Harvard Pilgrim Health Care has chosen Oracle Health Insurance to build its core claims adjudication solution.

The Oracle Health Insurance Claims solution will be the first application resulting from the combination of Oracle’s European health insurance market experience and intellectual property with the Oracle Insurance rules-based adaptive application strategy. The combination provides the foundation for the next generation of core Oracle Health Insurance applications, delivering the configurability required to address critical time-to-market issues for implementing new health benefits and those resulting from United States regulatory changes.

The service-oriented-architecture (SOA)-based solution offers numerous integration points and a phased approach to system replacement, enabling Harvard Pilgrim to simplify and extend its existing multi-claims platform environment, reducing system integration and custom coding requirements, and ultimately its total cost of IT systems ownership.

The solution supports the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10), which is mandated for adoption in the United States by 2013.

Claims adjudication for all types of claims and alternative reimbursement models will be highly automated in the solution, minimizing the need for human intervention. This will enhance comprehensive straight-through processing capabilities, driving down claims processing costs.

Critical back-office processes will be streamlined based on the solution’s integration with Harvard Pilgrim’s Oracle E-Business Suite (Oracle Financials).

The solution will replace a legacy system that is not equipped to support the ICD-10 mandate and is costly to adapt to other new regulatory requirements and market challenges.

The solution is being built by Oracle Health Insurance, a newly formed group within Oracle Insurance, the business unit created within Oracle to focus on the unique challenges of its global insurance customers.

Dell Services, Harvard Pilgrim’s technology and business process outsourcing partner, will work with Oracle to implement the Oracle solution.

Supporting Quotes

“U.S. health insurance payers are facing the most fundamental shift in their history. We must have systems to support rapidly changing product portfolios and the pending requirements of Federal healthcare reform,” said Deborah Norton, Chief Information Officer, Harvard Pilgrim Health Care, Inc. “Oracle’s European solution for claims adjudication, currently the dominant application in The Netherlands, addresses that hybrid public/private market with a uniquely flexible solution. Oracle’s proposal to combine this with a native service-oriented-architecture approach provides Harvard Pilgrim with a timely and compelling solution.”

“Oracle Insurance welcomes the opportunity to collaborate with Harvard Pilgrim in a collaboration that represents our entry into the U.S. core health insurance applications market – an area in which Oracle Insurance sees extensive room for growth as insurers seek solutions to help them navigate major industry changes,” said Michiel Walsteijn, Senior Director, Oracle Health Insurance. “With Harvard Pilgrim, we will bring to life our vision of the adaptive health insurer, one that can be nimble and profitable while managing regulatory change.”