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Opus Dei Tech

Representative Engagement · Digital Transformation

Claims Platform Modernization

A complex claims environment required modernization while maintaining operational continuity.

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Context

A payer claims environment carrying years of accumulated business logic needed modernization, while adjudication, EDI exchange and provider payments continued to run every day.

Challenge

A complex claims environment required modernization while maintaining operational continuity.

Approach

  1. 01Documented 200+ business rules
  2. 02Mapped EDI requirements
  3. 03Defined integration requirements
  4. 04Coordinated business and technology stakeholders
  5. 05Supported UAT and phased migration

This anonymized representative engagement reflects supplied project information. Results are context-specific and are not guarantees of future outcomes.

Outcome

Auto-adjudication
60% → 94%
Provider payment cycle
21 → 8 days
Reduction in manual processing
65%

Higher auto-adjudication, a shorter provider payment cycle, and substantially less manual processing.

Key takeaway

Modernization succeeds when business rules, integration requirements, and migration sequencing are documented before technology decisions are locked in.

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