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Overview

Benefit Configuration is the crucial platform connecting Providers, Payers, and Patients (3P). It is a multifaceted process that translates complex contract terms into digital rules governing enrollment, eligibility, and financial cost-sharing. The quality of this configuration is the primary driver for the percentage of Auto-Adjudication achieved in claims processing.

Our proprietary BEN-AI platform transforms manual health plan conversions into an automated experience. Whether handling new benefits, updates, or retroactive adjustments, we ensure flawless execution across FACETS, QNxt, NASCO, MAZE, and legacy Mainframe systems (Rumba, Emulator, etc.).

Plan Design and Setup

Plan Design & Setup

Define foundational benefit structures for Medical, Dental, and Vision plans, including coverage options and benefit hierarchies for consistent processing.

Eligibility and Enrollment

Eligibility & Enrollment

Configure complex rules for employee eligibility based on job status or location, as well as dependent rules and life event processing.

Rate and Cost-Share Configuration

Rate & Cost-Share Configuration

Define financial aspects, including co-payments, coinsurance, deductibles, and annual maximums tied to accurate payment frequencies.

Claims Adjudication Rules

Claims Adjudication Rules

Map medical services (CPT/ICD-10) to plan coverage to create rules for medical necessity and coordination of benefits (COB).

Testing and Validation

Testing & Validation

Utilize BEN-AI to run test claims and enrollment scenarios using sample data; includes validating the entire benefit hierarchy from program level to plan details.

Administration Summary

Administration & Summary

Generate system-readable formats that serve as a reference for Provider EDI exchange and Member Summary of Benefits.

Our Proprietary Tech

BEN-AI Platform: Our intelligent automation solution reviews complete benefit plan designs from diverse inputs—PDF, Excel, Word, and Custom—and converts them into standardized formats for customer system uploads.

Automation Scope: BEN-AI automatically interprets plan designs and codes them directly into your adjudication system, drastically reducing manual entry and improving speed-to-market.

Intelligent Fallout Management: While BEN-AI handles the bulk of configuration, specialized “fallouts” are manually coded and tested with the support of automation to ensure 100% accuracy.

BENEFITS

Streamline the claims process by transforming complex health plan benefits into flawless digital logic across platforms like FACETS, QNxt, NASCO, MAZE, and legacy Mainframes.

  • Achieve clean claims via high-fidelity configuration.
  • Reduce conversion time using automated reviews.
  • Minimize manual effort and overhead through automated coding.
  • Ensure accurate billing of rates, deductions, and cost-shares.
  • Catch discrepancies via regular audits and sample testing.
  • Drive auto-adjudication by converting contract terms into logic.
  • Improve satisfaction with accurate Summaries of Benefits.

30+ Years

Strong Deep-Domain Expertise

BENEFITS

Streamline the claims process by transforming complex health plan benefits into flawless digital logic across platforms like FACETS, QNxt, NASCO, MAZE, and legacy Mainframes.

  • Achieve clean claims via high-fidelity configuration.
  • Reduce conversion time using automated reviews.
  • Minimize manual effort and overhead through automated coding.
  • Ensure accurate billing of rates, deductions, and cost-shares.
  • Catch discrepancies via regular audits and sample testing.
  • Drive auto-adjudication by converting contract terms into logic.
  • Improve satisfaction with accurate Summaries of Benefits.
30+ Years
Strong Deep-Domain Expertise

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