--- title: "Insurance and Health Plan Software Development | Smart Data" url: https://www.smartdata.net/industries/insurance description: "Claims, member and policy system modernization and data platforms for health plans and insurers. $16M+ in Medicaid revenue recovered for a health plan." source: "Smart Data (smartdata.net). Markdown copy of the page; the HTML page is canonical." --- Insurance # Software and data systems for health plans and insurers Claims, member and policy systems modernized and connected, including the Medicaid file process where our team found $16M+ in lost revenue. $16M+ in lost Medicaid revenue returned to the health plan Hired to add a state-mandated code to a health plan’s nursing facility file, our team noticed the process was mishandling records. The plan confirmed it, filed corrections and recovered $16M+. - SQL Server [Health plan $16M+ in lost Medicaid revenue returned to the health plan Hired to add a state-mandated code to a health…](https://www.smartdata.net/case-studies/nfloc-platform-rewrite) ## Who we work with in insurance Health plans and Medicaid managed care Claims and assessment platforms, member apps and the data pipelines behind them, for a health plan we have supported for more than ten years. Payers and benefits companies Member, eligibility and benefits data connected across the systems that pay claims and serve members. Claims and recovery services Claims data brought together and checked, so recovery and reporting teams can trace each number to its source. Commercial insurers Application, integration and data engineering work for carriers that run their own IT teams. Health plan · Medicaid data ## A Medicaid file process that was losing revenue While implementing a state-mandated code update for a Medicaid health plan, our team noticed its nursing facility file was mishandling records. The plan filed corrections with the state and recovered $16M+, and we rewrote the process to stop the loss. ### Eligibility Retroactive eligibility changes arrive from the state ### Level of care The NFLOC historic file records each member’s level of care ### The gap The file sent records the state rejected: members not eligible on key dates, duplicates and updates for records the state did not have ### Correction files We showed the plan where the file was losing revenue, and the plan sent correction files to the state ### Recovered Lost Medicaid revenue came back, and we rewrote the process in SQL Server Our insurance services ## Claims, member and policy systems Most insurance work starts with a system already in production: a claims process losing revenue, a member portal that’s hard to maintain or reporting that takes weeks to reconcile. Claims platforms ### Claims and assessment platforms We rebuild the platforms that create claims-ready records, so assessments, eligibility and billing data line up before a claim is filed. For one Medicaid health plan, our team found a nursing facility file mishandling records during a state-mandated update; the plan recovered $16M+ and we rewrote the process. - State-mandated rules built into the workflow, on the deadline the state sets - Validation, routing and audit trails on every record - Monitoring that flags gaps before they turn into lost claims Member and provider apps ### Member and provider apps Secure member and provider experiences for claims status, benefits, care and documents, including single progressive web apps that replace separate mobile and portal builds and keep shipping after launch. - Member portals and progressive web apps on any device - Provider tools for availability, referrals and services - Role-based access, single sign-on and audit logging Claims and member data ### Claims and member data platforms Claims, eligibility, member and provider data brought into one governed platform on Microsoft Fabric, Databricks or Snowflake, with quality checks that catch errors before they reach a claim or a regulator. - Pipelines for claims, eligibility and operational data - Claims, quality and provider reporting - Data quality rules and monitoring on every feed Typical work - Microsoft Fabric - Databricks - Snowflake Policy integration ### Policy and core system integration We connect core administration, billing, CRM and provider systems through APIs, and move brittle legacy middleware onto services your team can support, without a disruptive cutover. - APIs for real-time policy, member and claims updates - Legacy middleware replaced in stages - Managed support after go-live, with P1 to P4 response times AI on governed data ### AI on claims and member data AI on claims and member data has to be explainable to an auditor. We build it on governed data, with access limited by role and a person in the loop wherever a decision touches a member or a payment. - Answers from claims and member data that come with the query behind them - Governed access, so AI sees only what each role is allowed to see - Human review before anything reaches a member How we deliver ## Pick the model that fits the program ### Support for the systems your business runs on Monitoring, fixes, updates and enhancements on a monthly plan, with response times set by priority from P1 to P4. - Applications, data pipelines and backend processes, legacy systems included - Structured monthly support with clear deliverables - Includes monitoring, bug fixes and performance updates ### We own the project from discovery to launch We lead discovery, design, build and launch, with a written scope and milestones you review along the way. - Ideal for full builds, integrations and migrations - Managed by Smart Data from planning through launch - Your team reviews milestones and makes the decisions ### Engineers who join your team and follow your lead You manage the work, and we provide the people. Our engineers work inside your team and your process. - Developers, data engineers, analysts and architects, screened by our technical team - Flexible team size based on your current needs - Available from our onshore, offshore or hybrid teams ### Help hiring permanent technical staff We help you find and hire technical professionals who match your needs. You choose whether to hire directly or start with a contract engagement. - Includes technical screening and cultural alignment - Contract-to-hire lets you see the work before you commit - Options for contract-to-hire or direct placement Step 1 ### Find the right fit A scoped project, engineers added to your team or a direct hire. We help you decide. Step 2 ### Assemble the team Onshore, offshore or a mix, matched to your timeline, stack and budget. Step 3 ### Start inside your systems We work within your environments, your review process and your compliance rules. Step 4 ### Deliver and adjust Regular demos and check-ins, with room to change course when the program changes. Case studies ## More health plan work ### Replacing a legacy mobile app and member portal with a single progressive web application for Medicaid members A 22-month React Remix PWA for one of the largest Medicaid managed care organizations, replacing the separate mobile app and member portal with one app. Smart Data is the engineering partner. - React - TypeScript [Replacing a legacy mobile app and member portal with a single progressive web application for Medicaid members](https://www.smartdata.net/case-studies/medicaid-member-experience-pwa) ### Replacing a costly third-party tool with a custom Medicaid platform Ohio’s largest healthcare plan provider retired a costly third-party system for a custom Medicaid waiver platform, built by Smart Data. - .NET Core [Replacing a costly third-party tool with a custom Medicaid platform](https://www.smartdata.net/case-studies/custom-medicaid-homecare-platform-for-ohios-largest-healthcare-provider) Questions ## What insurance teams ask us first Mostly health plans and Medicaid managed care organizations, plus payers, benefits companies, claims and recovery services firms, and commercial insurers with their own IT teams. Yes. We build on or connect to the systems already in production: claims, assessment, eligibility, billing and member platforms. We modernize in stages so the business keeps running. After the data is ready. We start with data quality and governance on claims and member data, then pilot AI with defined access and a human review step before anything reaches a member or a payment. Yes. Through managed services we own monitoring, support and upgrades, with P1 to P4 response times. When you need more hands, our engineers work inside your team. Industries ## Other industries we work in ### Healthcare Patient, pharmacy and clinical data systems held to HIPAA, including where AI is allowed to touch them. - Medicaid programs - Pharmacy services - Clinical documentation [Healthcare](https://www.smartdata.net/industries/healthcare) ### Manufacturing and industrial ERP, shop-floor and supplier data on one platform, so plant reporting and finance reporting reconcile. - SAP and ERP reporting - Shop-floor integration - Supplier portals [Manufacturing and industrial](https://www.smartdata.net/industries/manufacturing) ### Retail and distribution Order, inventory, credit and customer data connected across portals, branches and the platforms behind them. - Vendor and customer portals - Order and credit systems - Data platforms [Retail and distribution](https://www.smartdata.net/industries/retail) ### Financial services Bank data platforms, reporting that holds up to an audit and managed support for the financial systems the business runs on. - Bank data platforms - Managed ERP support - Legacy migration [Financial services](https://www.smartdata.net/industries/banking-financial-services) Next step ## Bring us the claims or member system that needs to change Tell us what runs today and what it is costing you. Here is what happens after you reach out. ### A short call about the claims, member or policy system What runs today, which rules it answers to and what has to change first. ### An engineer looks at what’s running Scope comes from your systems as they are, before anything is priced. ### You get a written proposal Covering scope, team, approach and price. [info@smartdata.net](mailto:info@smartdata.net) [(937) 886-9166](tel:+19378869166)