CMS to apply business rules engines to claims processing

The Centers for Medicare and Medicaid Services has requested information on how to integrate business rules engines and business process management software to modernize Medicare’s fee-for-service claims processing system.

The technologies have the potential to revolutionize the way health care claims are settled, CMS said in its request for information posted at FedBizOpps yesterday. CMS, an agency of the Health and Human Services Department, expects to redesign the claims processing systems in about five years.

The agency will employ business rules engines, business process models and data dimensioning to advance Medicare claims processing systems.

Business rules engines capture the business aspects of the system from the mainstream program code so nontechnical analysts can more quickly introduce business rule changes. The process allows legislative changes to Medicare policy to be implemented quicker and more reliably.

Business process models specify and create workflow logic, reducing the cost and amount of traditional coding needed to develop a system. When integrated with a business rules engine, the combination shortens traditional development time and significantly improves maintenance cycles.

With data dimensioning, which provides for making versions of all reference data, rules and processes, transactions that have been processed can be reprocessed using different criteria.

Vendor responses are due Jan. 14.

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