LiveClaims architecture follows the Micro-services architecture and orchestrated through API Gateway. Developing a loosely coupled components brings about separating out common activities, tasks and business events into common reusable components. The API Gateway is the core service mediator for a successful MITA architecture implementation.
API Gateway and Micro-services are flexible in integrating the system with external sources or COTS product coupled with security management. Each component interacts through API Gateway/Service Discovery and all the interfaces follow the standard (X12).
Application is engineered to interact to legacy or public administrative sources to facilitate data migration and with other necessary data sources.
LiveClaims supports Big Data (NoSQL – MongoDB), HBase / Hadoop. Healthcare Claims adjudication is such a bottleneck and always a challenge in processing them faster. LiveClaims with its modern architectures allows the database to scale horizontally (Scale Out) and high availability with a radical increase in performance on the processes.
LiveClaims is aligned with business rules by integrating with LiveRules business rules engine, which provides out of the box integration for web service, messaging interface and the ability to handle complex business rule decisions. LiveRules provides the ability to adapt to ever-changing healthcare policy and mandates, hence focusing on the functional versus the technical.
LiveClaims – Modules
LiveClaims uses the history data to adjudicate the claim to look at various duplicate claim submission possibilities. The duplicate claim process is a fully configurable solution and thus allows the changes to production in near realtime.
Limits and conflicts
LiveClaims uses the history data to validate various limits and conflicts within the submitted claim. This allows the huge cost savings when there are limits that are defined, the services that are billed has conflicts within or in the history of data. This is fully configurable solution as well.
LiveClaims uses the history data to validate the National Correct Code Initiative. The data set is used to validate the current claim against the dataset within and history claim data. This is a fully configuration solution within the LiveClaims system and allows faster deployment in minutes.
There are various pricing that are supported by LiveClaims. Professional Pricing, Institutional Pricing (DRG, Inpatient, Outpatient, etc), Auto Lab, Dental and more pricing. The pricing is based on various rules and they are configured in LiveRules for easily change when there is a pricing change is required.
The claims adjudication requires various edits to checked against. Some of them are Validation, Member (Beneficiary), Provider, Reference Data, History (Limits, Conflicts, Duplicates, NCCI, etc), Prior Authorization, etc. All these edits allows the claim to suspend, deny and/or pay. This is a critical element for the processing of claims within LiveClaims.
The Provider module in LiveClaims manages the entire Provider workflow. This allows the provider to update/edit their existing enrollment. This module also allows them to enroll them in LiveClaims. There are specific rules that are attached to the providers which would be run against to validate the policies before any changes are made to the provider file.
The Beneficiary module is to manage the entire beneficiaries in LiveClaims. This allows the eligibility, benefit service package, etc to be defined in a beneficiary file. The beneficiaries has a lot of validation rules to be run against before the changes are made as well.
Prior Authorization is a module where the providers are allowed to request a Service for a given beneficiary in advance to get the prior approval. This allows the claims to go through without holding them back as it is already authorized. This allows the on-time payment. Prior authorization has its set of rules to go through before approval.
The reference data are again heart of the LiveClaims as well. This contains various reference data such as procedure codes, diagnosis codes, type of service, revenue codes, pricing data, etc. This is a critical data that is used to validate the claim data for their correct and accurateness.
LiveClaims – Key Features
Support for multi-source claims (via EDI, mail, fax, web, web services), provider enrollment, prior authorization entry via multi-channel, and flat file
A proven technology platform with extensive throughput of claims processing based on our big data implementation
Efficient, accurate, and timely claim processing for providers and beneficiaries
Highly automated on healthcare policies by reducing the claim resolution process
Integrated machine learning techniques to guide and help automate across systems
Post-payment and pre-payment detection capabilities to analyze past incidents and automate claim payment
Customer controlled and configurable business rules engine
Reduce claims costs and risk through proactive detection, recovery of claims payments
Developed on NoSQL MongoDB for any big data systems. The system Scales Out rather than the traditional RDBMS way of Scale up
Built for Cloud Deployment – As needed, it can scale out on the performance without any code changes
One half reduction on operational cost
Improve customer satisfaction and retention by making it easy to provide detailed and sophisticated analytic assessments of the claims
Ability to move into new markets in months, not years
A complete modern web based healthcare claims processing architecture
Want to Learn More about LiveClaims
If you like to learn more about LiveClaims, please contact us for a demo. This will help us in showing the offering from Yorosis about what LiveClaims can bring it to the table and how it can help modernize your claims processing needs.