Real-Time Claims

Real-Time Claims is a Blue Shield of CA initiative to simplify and add transparency to the current claim submission process.

Blue Shield of California

Role: Principal UX Designer and Strategist

The claims submission and adjudication process at Blue Shield of California has been the same for the last 30+ years. The Real-Time Claims (RTC) tool does away with paper forms, faxes, and months-long waits to determine whether or not a claim was submitted properly. In seconds, a provider will know if they have submitted the claim properly, how much they will get paid, and the member's responsibility.

Background

Existing Process

The current process for claim adjudication can take from 3 months up to a year to find out the outcome of a rendered service. A claim is currently inputed by an individual in the back office from notes on a patients' chart. These claims processors require yearly training to keep up with industry changes.

Impact on Patient

Often these claims are processed long after a patient has completed the required care. Some providers have up to a year to submit their claims, resulting in the patient not receiving a bill for services rendered for up to 15 months.

Approach

Where we started

A proof of concept was created by the tech leads in 2018 as a test to see if they could create the capability to search by the medical numerical code and intake a claim into directly into the BSC systems.

Outdated processes

BSC and most of our competitors were still accepting faxed 837 forms. The only other alternative to submit a medical claim at the time of this writing was a digitally optimized PDF version of the paper form.

Goals

For Claims Processor

As a processor, I need an intuitive claims intake form with instant feedback that will result in an uptick of clean claim submission.

For Patient

As a patient, I need a way to estimate the cost of a service to make better decisions for my personal and financial health.

For Business

As a medical system administrator, I need claims processing and payment timeline to be accelerated to allow more time for to care for our patients and less time with back office requirements.

For BSC

As BSC claims adjudicator, I need a platform that removes the simple reasons that a claim gets denied so that I can focus on higher level claim situations.