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Smart Claims application development and testing for a US based Supplemental Health Insurance Provider


In this age of digitization, companies across industries are shifting to automated processes. Our client wanted to enhance their existing smart claims adjudication application to support new LoBs and guest users to advance their goal of making the claims submission process easier. The client wanted to provide a guided experience to claims portal users (both registered and non-registered) offering an alternative pathway for claims submissions.

About the client

Large US-based Supplemental Health Insurance Provider

Business Challenge

Although the client had an existing smart claims app, it only supported a couple of LoBs and registered users. The client wanted to improve the Claims Form submission process by providing an electronic claims submission route to additional LoBs and non-registered users. The client wanted the new claim submission to be an interactive, online, event-driven process. Some of the client’s providers were still filing claims manually through paper forms which were time-consuming, tedious with the probability of human error. In the manual process, the client was also facing issues with the collection and storage of completed claim forms; adjudication and correction wherever required. They wanted to reduce the time of claim processing for non-registered users also permitting them to submit claims online as guests before registering themselves in the company’s portal.

Our Solution

Coforge built web and mobile applications that enabled policyholders to file claims digitally resulting in lesser resolution time and more accuracy. Coforge adopted the following approach in this engagement.

Understand the as-is process and workflow to perform requirements gathering and write Epics and user stories. Enhancement of the hybrid HTML5 app to support new LoBs and non-registered/guest users. Coforge provided benefit level testing solution which covered end to end testing for all the LOBs. End to End testing approach was taken for verification on different OS, browser, and mobile platforms. Pega and Filenet interfaces were tested that included Transaction, questionnaire validation, and interface testing. A data-driven automation framework was developed using UFT to execute claims validation tests for all scenarios.

With the new smart claims application, users can now file claims for all LOBs- accident, cancer, hospitalization, intensive care, short term disability, vision, dental, life, group short term- as a registered as well as a guest user.

Delivering more value

Empowered app users to submit potential claims with ease and without any external assistance. Claim settlement turnaround time reduced to 3-4 business days which was more than a week, earlier. The number of claims processed through smart claims web and mobile apps was 13k-19k per day, which was a huge increase over the manual submission as any non-registered user could file a claim. Automated testing saved 30% of manual test execution effort.

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