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IT Services Offshore Development Software Development
Case Studies

Following are a few client case studies that will provide you an overview of our work structure and capabilities:

Software Solution

Drug Adjudication System

Drug Adjudication System is part of an existing product for Health Insurance System. The system is initially being built for Adjudication of Drug Claims for Canada, Brazil, USA and South Africa. The system is being developed on Windows 2000 with SQL 2000 as database server, and uses for VB and C++ for front-end clients and middle tier respectively as development platforms. The system interfaces with other databases for getting Recipient's information, Policy information, etc. The effort involved in developing it is about eight person years.

Drug Claims can be submitted on Paper or as Electronic transmissions. Electronic transmissions support CPhA version 3.0, NCPDP versions 3.2 and 5.0. The claims can be submitted in a batch as well. The Physicians' prescriptions are also processed for adjudicating the claims. There can be batch electronics submissions as well. After performing the basic checks and validating the inputs, the information is passed on to Benefits Determination module to determine the eligibility, duplicate claims, validating the Drug information, Drug eligibility, Drug plan, etc. The system supports the ability to define exceptions to a drug plan based on any of the drug classification parameters of a drug. The system supports the pre-authorization, Prescriber restrictions, days supply limits, Trial Drug processing, Maintenance Drug processing, Treatment Protocol rules and so on.

The system also performs Drug Utilization review, wherein various checks are carried out. The checks include Duplicate drug, Duplicate therapy, Refill too soon / too late, Drug to drug interaction, Minimum / maximum daily dosage, Pediatric precaution, Geriatric precaution, Drug to gender contraindication, Drug to known disease contraindication, Drug to inferred disease contraindication, Drug to allergy contraindication, Drug to pregnancy contraindication, Drug to lactation contraindication, and Duration of therapy. If any of the checks indicates a severity for the usage of the Drug, the claim can be rejected.

Subsequently, fiscal processing is carried for the claim to determine the portion of the eligible claim amount that is payable by the recipient. Various fiscal rules like co-pay, co-insurance, deductible and maximums are supported. There are various variations supported for the fiscal rules like simple, sliding, maximums, etc. The system supports the option for automatic pro-ration of limits based on the enrolment date of the certificate holder or recipient. The fiscal rules can be specified in variety of ways.

The system supports the maintenance of multiple prices for each drug in each province/state, for different effective periods. Drug pricing information includes wholesale price, retail price, BAP (best available) price, formulary (provincial or state) price, etc. Multiple pricing rules supported by the system include No drug pricing, Generic pricing, Mandatory generic pricing, LCA (lowest cost alternative pricing), GCN pricing and Therapeutic equivalent pricing. It supports definition of different rules regarding allowable sales tax when calculating the eligible drug cost and professional fee.

Lastly, coordination of benefits is done. It supports the ability to determine the primary payer for a Recipient. It supports various mechanisms like the ability to automatically adjudicate a claim under both the primary and secondary plan where both the certificate and spouse are covered under the same Insurer or ASP/PBM. It also supports the unique processing requirements of Bill 33.

Drug Adjudication System.
Application Migration from INGRES, FORTRAN to SQL-SERVER, VC++, CORBA.
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  Drug Adjudication System
Description :- Drug Adjudication System is part of an existing product for Health Insurance System...
  Ticketing and Revenue Management System
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