PEGASYS Case Study: Billing Interface

Royal Health Care Builds Streamlined Child Health Plus Premium Billing Process


The Challenge


New York State moved to a new transactional processing system, called CHP KIDS, for its Child Health Plus program. Plans were required to create new interfaces with New York State to send transactions for payment of premiums.


The Royal Health Care Solution


Child Health Plus is a New York State program for uninsured children who do not qualify for Medicaid. Royal has several clients in New York who participate in the Child Health Plus Program. The State pays Plans on a capitated basis for each enrollee.


New York State devised a new system called KIDS to track enrollment, collect necessary demographic and qualifying information, and issue payment to Plans. This comprehensive new system requires health plans to submit transactions such as additions, changes, disenrollments, and recertifications to the State along with associated data. The State edits these transactions and provides remittances that accept or deny the requests.


Royal Health Care integrated these requirements into the PEGASYS enrollment and billing systems to create streamlined business processes for its clients. First, logic was created to define key strokes and actions within the PEGASYS enrollment system as specific transaction types. Then PEGASYS was modified to produce extract files with these transactions for delivery to the State. Edits were built into the extract process to produce accurate files and error reports for data scrubbing. These files produce accounts receivable records at the member level.


Next, a process was created to read State remittance files back into PEGASYS to match premium receipts to receivables. In addition, acceptance and denial codes were transferred into the core system so that reconciliation reports could be generated. On-line reporting via the PEGASYS user friendly RAC/LST module allows users to design custom reports for member corrections and follow-up. On-line capabilities and new screens allow users to view remittance file history and member transaction history.


By understanding the new KIDS transaction system and integrating it within existing PEGASYS functionality, Royal was able to create a central repository for Child Health Plus enrollment, billing, and reconciliation, and allowed its clients to meet State regulatory mandates.


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