Case Study: Nonprofit Healthcare Payer achieves automated HIPAA-compliant claims validation and PHI breach prevention with Precisely

Precisely automates claims validation and ensures the integrity of their adjudication process within strict PHI compliance

Nonprofit Healthcare Payer, a nonprofit healthcare payer serving more than 700,000 members across multiple East Coast states with 1,500 employees, faced a complex, disparate claims adjudication flow that relied on manual review to prevent PHI breaches and costly fines. To automate and strengthen PHI compliance and data integrity, the organization engaged Precisely and its Data360 solution.

Precisely deployed Data360 non‑intrusively to reconcile data between the claims staging database and the adjudication system, implementing automated validations on TAX ID, NPI, ZIP Code and address fields and surfacing thousands of exceptions for remediation. Precisely’s solution delivered daily summaries, pended-claim details and real‑time dashboards, enabling HIPAA‑compliant, automated claims validation that reduced PHI breaches and associated fines while providing measurable visibility into adjudication errors and dollars impacted.