A diagnostic for health plan claims leaders who must decide which claims workflows to modernize first. It builds a reconciled baseline for each workflow and grades the evidence behind it. It then separates workflows ready for investment from those that need better evidence first and those to defer.
What this diagnostic covers
The asset sets out the decision and when to use it, an inputs table with an evidence grading scheme, and written-out formulas for the three core claims measures. It includes a weighted scoring model with anchors and an evidence gate, and business case rules that keep released capacity apart from cash. Execution, governance and measurement tables follow, then a synthetic worked example with a failure case and an alternate scenario. Editable tools cover the questionnaire, evidence inventory, prioritization matrix, challenge log, root-cause worksheet and review record.
- Purpose and decision
- Context and applicability
- Inputs and evidence
- Definitions and assumptions
- Method and analytical logic
- Current-state assessment
- Options and business case
- Recommended design
- Execution and activation
- Governance and risk
- Measurement and benefits
- Worked example and practice
- Working tools and references