Managing Healthcare Payer Content, Process, and Cases

Stop relying on complex manual processes that hold you back. You may manually manage deadlines or expedite urgent items. Or maybe you use manual processes to keep up with compliance requirements. Regardless, manual processing does not optimize your efficiency. But there is a solution.

Become an industry leader by substantially reducing processing times. This digital transformation can happen in a variety of areas:

  • Provider Enrollment
  • Appeals and Grievances
  • Secure Medical Information Exchange

Combine the power of document management, workflow, complex case management, and retention. Together, these tools will increase your efficiency while automating regulatory compliance needs.

Health Payer Provider Enrollment case management solutions help health payers manage Provider Credentialing. You can use it to enhance your processes’ efficiency, and accuracy.

Your solution can solve all your visibility problems, and allow you to capture all your important information easily in one place. It then stores all this data in accessible, easy-to-view tabs. When your information is in the system, you can do a lot with it. For example:

  • Manage expiration dates, practice locations, and more
  • Collect, verify, and track all required provider contracts and credentialing data and documents
  • Complete all actions within a single, secure, and accurate location
  • View checklists, outstanding tasks, statuses, and related credentialing items
  • Ensure clinicians have the correct qualifications and current credentials

You gain a solution that requires fewer resources to manage the provider credentialing process. Then, you can focus on more value-added tasks like fostering provider relationships.


  • Systematically enforces CMS compliance
  • Easily meet the 60-day Medicare-based limit for provider enrollment, credentialing and onboarding
  • Leverage audit trails to offer transparency
  • Automatically generates Communications via email, fax, or printed letter to request required information from providers

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Appeals and Grievances (A&G) is a complex area to manage. Volumes are unpredictable and A&G types vary in severity. Some are procedural issues that need timely responses. But others are less flexible and require immediate action. And varying service level agreement requirements make this process challenging.

With an A&G solution, members and providers can submit materials directly via a portal. This action immediately triggers a workflow process to begin. Once documents are in the system, it automatically classifies them. It makes these decisions using a set of criteria that you determine. Here are some powerful features that A&G solutions offer:

  • Accurately triage, manage, and document every appeal and grievance
  • Connect to core admin platforms
  • Store all information in one location
  • Track status and deadlines
  • Generate letters
  • Provide real-time dashboards to ensure audit-friendly, compliant processes

These helpful tools allow your team to focus on resolving appeals quickly. As a result, you won’t have to cherry-pick work. You won’t even have to worry about The Centers for Medicare & Medicaid Services (CMS) compliance regulations. Your solution will completely track, manage, and document every appeal and grievance to the required specifications.


  • Systematically enforces CMS compliance
  • Prioritize work by classifying appeals as life threatening or monetary
  • Leverage audit trails to offer transparency
  • Automatically generates Communications via email, fax, or printed letter to share or request required information from providers and members

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With an Electronic Medical Information exchange solution, sharing data and documents occurs in seconds, not days. It ensures authorized users have immediate access to accurate, current data. As a result, you can improve communication with stakeholders. And this way, Payers can make more informed decisions faster. Staff can also provide first-call resolution for member and provider inquiries.

OnBase workflows are another critical feature of these solutions. With them, you can request medical documentation directly from providers. It’s simple: Payers issue a digital request to providers. Then, the providers attach the necessary records. After that, they can return the data and documents electronically and securely. This process makes for secure, reliable electronic collaboration. You can finally eliminate sharing via fax, postal mail, and portals, and better serve your clients.


  • Reduce time required to share information with providers
  • Increase transparency
  • Improve coordination of care
  • Reduce appeals for time-based exceptions
  • Increase member satisfaction and retention

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You can automate Mobile Medicare, Open Enrollment, or Traditional New Business processing efficiently with a New Business solution. Working with Naviant, you can implement a solution that offers electronic enrollment that provides managers with greater transparency and improves the quality of applications.

Capture prospect forms and signatures via a mobile device and immediately send materials through your enrollment workflow. Onboard Medicare members, while confidently and correctly capturing all required data and signatures at the point of contact, avoiding delays, costs, and missed enrollments.

To expedite underwriting new business, you can extend your solution outside your walls to allow producers to capture a prospect’s information and signature while onsite, directly from a tablet or PC, immediately entering the application into an underwriting workflow.


  • Improve the quality and timing of new business processes
  • Meet compliance rules by automating the validation of fields like age requirements, appropriate use of application by state or product, and signature detection
  • Automatically route applications and information
  • Speed up enrollment with mobile processing

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Paper-based claims are only about 20% of your total volume. However, they present the highest cost to process. But leveraging a claims case management solution can ease the burden. This solution identifies and classifies forms for you. It also automatically notes any duplicate claims. It then extracts line item data from claims forms, such as UB04 and CMS1500. After this, it converts the values to an XML data stream, and can then import this directly into core applications. This action creates an EDI file which outputs data straight into an 837 EDI file. Then, it stores the images directly in your image repository. With this, it’s clear that automated workflows are powerful tools. They will expedite your suspended claims processing and auditing.


  • Eliminate costly data entry
  • Improve process quality
  • Improves compliance through greater visibility, audit ability and adherence to internal controls
  • Reduces processing times

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Your customers communicate via email, text, and social media. And these habits affect their expectations for you. You must manage complex communications without manually assembling content. Integrating directly with your Document Management solution can help. Personalized communication is time-consuming when it’s manual. But integration can make it easy and reduce costs. It also provides a record of each interaction with your customers. And you can access all this data in one secure place.


  • Improved customer satisfaction while lowering the cost of assembling communications
  • Let your team focus on higher value tasks
  • Increase the consistency and accuracy of communications
  • Support compliance for corporate or regulation standards

Our Go-To Tools

  • Content Composer
  • Document Management
  • Document Composition
  • Document Packaging Capabilities
  • Integrations with Microsoft Product Suite

You can also use document management to automate your business processes in the following areas:

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