An integrated insurer claim processing and reporting solution for mandatory compliance.

Business Need

The government implemented various mandatory rules and regulations for the insurance industry. Among them, the Section 111 of the Medicare, Medicaid and SCHIP Extension Act mandated the claim reporting to Center for Medicare & Medicaid Services (CMS) by the Responsible Reporting Entities (RREs) to enable CMS to pay appropriately for Medicare-covered items and services furnished to Medicare beneficiaries. Our client wanted to provide a value added service to RREs, who are their existing clients, with an automated system to submit and report the claims to CMS on a quarterly basis. Following were the client’s business requirements:

  • A scalable system to receive and process the claim files in various formats including Excel, Flat File and XML formats from the claim data providers.
  • A front end system to add or update the claims with a feature to send frequent updates to the data providers on the claim status changes.
  • A validation engine to validate the claims based on the CMS guidelines with a provision to rectify the errors.
  • An automated process to generate and send reporting files in EDI and flat file formats to CMS based on the specific rules.
  • A process to exchange relevant claim data with other Reporting Agents
  • A history tracking system where the users can view the claim details, the changes to the claim and the file exchange details to ensure HIPAA compliance.
  • Single Sign-On (SSO) functionality for smooth and secure switching from one application to another based on the user’s access rights.


The client expected a meticulous system to handle large volume of data transactions. The data had to be effectively transmitted across various targeted locations on time without any errors. The major challenges faced while building this application are listed below:

  • The reporting process involved inward and outward transactions of large number of files in multiple formats like XML, flat file, EDI and excel with huge volume of data. Managing such data files without impacting performance was complicated.
  • Organizing large number of concurrent users utilizing performance intensive functions was not easy. Managing the concurrency between manual and XML data was also challenging
  • Multiple validations were required at different stages of claim life cycle to meet regulatory requirements and to minimize the errors
  • Implementation of Single Sign-On process as there were complexities in collaborating the functionalities and user role definitions of each system.
  • The whole system performance was to be considered while introducing status tracking at all levels including file, record and field level.

Our Solution

Our team has closely associated with the client in many technology initiatives and offered a Microsoft SQL server based data warehouse platform that well aligns with their business strategies. The BI solution delivered provides better analytics for taking insightful decisions to handle the upcoming business needs of the client. Our solutions had the following key features.

Data Loading:

The claim details from both In-Network and Out-Of-Network data sources in different formats are extracted to flat files and then loaded to staging tables by SSIS technology.

Mapping and conversion:

Mapping and conversion of data based on business rules occur in staging database. The loaded data is stored in the stage tables. SQL agent jobs load the data to different facts and dimensions in the data warehouse.

Outbound data feeds:

The solution included the deployment of outbound data feeds from the new EDW to downstream systems for enabling better automation of regulatory reporting and for providing value added services across the claim life cycle for cost savings.


The system generates multiple reports using MicroStrategy and SSRS technologies to provide powerful visualization of the custom data based on the user’s preference. The reports are sent as a scheduled mail or as a web link. It facilitates the client to avail quarterly business reviews and other details that provide better business insights. This includes data on:

  • Claim Load:

    The claims to be processed are received in Excel, Flat File or large XML format that poses performance bottlenecks. Hence flat files are created from XML using BizTalk. The bulk claims are loaded into the application with the scheduled jobs. Faster file loading is facilitated by BizTalk and SSIS technologies.

  • Validation Engine:

    The claim validation engine validates the claims at multiple levels using CMS rules and validation guidelines. The solution also ensured that the changes to these could easily be configured within the system. While loading files or creating new claims, system performs the validation based on the claimants main key fields along with Beneficiary check. When the claimant is found as a beneficiary in CMS system, the engine performs a full file validation for the final CMS reporting.

  • Beneficiary Match:

    The claimants are identified as beneficiaries through an internal beneficiary verification, then an internal validation process and finally through an EDI exchange capability with CMS.

  • Mandatory Insurer Reporting (MIR) Module:

    The MIR module reports eligible claims to CMS after beneficiary check. It validates the claim data and generates the outbound files to CMS in the predefined flat file format. The CMS response files are processed by our system for further upstream reconciliation with data providers.

  • Response File Generations:

    The system sends an acknowledgement file when it receives the files from data providers. It also sends specific response files for all the updates from CMS

  • TPA (Third Party Reporting Agent) Files Processing:

    The system sends the files that are to be routed to other TPA’s in the flat file format at RRE level. If there is a change in the claim’s RRE; it generates a different file to the older TPA to stop reporting those claims to CMS. In the case of claims received from other TPAs, the system creates acknowledgement files and response files based on the information from CMS.

  • Status Tracking:

    Status tracking is done to track the entire changes and the field error information of the specific claim in detail. It helps the user to easily identify the error and rectify it. The tracking also involves the logging of all inbound and outbound file exchange details.

  • User Interface:

    The user interface dashboard has links to all claim transaction activities. Authentication is made against Windows Active Directory for better security. SSO facilitates smooth and secure switching for the users from one application to another based on their access rights. An additional layer of security is provided with secured URLs. The Telerik web UI controls are also utilized to meet the complex client usability requirements.

  • Data Provider Integration:

    It is an internal facing web interface for the client’s administrator users to manage and maintain the entire data provider related information.

Technologies Used

Microsoft ASP.Net, C#, BizTalk, Active Directory, MS SQL Server, SQL Server Integration Services(SSIS), Microsoft Enterprise Library, AJAX, Telerik controls


The automated reporting solution is recognized for its high rate of claim acceptance when compared with the competing reporting agents and has the following benefits.

  • Stringent claim validations at different stages to ensure error free reporting.
  • Claim reporting to CMS is easily manageable and configurable based on the eligibility, reporting period and the type of RREs.
  • The client offers multiple electronic, manual and user friendly options to its claim data providers for claim submission.
  • Users can have a detailed overview and can track the entire claim life cycle.
  • Precise exception notification mechanism and reliable file generation and distribution systems.
  • Claim processing time is reduced for on-time reporting