The most common transactions for today’s insurers are patient-related matters regarding membership, benefits, pre-authorizations and claim payment, maintenance-related issues and long-duration case management. Extensive documentation is associated with each of these transactions and often manual, paper-based business processes. This causes processing delays, inefficiencies and inaccuracies and increased administrative costs.

Manual business processes prevents universal access to case-related documents, preventing effective first-call issue resolution. Additionally, transactions subject to regulatory compliance mandates cannot be managed as organization records.

Insurers needs comprehensive solutions that enable them to expedite provider transactions by supporting timely and consistent workload management. Business process automation solutions can reduce costs and improve efficiency as well as achieve high levels of first-call resolution by supplying personnel with the information needed to respond immediately to provider inquires. Additionally, insurers must also be able to comply with increasingly stringent and wide-reaching regulations and requirements for managing organization records.

With this type of software, transactions received by paper, fax, email or via self-service portals are captured, cataloged and stored in a content management repository. Provider transactions are managed, which offers a single secure interface for documents, host system data and task completion. Configurable business rules automate work distribution, creating and dispensing electronic work items to the appropriate person at the next step in the business process. If supplemental documentation is received at a later date, the solution automatically matches it with the existing work in progress.

The solutions extensive case management capabilities also present credentialing personnel with a single electronic case file contain all associated documents, extensive data from administrative and other business systems along with task guidance and process management features. This not only eliminates manual case assembly, searching and sorting, it also simplifies reviews by providing navigation to all pertinent information and consolidates decision-making data into easy to use interfaces specific to each step in the credentialing process. Additionally, process management features automate credentialing assignment, create task reminders and generate needed follow-up activities.

When provider documentation must comply with regulation such as Sarbanes-Oxley, the application invokes its records management capabilities. The solution supplies efficient capabilities for answering routine provider request immediately and also resolving complied requests rapidly an accurately. Ultimately, it replaces paper-driven processes with more efficient content and process automation.

These interfaces increase productivity and accuracy by allowing provider relations representatives to work within a single, consolidated view. This enables them easy access to all of the information available in order to process insurance transactions, as well as the ability to view tasks in the order in which they must be fulfilled.