Case Study: HealthEdge achieves rapid MA-PD launch and 100% claims processing accuracy with Optum

HealthEdge - Customer Case Study

HealthEdge, a Medicare Advantage Prescription Drug (MA-PD) plan focused on underserved seniors, faced a compressed five-month go‑live window and two back‑to‑back CMS deadlines (first enrollment, then claims/authorizations) with limited internal implementation experience and more than a dozen trading‑partner integrations to complete. To meet these demands, HealthEdge engaged Optum and chose a platform built on HealthEdge® solutions, including HealthRules® Payor, HealthRules® CareManager, HealthRules® Connector, HealthRules® Answers, and HealthRules® Answers Ad Hoc.

Optum staffed experienced consulting leaders and SMEs, used an agile delivery approach centered on HealthRules configuration and integration, and implemented a risk‑profile with mitigations reviewed weekly. Optum configured and integrated HealthRules Payor and CareManager, complied with CMS requirements (including April 2020 COVID mandates), met the enrollment and claims deadlines, and achieved 100% claims processing accuracy in Q1; many temporary manual workarounds were automated and the team is now working with HealthEdge to expand products and service areas.

HealthEdge