Cigna Improves The Performance, Agility And Scalability Of Claim Intake Process With Progress

To stay agile in an ever-evolving regulatory climate, Cigna turned to Corticon to automate the business decision process within its holistic enterprise claim intake system.

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Corticon

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Challenge

Reduce complexity and improve quality of existing process for routing health insurance claims in compliance with HIPAA 837.

Solution

Built a revised claim intake system using Progress Corticon.

Result

Increased the accuracy and timeliness of claim intake routing; reduced maintenance and support; increased agility to respond to business and regulatory change.

Story

Challenge

In highly regulated markets such as healthcare and insurance, the ability to quickly react to new legislation as well as changes in state or federal regulations remains a top priority.

Cigna is a global health service company with approximately $35 billion in annual revenue focused on helping people improve their health, well-being and sense of security. Cigna is dedicated not only to meeting stringent and evolving policies and mandates, but doing what it can to get ahead of them. 

As with all health insurance companies operating within the U.S, Cigna receives and processes Electronic Data Interchange (EDI) 837 healthcare claims. This format was established to meet the Health Insurance Portability and Accountability Act (HIPAA) requirements for the standardized electronic submission of healthcare claim information, such as a patient description, the patient’s condition for which treatment was provided, the services provided and cost of the treatment.

To better process these claims and determine customer eligibility, Cigna wanted to build a holistic enterprise claim intake system. A business rules management system (BRMS) would play an important role in this system, automating critical business decision-making and supporting the creation, testing and deployment of business rules.

Solution

Cigna turned to Progress® Corticon® BRMS to automate the business decision process within its holistic enterprise claim intake system.

Cigna chose Corticon to enable automated and integrated business decision support. By separating the business rules from the underlying application code, Corticon provides Cigna with the agility to better develop, test and deploy new rules or modify existing rules.

The ability to centralize Cigna’s rules-based processing has improved both the efficiency and accuracy of the claims routing process, while also reducing maintenance. Additionally, Corticon helps Cigna respond better to business and regulatory change, providing Cigna with the flexibility to scale the system by 2.5 times current daily volume.



Result

Using Corticon, Cigna’s new claim intake system leverages automated business rules to determine a customer’s eligibility for payment based on factors such as coverage, medical procedure and who submitted the claim, among others. It then determines which claims management system the claim should be routed to for processing.

“The goals for us from a customer and business perspective were to ensure accuracy, timeliness of processing and ease of maintaining and support,” said Greco.

The ability to centralize Cigna’s rules-based processing has improved both the efficiency and accuracy of the claims routing process, while also reducing maintenance. Additionally, Corticon helps Cigna respond better to business and regulatory change, providing Cigna with the flexibility to scale the system by 2.5 times current daily volume.
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