Cerulean, Electronic Processing of Healthcare Content

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Business Challenge

In an effort to comply with new HIPAA regulations and healthcare reform, organizations are seeking ways to meet the challenges of improving healthcare through better technology and information access. They’re seeking more efficient ways to manage "health records".
New HIPAA standards mandate secure electronic exchange of medical documentation. There are also a number of requirements for medical records management, including: accurate and timely payment of claims; compliance with HIPAA mandates, and local and federal regulations concerning privacy/security. The requirements span across both the traditional paper-based (mail or fax) as well as electronic (EDI) channels. Organizations are now looking to lower cost and become more efficient in routing all medical records among internal departments as well as with vendors and partners. As they move towards automated content processing, enhanced reporting capabilities (provided by systems automatically) will ensure proper compliance.
These needs typically require a combination of enterprise content management (ECM); automated content recognition and classification, as well as Business Process Management (BPM) solutions that easily integrate with existing line of business applications (claims processing systems). Customers are looking to expand capabilities to securely process healthcare related information (both data and content) across fax, email, FTP, XML Web Services; EDI; message queuing. Additionally, they are looking to provide contextual collaboration capabilities that will eliminate the manual and error-prone handling and processing and improve real-time communication across departments as well as with partners and clients.

The Solution
Cerulean is a healthcare "attachment" content management and automated-processing solution for healthcare insurance companies, third party administrators, self-insured employers, large medical groups, and workers compensation carriers. As a comprehensive case-management solutions, it will enhance claims and billing processes through automated content ingestion, classification, reivew and processing including full audit-reporting. It includes application templates for soliciated and unsoliciated attachments, misrouted claims, etc. Cerulean integrates with existing content repositories, claims processing systems and other systems that require medical attachments to provide a single view of medical record images with associated data through a portal.
The solution offers a secure means to view supporting documentation, route content (electronic case files) for use in claims adjudication, medical management and other internal processes. Cerulean satisfies both public (e.g., Medicare, Medicaid, Workers compensation) and private claim processing mandates. Combining best-of-breed enterprise content management functionality and business process automation, Cerulean can be tailored to an organization’s specific requirements via a modular solution approach that seamlessly integrates with client processes and IT software systems.

Value Proposition
The Cerulean solution enables payors to control administrative expense, reduce storage costs, comply with HIPAA and other legislation, and improve provider relationships. With Cerulean, payors can achieve a 30-40 percent reduction in claims processing costs by eliminating duplicate claims received due to insufficient supporting documentation or timeliness of payment. Payors using Cerulean significantly decrease calls, lost documents and reprocessing of claims by enabling the automated processing of supporting documentation.
Additional benefits include:

  • Increased use of lower cost and more streamlined EDI transactions;
  • Reduced costs related to manual sorting, storage and tracking of attachments;
  • Improved member and provider satisfaction;
  • 24x7 online access to attachments;
  • Streamlined workflow processes;
  • Improved data accuracy for processing and reporting;
  • Support for full compliance with HIPAA records management regulations; and,
  • Ability to handle the ANSI X.12 275 Transaction Set (will require payors to be able to electronically accept a standard attachment).

>> Download IBM Solution Brief (Cerulean)


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