Oracle Press Release

Oracle Launches Oracle Insurance Claims Adjudication for Health

First Application in Next-Generation Suite Offers Higher Auto Adjudication Rates, Improved Quality and Transparency, and Superior Scalability and Flexibility

Redwood Shores, Calif. – Jan. 18, 2012

News Facts

Oracle today introduced Oracle Insurance Claims Adjudication for Health, a highly configurable, rules-driven claims system that helps payers reduce administrative costs and increase member and provider satisfaction. The application enables healthcare payers to:
Easily configure business rules to process more complex claim scenarios automatically, increasing consistency in claims payments while reducing the number of claims processed manually;
Achieve more accurate first-pass adjudication of claims, reducing the number of claims requiring manual review and thus lowering administrative costs;
Create business rules to precisely reflect the benefits offered, avoiding manual errors that can lead to over- or under-payment of claims;
Accelerate payments to providers and members, improving service levels;
Avoid payment adjustments by automatically detecting and flagging potential errors across all claim types.
Using a user-friendly approach to business rules creation, payers can quickly – and without the need for custom software code – change the software’s settings to meet new regulatory requirements and support new products or benefits.
With Oracle Insurance Claims Adjudication for Health, insurers can create rules governing any type or set of codes – including procedure, diagnosis, provider, facility and custom codes. The solution is International Classification of Diseases, 10th Edition (ICD-10) compliant, preparing U.S. health insurers for the 2013 phase-in date.
The solution supports major medical, dental, vision and behavioral health claims. The application is designed to scale for very high volumes to support consolidation of various claims engines into a single instance.
Oracle Insurance Claims Adjudication for Health integrates easily with financial systems – such as Oracle E-Business Suite – for end-to-end claims processing and payment. Additional out-of-the-box integration points support the exchange of data with customer relationship management (CRM), membership accounting, provider management and other critical payer systems, as well as with third-party systems.
Built on the same modern technology as Oracle Fusion Applications, Oracle Insurance Claims Adjudication for Health is the first application in a planned, next-generation suite of core solutions for health insurance companies. The component-based architecture of these applications allows healthcare payers to avoid a risky “big bang” replacement of their current systems, making the most out of their existing IT investments.
The claims application was recently implemented at Harvard Pilgrim Health Care, Inc., the number one private health plan in America for eight straight years, according to the National Committee for Quality Assurance.

Supporting Quotes

“In a highly tumultuous market, healthcare payers who can reduce their administrative costs by even a percentage point can achieve a huge competitive advantage. In addition, payers are seeking to position themselves for future market requirements such as healthcare reform. A high performing, flexible, auto-adjudicating claims system can serve as the foundation for transaction efficiency, and as a timely and reliable data source that will drive future market opportunities and better health and clinical decision-making,” said Janice Young, program director, payer IT strategies, IDC Health Insights.
“Health insurers are targeting their claims operations with the goal of reducing costs and increasing agility related to benefits, networks and re-imbursement models. However, they are often constrained by inflexible legacy systems that are expensive to adapt. Oracle Insurance Claims Adjudication for Health offers a flexible, highly scalable component approach which enables a phased implementation path. The rules-based solution offers a higher level of automated claims adjudications, improves quality and transparency, and provides the flexibility that insurers need to outpace the competition,” said Michiel Walsteijn, vice president, Oracle Health Insurance Solutions.

Supporting Resources

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Contact Info

Caroline Vespi
Oracle
+1.650.506.8920
caroline.yu@oracle.com