Healthcare documents · 22 of 31 · Evidence · 4 minutes
Healthcare products. From problem to production.
Claims automation, provider matching and a legacy claims integration replaced — explored through the documents and decisions.
01
Launch
Launch copy explaining the new administrative path, exception handling and operating boundaries.
Product decision
Explain what changes and what still requires review.
Portfolio sample from my healthcare product experience. Requirements, thresholds and review records are illustrative; they are not employer documents or historical sign-offs.
Supported paper claims now have a clear path from intake through extraction, provider resolution and validated electronic handoff. Eligible work advances with less repetitive entry; unresolved work stays visible with a reason and an owner.
One conversion. Two connected outputs.
saved per claim
in manual processing
claims per month
of manual claims avoided
Select any step to explore. Form layouts are simplified.
Incoming paper claims include CMS-1500/UB-04 forms and a primary-payer Explanation of Benefits (EOB). CMS-1500 professional claims convert to EDI 837P; UB-04 institutional claims convert to EDI 837I. The primary-payer EOB is an input, distinct from the EOB generated after adjudication. The simplified forms contain no patient data.
Process explanation: Confirm the form type and legibility before extraction.
OCR and AI extract the information from the paper forms for conversion.
Process explanation: Check incomplete or uncertain values against the source image before applying conversion rules.
Custom conversion rules create EDI files alongside image and index files.
Process explanation: Validate required values, apply the corresponding 837 format and route generation errors for review.
The image and index share a common claim ID in OnBase. Stakeholders can retrieve the original claim for appeals or re-review. Storage supported the project's stated 10-year retention requirement.
Process explanation: Keep the image and index associated, and surface a failed lookup or storage handoff.
Professional claims use EDI 837P; institutional claims use EDI 837I. The files go to the claims processor for adjudication.
Process explanation: Confirm receipt and investigate missing or rejected acknowledgements. File acceptance is distinct from adjudication.
The claims processor adjudicates the claim, followed by payment, invoice and Explanation of Benefits (EOB) outputs. The generated EOB is distinct from the primary-payer EOB received with the incoming paper claim.
Process explanation: Processing and its downstream outputs follow the receiving workflow. This conversion project is separate from the claims-engine replacement.
The change is valuable only when the people handling exceptions can understand and use it.
| Capability | Operator meaning |
|---|---|
| Supported CMS-1500 / UB-04 intake | Less repetitive transcription for eligible work |
| Provider resolution | Central evidence and normalized representation |
| Validation and handoff | Rejected transactions have an actionable state |
| Review and reporting | Exceptions retain reason and ownership |
| Controlled recovery | Retries and replays remain reconcilable |
Extraction does not determine benefits or clinical necessity. Medical 837 processing remains separate from retail pharmacy NCPDP transactions. Operators and customer care receive the same status definitions; legal/compliance and relevant patient-safety partners review consequential workflow boundaries. The announcement focuses on the claims path and does not combine separate provider and platform releases.