Harvard Pilgrim improves eligibility and claims efficiency

Faced with aging systems that struggled to keep up with evolving demands, Harvard Pilgrim Health Care found new agility with Oracle Health Insurance.


We were facing a strategic need to upgrade our systems and sought a solution that supports our objectives and helps us achieve transformation. Oracle Health Insurance enables flexibility for our business, while allowing for growth and change while we are undergoing that transformation.

Deborah NortonCIO and Senior Vice President, Operations, Harvard Pilgrim Health Care

Business challenges

Harvard Pilgrim recently celebrated its 50th anniversary—beginning as a staff model HMO and expanding across New England, offering multiple product lines, including Medicare Advantage.

As it begins its next decade, Harvard Pilgrim is focused on three strategic imperatives: stabilizing performance and generating investment income; creating differentiating experiences and health outcomes; and growing profitable membership.

The health network was getting by with its aging—but reliable—legacy platform. However, the release of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) was a turning point—Harvard Pilgrim knew a full IT transformation was critical to ensuring the flexibility and agility required for compliance and to achieve its strategic imperatives. Oracle Health Insurance was the foundation for its transformation.

Flexibility and agility is critical in our industry. At the onset of the COVID-19 pandemic, this was even more apparent. We were receiving new instructions from regulators on a daily basis—and Oracle Health Insurance solutions enabled us to react quickly and efficiently to these changes.

Deborah NortonCIO and Senior Vice President, Operations, Harvard Pilgrim Health Care

Why Harvard Pilgrim Health Care Chose Oracle?

Harvard Pilgrim has a long, positive history working with Oracle—and a large Oracle E-Business Suite footprint. At the start of the transformation, it made the decision that all solutions should be Oracle-based. 

The company was looking for a component-based benefit administration and claims adjudication product, and Oracle Health Insurance delivered a modern, flexible, and reliable option.


Harvard Pilgrim set out to transform its IT infrastructure—and improve the customer experience. Declared a “best-in-class” claims shop, the bar was set high. Further, the company was focusing on ambitious growth, forecasting 2020 membership across various markets and product lines to be 1.2 million.

The company did not want a big box solution, instead  it was seeking a componentized solution that enables it to deploy additional modules as the transition continues. Oracle Health Insurance, a component-based solution built on a service-oriented architecture (SOA), delivered on this requirement.

Since implementing Oracle Health Insurance, the company’s auto-adjudication rate now exceeds 92%, up from 85%. Spending is decreasing—despite adding multiple medical management and utilization programs. Harvard Pilgrim also processes claims faster and more accurately, further elevating the member experience.

As the COVID-19 pandemic drastically changed operations across the healthcare industry, Harvard Pilgrim rose to the challenge, thanks to its preparation and infrastructure investment. Since March 2020, staff is working and managing systems remotely—and operations are working efficiently and the customer experience is not impacted.

Harvard Pilgrim’s Oracle solution combines technology and business processes—enabling staff to seamlessly manage eligibility, assess claims, and respond quickly to incoming regulator requests related to utilizations management. The flexible, rules-based system supports the need for ever-increasing agility.

Published:January 27, 2021