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Claims and Membership Eligibility Testing Services for a leading Medicare/Medicaid services provider in US


Coforge assisted its client, a leading provider of solutions and services for Medicare, Medicaid and CHIP programs, to roll out their platform to support Medicaid and CHIP LOBs for a state in US Southeast in an accelerated manner. Our client had gotten into an agreement with the state’s Department of Health towards to consolidate and upgrade their legacy Medicaid and CHIP platforms with our client’s solution. Therefore, our client wanted to onboard a reliable partner to assist them in launching a MITA/MMIS-compliant Claims/Encounters and Eligibility/Benefit management platform for the state and entrusted us with testing and validation services for the product launch.

About the client

A market leader for providing technology-enabled healthcare platforms and solutions for Medicare, Medicaid and CHIP health plans in US ​

Business Challenge

Towards the new Medicaid/CHIP platform launch, client wanted to achieve early defect detection and/or defect removal through shift left testing, enhanced test automation and high repeatability and predictability for Claims, Encounters, Membership Eligibility and Benefits testing comprising of

  • Claims Intake (EDI 837, HCFA 1500, NSF etc.)
  • Claims adjudication (including Auto Adjudication) – Auto Adjudication for First Pass, Claim corrections, Re adjudication, Claims Repricing
  • Claims payment processing (EDI 835)
  • Claim Status Inquiry & Response (EDI 276, 277)
  • Encounter Processing for Capitated Providers
  • COB claims
  • Membership Eligibility and Benefits (EDI 270, 271) etc.

Our Solution

Coforge set up a Healthcare Testing Center of excellence for the client in a very short span of time and prevented any major disruption from occurring to client’s platform and LOB launch plans.

  • Domain experts and highly experienced staff for quick understanding and knowledge transition, thereby reducing the risk of the vendor leaving early
  • Leveraged Medicaid/CHIP Claims domain SMEs in the training of testing resources.
  • Core-flex staffing model to support variances in claims processing volumes
  • End-to-End functional testing of implemented solution including claims/encounters testing, claims migration testing, membership eligibility/benefits testing, EDI gateway integration testing and others
  • Besides functional/blackbox testing, Coforge’s Testing Services for the client also comprised of horizontal testing services such as System Integration Testing, Regression testing, Usability Testing, Performance Testing, Automation Testing, Test Environment and Test Data Management

Delivering more value

Coforge was able to add value to client’s program with the following outcomes

  • Increased sprint velocity to reduce time to market
  • Reduced overall quality engineering cost by leveraging core-flex model and offshore operations
  • Shift-left of QE/QA efforts for early detection of defects
  • Leveraged our proprietary AI/ML use cases for defect prediction, test case generation and optimization, requirements traceability, continuous monitoring etc. for test process automation


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