eClaims Managment

Santeon Electronic Claims Management System

The Santeon eClaims Managements System is a highly customizable multi-module based system that covers the full life-cycle claims adjudication including:

• Beneficiary Online Enrollment
• Beneficiary Eligibility Verification
• Beneficially Authorization
• Claims Adjudication with Customizable Business Rules
• Payment Processing and Remittance
• Reporting and Auditing
  
  

eClaims Management Capabilities:

• Automated system that collects data from thousands of customers in various formats
• Connects multiple systems within and outside the organization (Systems are diverse with variety of databases (VSAM, DB2, MS SQL), variety of data types, variety of business rules logic, different administrators.  It connects with systems outside of the State Enterprise, as well as connect with the State’s internal legacy system that are over 20 years old)
• Handles complex process automation for each of the program groups, with each group having significantly different claims adjudication processes and rules (some are fully automated and others are complex rules based processes)
• Intelligent forms for personnel to interact with claims information and data for decision making and data modification
• Web based Portal to apply, check eligibility, get status and edit claims
  
  

The expected impact of the system is:

• Significant savings in claims payments by reducing errors and fraud
• Reduce costs of processing claims (labor)
• Reduced length of time to process claims
• Reduced time to respond to customer inquiries on claim payment and status
• Increased customer satisfaction and responsiveness

The result is an improved process efficiency, improved internal audit, financial and legal requirements as well as federally mandated compliance.

Santeons eClaims Management System (eCMS) Technical Overview:

The Santeon software platform is used by hundreds of payers reliably processing millions of transaction daily with the highest level of transactional integrity and reliability. The following is a summary of the Santeon software infrastructure technology reliability example.