HealthRules® Payer System Implementation
Elderplan | HomeFirst | Metropolitan Jewish Health System
Multi-Phase Implementation (Over 3+ Years)
About this Project
This project focused on transitioning Elderplan/HomeFirst from an outdated MCO-based system to the HealthRules® Payer System to support Medicaid, Medicare, and the FIDA duals program.
I served as the operational testing and transition lead, overseeing benefit rule validation, clinical edit logic, vendor claims-load oversight, crosswalk development, regression testing, and go-live stabilization. I supervised UAT processors, coordinated daily with IT and vendors, and ensured all claims outputs (GUI, EOB, 028 files) matched state requirements. Through structured testing, workflow translation, and operational leadership, the organization achieved a stable, compliant, and accurate system launch.
The Challenge
Metropolitan Jewish Health System (Elderplan/HomeFirst) was transitioning from an outdated MCO-based platform to the HealthRules® Payer System to support Medicaid, Medicare, and the state-awarded FIDA (Fully Integrated Duals Advantage) program.
As with any large-scale system implementation, the organization faced several operational, configuration, and testing challenges, including:
Limited translation of benefit rules into system logic
No established UAT structure for Claims
No complete crosswalk between legacy MCO processing and HealthRules benefit logic
Configuration gaps affecting EOB accuracy, code mapping, and clinical edits
Heavy dependencies on external vendors (Emdeon, Axiom, Transcend) for claims-load and testing
Limited pre-launch validation around routing, pricing, and adjudication
Gaps in business-user understanding of how HealthRules would behave once live
Compressed timelines due to the FIDA program launch and state compliance requirements
The implementation required someone who could bridge operations, claims processing, benefit logic, system configuration, testing coordination, and vendor management to ensure a successful launch.
My Role
I stepped in as the operational transition lead — the person responsible for turning a technical system implementation into a functioning operational.
Claims UAT Lead
Benefit Rule & Coding Validator
Crosswalk Architect
Claims Stabilization Lead
Vendor Coordination Lead
Operational SME for Clinical Editing, EOB logic, and adjudication outputs
Trainer + Supervisor for UAT processors
Responsibilities included:
Leading User Acceptance Testing for Claims adjudication
Validating clinical editing, including fire logic for Review vs Denial
Crosswalk CARC codes, RARC codes, and reason codes
Ensuring EOBs, 028 files, and GUI payment outputs matched state rules
Working with Emdeom, Axiom, Transcend for claims-load validation
Building crosswalks from old MCO processing to new HealthRules logic
Running regression testing across multiple phases
Supporting daily standups
Stabilizing adjudication behavior for the new FIDA program
Overseeing your UAT claims team and training them on test-case execution
Reporting system defects and guiding the consultant team on fixes
Monitoring claims inventory claims behavior during go-live
The Solution Framework
Establishing a comprehensive operational testing framework that included:
Benefit-Based Test Case Matrix
Mapped every Medicaid/Medicare/FIDA benefit rule to HealthRules system behavior.
End-to-End Claims Scenario Library
All scenarios for pricing, routing, duplicate logic, eligibility, and benefit overrides.
Crosswalk Validation Process
Legacy → HealthRules comparisons to ensure accuracy, pricing logic, and correct discounting.
Clinical Editing Governance
Worked with Optum vendor/system rules to determine:
— when an edit fires
— if review or denial
— if customization was required
— if the edit aligned with dual program requirements
Claims Load Validation (Vendor Oversight)
Supporting the AVP to ensured all incoming claims from Emdeom, Axiom, Transcend were accurately formatted and clean for HRP ingestion.
Daily Standups + Issue Coordination
Supporting IT, vendors, business, and testing teams stayed aligned.
Go-Live Stabilization
Monitored live claims for accuracy, benefit alignment, and system logic defects.
UAT Team Supervision
Trained and supervised staff reviewing live FIDA claims, identifying issues, and reporting benefit-level misconfigurations.
The Impact
Accurate claims adjudication for the FIDA dual program
— Correct benefit logic
— Correct pricing
— Correct edits
— Correct outputs
Stabilized claims processing
The inventory stayed under 30 days, even during system transition — unheard of during a payer system go-live.
Strong collaboration between business + Consultant team + IT + HealthEdge + Vendors
Detecting + fixing configuration defects BEFORE go-live
Preventing thousands of potential incorrect claims.
Operational readiness
Teams were trained, test cases were completed, and workflows were understood.
A compliant launch
System outputs (028 files, EOBs, edits) aligned with state requirements.
Long-term sustainability
Testing framework continued to be used even AFTER go-live.