The Solution
TEKNOVARE, working as a subcontractor, managed and delivered the business rules and rules engine for eligibility and claims processing system for this national healthcare provider.
TEKNOVARE's involvement on the project included:
- Assisted the business analysis team and the provider's Policy and Compliance group in developing policy requirements to a level of detail that was sufficient to implement as business rules.
- Designed and implemented business rules for processing medical claims for the provider’s specific healthcare programs.
- Designed and implemented business rules for determining eligibility for the provider’s specific healthcare programs.
- Developed automated unit tests and a test harness to automate the regression testing of the above rule sets.
- Worked with the provider’s QA testing team to perform acceptance testing on the claims processing and eligibility rule sets.
- Developed a strategy to allow the provider’s Policy and Compliance group to maintain the eligibility and claims processing rules.
Eligibility and Claims Page 3 of 3