Case Study: Large Health Insurance Exchange Company achieves 70% automated DMI adjudication and faster ACA enrollments with Tungsten Automation

Large Health Exchange Boosts Insurance Coverage as Applications Soar During Pandemic

A large, state-run health insurance exchange created under the Affordable Care Act faced a massive intake challenge: processing thousands of documents and up to 600,000 data-matching issues (DMIs) per year to determine eligibility. Manual DMI handling averaged about 13 minutes each, required a full audit trail, and had to ingest mail, fax and online submissions—constraints that became critical when applications spiked by 40% during the COVID-19 pandemic.

Working with Kofax and partner InfoCap, the exchange deployed Kofax TotalAgility to create a unified, AI-driven document intake and adjudication workflow with full auditability and real-time dashboards. Deployed in eight months, the solution now adjudicates over 70% of DMIs with minimal human involvement, resolves 25% of cases within 24 hours, cut DMI processing time by 30% to date, scaled through the pandemic surge, and has increased automation levels sevenfold.