Complete Core Platform for Health Insurance (Oracle solution). – ATSC
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Complete Core Platform for Health Insurance (Oracle solution).

Complete Core Platform for Health Insurance (Oracle solution).

Modernize core systems.

A modern, flexible core administration platform by Oracle is at the heart of the solution architecture.

Complete Core Platform

Oracle equips healthcare payers with advanced IT solutions, so that payers can provide more value while reducing costs. Oracle Health Insurance Cloud Services is an adaptive cloud solution that enables payers to incrementally consolidate their systems, improve customer service, and reduce risk while optimizing business performance through a flexible, rules-based system.

Oracle’s solution can help health insurers achieve all three steps. Here is a rundown of health insurance operations and how Oracle’s solution can transform every detail while reducing operating costs.

Call Center Customer Support

In an industry full of complex terms, pricing, and waiting periods, customers need clarity. Call center agents are finally equipped to provide that clarity with Oracle Health Insurance Cloud Services. They see a consolidated view of the member’s account, which helps them respond to all kinds of inquiries. Most importantly, they can answer the common question “Why?” For example,

“Why did you reject authorization for this medical treatment?” or “Why did you pay only 20 percent of my claim?” Consumers want to understand. Oracle’s solution tracks every step of the process. Insurance representatives can easily find how a payer came to a certain conclusion or calculation, and then explain to the customer.

Digital Customer Support: Portals and Mobile

Consumers not only prefer online self-service, they’ve come to expect it from every industry. In health insurance, self-service is being able to submit claims, view eligibility, or find a doctor—all with a few mouse clicks. Oracle Health Insurance Cloud Services integrates with online portals providing members with instant support 24/7. Mobile-friendly portals are especially valuable for service on the go.

By integrating portals with the back end, Oracle’s solution offers data capture from the first step of many processes, including enrollment. Members enter data into the portals, which then flow directly into the system for automated processing. Health insurance staffers no longer have to input data manually, which means no redundant work, holdups, or input errors.

Work Queue Management and Business Process Management

Health insurers need to manage many moving parts and service stakeholders at all times. System delays or interruptions can result in grave consequences. That’s why health insurers need an IT solution with a high-performance engine and 24/7 availability.

Oracle Health Insurance Cloud Services helps insurers radically increase productivity through straight-through processing and continuous processing, also known as trickle feeding. A claim, for example, gets processed from the moment it enters the system.

There’s no waiting period for night batch processing, which is common among legacy systems.

Membership and Enrollment

For too long, health insurers have struggled with legacy systems designed solely for group health plans. Many of the older systems weren’t built to administer individual health plans.

Oracle’s solution gives health insurers the flexibility and transparency they need in their enrollment and membership functionalities in both group and individual lines of business. That flexibility goes even further in accommodating all kinds of situations for the member and the insurer. For example, if a member enrolls late or an employer offers a cafeteria style health plan, Oracle’s solution knows how to manage without human intervention.

High-volume health insurers can rely on Oracle’s solution, which is benchmarked to handle 100 million policies. One Latin American payer servicing 13.5 million members uses Oracle Health Insurance to process 32 million data intake records per month and up to 6 million on any given day.

Billing and Collections

Part of the digital experience that consumers expect is accurate, timely access to billing data. Oracle Health Insurance automatically calculates the premium upon enrollment, sends out the bill, and updates the system when the policy is paid. The

payer can easily configure the system to automatically respond to a given situation. For example, if a member does not pay a premium, the user can set up the system to deny claims, put claims on hold, or allow a grace period.

Through automation and integration, Oracle’s solution improves financial accuracy and eliminates errors resulting from manual processes. It also supports specific needs such as ASO arrangements and stop loss billing. Insurers can manage billing and collections for large group, small group, and individual lines of business. Healthcare payers can process premium bills for 56 million policies in a single day.

Claims, Encounters, and Value-based Payments

Because Oracle’s solution is equipped with straight-through processing, most routine claims no longer need a single human being for processing. In addition to saving significant funds, automation leads to higher accuracy rates and more capabilities. Health insurers can simply do more without draining resources. Automation enables healthcare payers to manage innovative, value-based payment models including bundled payments, pay for performance, and traditional capitation. Authorizations and other tasks related to hospital visits also speed up through automated processes. One nonprofit health plan in New England achieved an automated claims processing rate of 90-92 percent after implementing Oracle Health Insurance. A nonprofit health insurer in the Netherlands reduced operational costs by 30 percent because of Oracle’s automated claims processing.

Provider Data Management and Network Modeling

Through Oracle partnerships with quality business process outsourcing (BPO) providers, health insurers can integrate with platforms to expand capabilities even more. Connecting with a business process as a service (BPaaS) provider enables insurers to save costs while storing provider data such as contact information, credentials, and network models.

External Integration/Electronic Data Interchange (EDI)



Streamlining claims submission and cutting out unnecessary steps are critical for all health insurers. Oracle’s solution can integrate with BPO providers offering EDI, enabling health insurers to submit claims electronically in a standardized format. EDI, an essential part of the automated process, allows insurers to receive an 835 format and produce claims in an HIPAA- compliant 837 format.

Medical Management, Case Management, and Disease Management



Patients with chronic conditions like diabetes or cancer have unique needs that health insurers must be prepared to handle. That includes managing medications, case workers, and behavioral health. In order to serve those patients, payers must be able to integrate population health capabilities with their claims and policy administration systems. Oracle integrates with medical management, case management, and disease management systems specifically designed to handle ongoing care.

Enterprise Data Management, Business Intelligence, and Reporting



Healthcare executives need powerful, yet easy-to-use analytics to uncover previously hidden patterns and unknown trends. They need to be able to mine data in order to pinpoint what areas need improvement and make more informed decisions. For example, “How much time does the average claims process require?” “What are my team workloads?” “What’s the typical amount of time between a claims submission and a claims payment?”

Oracle’s solution includes a rich set of business intelligence dashboards that are ready to use. In addition to the 100+ predefined KPIs with drill-down analysis, healthcare payers can easily create their own ad hoc inquiries and create reports. A small Netherlands-based health insurer had once been among the slowest in government reporting. After implementing Oracle’s solution, the payer’s reporting took a 180-degree turnaround. The payer received a government award for being the fastest reporting healthcare payer in the Netherlands.

Source: Oracle.