Abstract Icon - SDLC Case Study


A technology solution subsidiary of one of the nation’s top 10 largest health insurers was looking for a way to improve and streamline their compliance workflow and reporting that must be submitted to different states for Medicaid claims. In particular, they needed to include encounter data, but in compliance to individual state requirements.

SDLC Partners leveraged existing technology as the foundation for creating the Encounter application – a configurable, auditable and extensible system, enabling business rules and configuration-driven data processing.

The Encounters application (ENC) applies business rules on claims data; creates and submits the compliant file for each state.

About the Client:
As a technology solution subsidiary of one of the top four Blue Cross and Blue Shield-affiliated insurers, this consultancy serves eight national health plans, providing cutting-edge technology and unparalleled industry knowledge.

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The Challenge

Each state mandates that Medicaid health plans submit encounter data, detailing the patient-provider interaction with specific, traceable information.

This encounters data, as part of claims data, must be configured to each state’s requirements, otherwise, the claims are denied and auditable for compliance.

In order for claims to meet regulatory requirements and be paid correctly and timely, the information submitted needs to be accurate, complete and compliant.

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The Solution

At its core, the Encounters app goes far beyond basic data processing and gives end-to-end control over Medicaid claims data according to individual state rules, plus:

  • End-to-End Auditability – Identifies key approvals and data submission points throughout the claim process.
  • Track and address state responses to Medicaid submission – Manage state inquiries for information or clarification directly through the app.
  • Configure reporting data for multiple states – Quickly submit to several states at once, as well as see how the claim needs to be addressed for individual state mandates.
  • Business Rules Driven – Configurable business rules allow quick defect fixes without code changes and product deployment effort.
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The Results

SDLC Partners collaborated with this health plan tech accelerator to create an application that applies business rules on claims data and creates a more efficient, auditable and configurable data submission customized to meet each state’s Medicaid regulations.

The project yielded several benefits to the client:

  • 25-30% reduction in development effort for onboarding new states.
  • Creates more efficient, auditable and configurable data submissions for Medicaid claims to meet individual state requirements.
  • Saves time on error corrections, meeting SLAs (Timeliness, Quality, and Accuracy) with the States.
  • Supports successful quality metrics for Risk Rating reviews, compliance, and encounters.

The Encounters application is a simple, yet powerful tool for submitting more accurate and correct Medicaid claims to individual states, complying with their specific and varying requirements.

Learn more about how the Encounters application can improve the accuracy, compliance and efficiency of state-based Medicaid claim submissions by contacting SDLC Partners.

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