IT Services and Solutions for Health Insurers

Software that automates member onboarding, eligibility verification for particular health plans, and creating enrollment records in compliance with HIPAA. It can automate the processing of EDI 834 transactions and can be integrated with federal and state marketplaces to handle ACA, VA, and Medicare enrollments.

Solutions that enable actuarial teams to analyze demographic, provider, and loss run data, model financial risks, and calculate plan-specific premiums. Such solutions can be powered by machine learning (ML) models to forecast claim expenses based on disparate data like population health stats, utilization patterns, and healthcare costs.

Software designed to automatically process insureds’ health and socioeconomic data, evaluate individual and group risks, and calculate personalized health insurance premiums. It applies user-defined rules and AI algorithms to assign the optimal risk-adjusted premiums. Custom solutions can automate risk adjustment under HCC coding and other specialized models.

Systems that automate the entire policy lifecycle, from issuance through endorsement to renewal or cancellation. They offer centralized storage and rule-based updating of member plan details, coverage limits, and benefit structures. Such solutions let health payers automatically generate explanations of coverage (EOC), including EOCs for complex plans like Medicare Advantage.

Software used to automate claim capture, validation, adjudication, and payment. It can process EDI 278 prior authorization requests and EDI 837 claim transactions and generate EDI 835 remittance advice and explanations of benefits (EOB). Advanced solutions can apply AI-fueled ML, image analysis, and natural language processing (NLP) tools for multi-format claim evidence processing and fraud detection.

Collaborative digital platforms for insurance and healthcare teams to manage innovative health plans and care programs for insureds with chronic diseases. Such software includes monitoring and analytics modules to track interventions, evaluate treatment outcomes, and identify gaps in care. Payers and providers can handle prior authorizations and medical necessity reviews via role-based utilization management dashboards.

Software that monitors operational compliance with the necessary legal frameworks (HIPAA, AML/KYC, HEDIS, CMS, NAIC, NICB, etc.). It tracks service events, transactions, and data access logs and notifies responsible employees about compliance breaches. Such software also automates the creation of regulatory reports.

Specialized solutions that automate health insurers’ back-office functions, such as document management, medical billing, premium payment processing, reimbursement payments, and general accounting. Such solutions can include advanced analytics for accurate detection of payer- and provider-induced fraud, waste, and abuse (FWA).

Software that helps health insurers centralize insured information, manage omnichannel leads, and plan customer service (handling enrollments, claims inquiries, support cases, and more). CRM automates quote generation, policy and claim status updates, personalized policyholder communication (emails, text messages), and reporting. Advanced CRMs feature intelligent customer behavior analytics and AI-supported service planning.

Solutions that make it easier for health payers to manage relationships with healthcare providers and pharmacy partners. These systems can automate the creation and updating of partner contracts, verify healthcare organizations’ credentials in compliance with NCQA standards, and track partner performance based on tailored KPI sets.

Web and mobile solutions that give members secure access to their insurance plans, digital policies, and benefit summaries. Insureds can apply for coverage, pay premiums, file claims, and track claim resolution statuses via an app. To provide 24/7 user support and natural language search via member apps, you can implement context-aware AI assistants powered by LLMs. Such apps can also offer personalized care reminders and integrations with telehealth services.

Web platforms that provide self-service options, secure access to insured policy data for eligibility verification, and live communication tools for healthcare providers. Providers can file prior authorization requests and claims, share utilization and specialty care details, track claim settlement statuses, and open disputes for denials. The portal can be integrated with providers’ billing systems to automatically import reimbursement invoices.

Digital platforms that allow individuals and businesses to compare multiple health plans and enroll in the best-fitting programs, including federal options (Medicare, Medicaid, etc.). They automate open and special enrollment transactions, process premium payments, and calculate premium subsidies based on IRS guidelines.

Software that enables HIPAA-compliant transmission of protected health information (PHI) between insurers and healthcare providers using ANSI X12, FHIR, and HL7 protocols. Such software automatically converts multi-format insurance-relevant data to and from standardized electronic formats (CSV, JSON, etc.), maps data flows between payer and provider systems, and auto-validates the sent and received data.

Solutions that let health payers automate the calculation, forecasting, and reporting of tailored metrics across sales, customer experience, underwriting, claims, and risk management areas. Advanced systems provide ML-powered predictive analytics and intelligent suggestions on optimizing service workflows, insurance decisions (e.g., policy pricing, claims triaging), and financial plans (cash prediction, loss reserving, etc.).

Software that helps payers manage behavior-based health insurance programs. Such solutions collect data on insureds’ health-related behaviors from consumer health apps and analyze policyholders’ adherence to treatment, fitness, and preventive care targets. They dynamically adjust premiums and distribute rewards based on predefined rules.

Software that automates payouts based on predefined events (e.g., a pandemic outbreak, policyholder ICU hospitalization, or changes in insured health indicators). It continuously analyzes data from customers’ wearables and public health databases and enforces payments upon trigger events. Such solutions can employ tailored smart contracts for instant, fully automated payouts.