TUFTS HEALTH PLAN, BOSTON, MA

With the growing demands in the Healthcare insurance industry, TUFTS had chosen TIBCO to be the Enterprise Architecture solution to implement their claims submission processing and other Web Service solutions. At TUFTS, TIB/BusinessConnect would connect to third party insurance companies and hospitals to price and receive insurance claims. TIB/BusinessWorks would process and publish all claims and any web services.

CHALLENGE

With a growing member base, TUFTS has made strategic partnerships with major insurance trading partners around the US. In establishing these partnerships, TUFTS now had strict requirements in claim turnaround to support the major insurance providers. The existing claim processing solution did not meet the requirements of the third party trading partners and a new solution had to be implemented.

SOLUTION

TUFTS had chosen TIBCO Software to be the EAI software solution. A new Message bus architecture was implemented along with B2B connectivity and Web Services with their trading partners.

As part of the Integration solution team, EA Technologies responsibilities were:

• Architect & Design Enterprise Integration solutions of complex claim processing with CIGNA.
• Design HIPPA compliant processing of claims and member information.
• Design & Implement claim processing with different 3rd party doctors and hospitals using BusinessConnect and BusinessWorks.
• Design & Develop Member/Group benefit processing which come in from 3rd party trading partners.
• Build Object model relationships using TIB/Smartmapper for gaps or complex Oracle database lookups.