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.