Large Health Plan Streamlines HealthRules® Implementation

Client Snapshot: 700,000+ members | 34,000+ network providers | 40 hospitals | 110 urgent care centers

Challenge: Transitioning from Legacy System to HealthEdge’s HealthRules®

Tasked with safeguarding both performance and financial stability, the healthcare plan’s CIO confronted critical hurdles:

• Legacy Constraints: The client’s system—over three decades old—could not scale for 5 years of projected growth and lacked digital connectivity between providers and members.
• Low Adjudication Rates: Limited automation resulted in lower first-pass claim approvals and increased manual workloads.
• Limited In-House Expertise: The client required external guidance for HealthRules^® configuration.
• Incomplete Documentation: Fragmented requirements and inconsistent documentation for HealthRules Payor hindered clarity.
• Multi-Line Complexity: Addressing unique needs of Exchange, Commercial, Medicare, DSNP, and Medicaid with staggered implementation dates.
• Process Integration: Integrating best practices across provider, pricing, Guiding Care, member, claims, and benefits added further complexity.

Solution: Comprehensive Workflow Implementation and Enhancement

Alivia Analytics implemented a multi-phase consultative approach to guide the configuration process:

Phase 1: Assessment & Requirements Review

• Participated in in-depth requirements and design sessions with subject matter experts across provider, pricing, GuidingCare, member, claims, and benefits.
• Reviewed and analyzed existing documentation to identify gaps and inconsistencies.

Phase 2: Recommendations & Best Practices

• Developed best practice recommendations tailored to HealthRules^® Payor, ensuring alignment with industry standards.
• Provided detailed feedback on HealthEdge’s configuration documentation, highlighting areas for improvement.

Phase 3: Validation & Stakeholder Alignment

• Facilitated follow-up sessions to validate proposed configuration enhancements.
• Ensured all recommendations addressed the complexities of managing five lines of business with staggered implementation dates while setting the stage for subsequent phases of the overall transformation.

Phase 4: Modernization & Scalability

• Ensured the updated platform could accommodate five years of projected member growth, reducing the need for frequent system upgrades.
• Established a digital thread to connect members and providers, streamlining claims processing and enabling faster access to vital healthcare data.
• Guided the client’s IT teams to align the solution with the CIO’s overarching modernization strategy, acting as the “glue” across all related initiatives.

Alivia’s Role: Implementation Leadership and Process Development

Alivia Analytics served as the expert partner by:

• Deploying subject matter experts who specialized in critical configuration areas.
• Leading requirements review sessions and providing strategic, consultative feedback on HealthEdge’s documentation.
• Guiding the client in establishing clear, best-practice configuration standards to optimize their HealthRules Payor implementation.
• Coordinating across multiple business lines to ensure that configuration recommendations were applicable to Exchange, Commercial, Medicare, DSNP, and Medicaid.
• Served as the unifying partner across all modernization efforts, ensuring the legacy platform, new HealthRules configuration, and digital connectivity goals worked cohesively to support the client’s growth objectives.

We helped create and train two new positions dedicated to supporting the workflow system, ensuring long-term sustainability of the improvements.

Outcome: Increased Efficiency and Sustainable Operations

The client is positioned to achieve significantly higher first-pass adjudication rates, modernizing a 30-year-old system to handle five years of projected membership growth. 

Enhanced digital connectivity between members and providers supports faster, more accurate claims processing and real-time access to essential healthcare data. 

By aligning directly with the CIO’s strategy, the initiative lays the groundwork for ongoing optimizations—potentially delivering a 10X improvement in process clarity, system reliability, and overall operational efficiency.