Point of Service products have unique characteristics that are different than other products. HCT delivered a seamless and accurate implementation to ensure accurate benefits administration and claims adjudication of a POS claims system – without interruption to other products processed by the system.

Client:

A statewide health plan

Project Definition:

Implement Point of Service (POS) for a national health insurance provider

Project Complexities/Deliverable:

• Consulted during critical planning of claims system selection and membership location for the membership data:
  • Client has two claims processing systems. Both systems require analysis, to determine which is most suitable to house the POS process
  • Client has two membership data repositories. Design optimal solution to store membership data
  • Design solution for claim format POS processing
  • Design two new claim POS processes: Capitation Billing and Provider Data
• Modify in-house claims processing system to process POS claims
• Create mapping from membership data to in-house membership and primary care physician formats
• Integrate membership daily and monthly (reconciliation) processing
• Modify existing in-house provider data stores to include new fields required by the physician formats
• Create physician format mapping and develop the process to create this file weekly

Project Technologies:

• IBM S/390
• COBOL
• JCL
• CICS
• VSAM