claims Processing to Achieve Compliance SLAs

Customer since 2007 – This insurance plan works with federal and state agencies to provide health coverage for diverse populations in four states. It has more than 1 million members and 3,000 employees

Challenges

01

Strict government-mandated deadlines

02

More errors as business and claim volume grew

03

Need to handle spikes in day-to-day activity

04

Inaccurate reporting from multiple inputs including customized claims processing app

Situation

Claims are received from insurance company partners throughout the day. Spikes in daily activity – 25,000 to 100,00 jobs per day – and growing claim volume require short- and long-term scalability. Accurate reporting that incorporates multiple inputs is essential.

The plan must submit claims it receives to government agencies by 9:00 a.m. the next business day. Breached deadlines result in financial penalties. The batch scheduler was not able to process the growing volume of jobs or integrate with the customized claims processing application. Deadlines were at constant risk of being breached.

Results With Tidal

Operate in compliance with government deadlines – no SLA missed since deploying Tidal in 2007

Process 25,000 – 100,000 jobs/day flawlessly, increased from 6,000

Seamlessly integrate all inputs including proprietary claims processing application

Easily set up and run customized reports