Application & Database Support for Javelina– Benefit Administration System

Background

Client – a leading third party administrator (TPA) uses ‘Javelina Benefit Administration System’ (owned by Eldorado, Mphasis) to run their benefit management service line. After detailed deliberations internally, followed by a strict due diligence process, client decided to rope in 4iSoft as a partner to support Javelina application. Client had multiple objectives – Enhance level of customer support, Operational ease, Lower cost of operations and Ensure strict compliance to HIPAA norms.

Business Challenges

Client faced multiple challenges -

  • Strict time bound activities, which needed to run with clockwork precision
  • Needed to interface with IT teams of clients as well as insurance carriers to ensure database is current and updated at all times.
  • HIPAA compliance had to be strictly adhered to; failing which severe penal clauses can be invoked.
  • Limited in-house manpower
  • Directive to reduce operational costs

Client chose 4iSoft

Following a strict due diligence process, client chose to partner 4iSoft as the company offered best of both the worlds – deep expertise in the functional aspect of benefit administration and strong IT capabilities.

4iSoft Solution

4iSoft deputed a data analyst along with a team lead at the clients’ site, while the rest of the team, including application support personnel and database developers, worked through extended development center.

SLA signed, included a commitment on 24X 7 support, has been adhered to – both in letter and spirit till date.

Scope of Work

4iSoft undertook the following activities on behalf of the client -

  • Eligibility Data Management - Record creation, updation and termination
  • Open Enrollment Management – On a new client sign-up, their database is merged with TPAs’, prior to ‘going-live’ in the system.
  • Manage Inbound Data – Update TPAs database with the client’s eligibility data
  • Manage Outbound Data – Send 834 files to keep Carrier’s database in sync with TPA’s.
  • Data Validation for HIPAA Compliance – Inbound and outbound data is verified for HIPAA compliance using tools – Faciledi and Claredi
  • Maintain Benefit Accumulators – Includes data on accumulator services like ambulance, physiotherapy, nursing etc
  • Generate Billing Information – As per the accumulator services being used by patient(s).
  • Provider and Network Maintenance – Data pertaining to providers and networks are maintained and updated to keep them current
  • Set-up new EDI Clients – Mapping of new client database with existing database of TPA, especially EDI 834 segments.
  • Non EDI Data Management – Conversion of eligibility information from spreadsheet format to XML and further processing within the system.
  • Maintain Pre-authorization data – If the claim contains a service that requires authorization, Javelina will determine if an authorization within the patient record matches the service conditions on the claim.
  • Medicare fee rule management – Executed quarterly, the fee schedules are updated for different hospitals / localities.
  • Generate Actuate Reports – Over 2 dozen reports generated for data validation as well as decision support tasks.