National Healthcare PPO

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National Healthcare PPO

CLIENT STORY
A National Healthcare Preferred Provider Organization (PPO) turned to Tallan for help in migrating their existing claims management system, while gaining more transparency for their overall claims intake process. With EDI experience and a suite of products available, Tallan was able to provide the PPO the necessary tools to build an effective claims intake process with end-to-end visibility.

THE CHALLENGE

A National Healthcare PPO based out of Maryland turned to Tallan for its expertise in BizTalk solutions and services. The organization’s initial goal was to work with Tallan to migrate their existing claims management system to Trizetto QNXT.

However, during the project the PPO quickly realized they required more transparency and manageability for their overall claims intake process. Tallan needed to build a solution that answered the needs of the organization that included:

– Migration to Trizetto QNXT Claims Administration platform

– A variety of Claims enrichment functions to be performed prior to claims ingestion, as well as mid-process (Pre/Post Agent)

– Eliminating the lack of end-to-end visibility to Claims from receipt to acceptance in QNXT

– Working through large files with throughput limitations

THE SOLUTION

With a high volume of EDI experience and a suite of products available, Tallan was able to provide the National Healthcare PPO all the necessary tools to build an efficient and effective claims intake process. The new claims intake process delivered a solution to the Health Plan Provider with the capabilities of utilizing:

A Powerful Enrichment Model

Powerful enrichment model using familiar development tools

A Data Correlation Model

Data correlation model for tracking claims into QNXT provides the Organization end-to-end claims visibility

Minimization of BizTalk Dependencies

Minimal dependence on BizTalk and skillsets required to support it

OUR TOOLKIT

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