The solution

Migration to common A&G platform with strong automation and reporting

By partnering with Virtusa, the company consolidated disparate processes, automated manual methodologies, implemented strong reporting, and migrated to a unified, centralized platform.

Virtusa designed a solution promoting uniform and equitable responses to appeals & grievances claims. We helped the payer migrate the scattered and siloed legacy A&G systems to a common platform with these primary components:

Intake: Virtusa crafted an enterprise intake process that accepts A&G claims in four formats: verbal, written, fax, and web. Case processing uses a well-defined SLA in the Pega decision algorithm. Automated intake includes digital agents that do not require human interactions.
Data and reporting: We made data access seamless with an internal SOA layer that interacts with membership source systems. Custom-built data structure maintains online traction data. The reporting data layer uses regular automated BIX extracts.
Automation: We fine-tuned an automated decision model with Pega robotic process automation (RPA) on commercial lines of business.
Document Repository Integration: Integrated existing document repository to add/ attach documents to the cases.
Artificial Intelligence: We populated required fields automatically and the solution also checks for duplicate/similar types of previously closed cases and gives case insights for quick resolutions.

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