Smart claim application designed for non registered users for a US based Supplemental Health Insurance Provider

Synopsis

In this age of digitization, companies across industries are shifting to automated processes. Our client not only wanted to invest in a smart claim application for the existing users but also for non-registered users. They understood the need for customer centricity across their organization and needed our help in achieving a seamless experience and reduced complexity in filing claims for their guest users.

To support client’s goal of expanding their Digital capabilities and to make the process easier for the individual policyholders (Columbus & NY) they wanted to provide a guided experience and to provide an alternative to claims being Faxed or mailed to the users not registered in the Claims portal.

About the client

US based Supplemental Health insurance Provider ​

Business Challenge

Client wanted to reduce the time of claim processing for non registered users bypassing registration process, email verification, user agreement acceptance. The claims department wanted non registered policyholders to submit claim online as guest before registering themselves in company’s portal.

Our Solution

  • Client helped the unregistered user to file a claim without imposing any registration process on them. Policyholder is free to file minimum of 5 claims
  • Smart Claims application through guest user-
    • Smart claim registered users can only submit claims for Accident, Cancer, Specified events hospitalization and Intensive care. With this change implemented user can now file claims for short term disability, vision, dental, life, group short term along with the previously mentioned events as GUEST or as a registered user.
    • Coforge provided benefit level testing solution which covered end to end testing for all the LOBs. Each question or combination of questions asked during claim filing were mapped to benefits. The most difficult LOB being CANCER were tested for the benefits Chemo-Injection, Chemo – Oral, Experimental treatment, Radiation, Skin, Surgery and many more.
    • Integrating interfaces with PEGA, FileNet was tested to work with two applications simultaneously, Integration testing includes Transaction, questionnaire validation, and interface testing.

Delivering more value

With the solution implemented, the number of claims processed will drastically increase as any non-registered user can file claims for any line of business.

  • Total Claims processed each day by the client are 34K- 42K which is approx. 175K – 190K weekly.
  • Smart Claim web and mobile-based claims account for 13K – 19K claims daily, of which COL regions claims are 12K -18K and NY region claims are 1K -1.6K.
  • Wellness claims which are straight through the claim process account for 16K -20K for the COL region whereas it is 1200-1500 claims for the NY region daily.
  • Non-Wellness manual claims account for 14K-16K for COL region whereas it is approx. 1500 claims for the NY region.
  • There are around 400-500 specialists involved in processing claims for the client.
  • Total Claims processed each day are 32K- 40K which is approx. 165K – 182K weekly.
  • Smart Claim web and mobile-based claims accounts to 13K – 19K claims daily.
  • Wellness claims which are straight through the claim process account for 16K -20K for the COL region whereas it is 1200-1500 claims for the NY region daily.
  • Non Wellness manual claims accounts to 14K-16K for COL region whereas it is approx. 1500 claims for NY region.
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