Payer 360 — HCC Risk Adjustment, Claims Intelligence & Quality Analytics on Sigma
Payer 360 — HCC Risk Adjustment, Claims Intelligence & Quality Analytics on Sigma
Health plans today sit on massive volumes of data — EHR records, claims, pharmacy data, quality measures, and risk scores — yet most payer organisations still operate with fragmented systems and delayed reporting that prevent timely decisions.
The result: mis-coded HCC suspects draining RAF revenue, unchecked claims leakage, rising denial rates, missed HEDIS thresholds, and care gaps that go unaddressed until the measurement window closes. These are the KPIs payer leaders monitor most closely because they directly impact CMS reimbursement, Star Rating bonus payments, and member outcomes.
PROLIM has built the Payer 360 Intelligence Framework — a production-ready analytics solution powered by Sigma Computing on Snowflake. It integrates seven source domains: EHR and clinical systems, claims and RCM platforms, member and enrollment data, HCC risk adjustment data, quality and outcomes programs, pharmacy records, and external benchmarks including CMS and SDOH data — all consolidated into a governed Snowflake environment with zero extracts and zero data movement.
Sigma delivers the intelligence layer: live dashboards, a natural language AI Agent, secure writeback, and a closed-loop action framework — all queried live from Snowflake.
Built for Risk Adjustment Managers, Actuarial, and Clinical Coding teams. Surfaces the full HCC suspect pipeline — with 50% of suspects still OPEN across 21,000+ records — broken down by status (Open, Closed, Deferred, Invalid), HCC code, member ID, and condition description. Coding teams see exactly which members and HCC codes to act on before the RAF submission window closes, with the RAF-weighted priority queue built live from Snowflake. The Sigma Writeback Input Table allows reviewers to log Suspect ID, reviewer name, notes, and review date directly in the dashboard — writing back to the source system in real time.
Built for Claims Directors, RCM Managers, Billing Specialists, and Payer Operations teams. Surfaces denial rate trends, AR outstanding, average days to resolve, Pareto-ranked denial reason codes, and AR aging by payer. Identifies overpayments, duplicate submissions, and upcoded claims as quantified leakage — not estimates. Users filter to denied claims sorted by billed value and update claim status and resolution notes via Sigma Writeback — no system switching required.
Available across all dashboards. Users ask in plain English:
Answers are delivered instantly from the governed semantic layer — same RAF logic, same HEDIS definitions, same data the dashboards run on. No SQL, no IT dependency.
Built for CMOs, Quality Analysts, Care Managers, and Population Health teams. Tracks every HEDIS measure against CMS threshold, quantifies open care gaps by measure and member, and shows the Star Rating gap between current performance and the next bonus tier. The Member 360 view delivers a complete picture for each member — risk tier, open care gaps, recent claims, active medications, prior auth status, and last contact date — filtered to a live outreach list in one click.
The Closed Loop Action layer is the solution’s key differentiator. HCC reviewers log coding decisions. Billing specialists update denial statuses. Care managers record gap closure actions. Quality analysts flag members for outreach. Every action writes back to the connected data platform via secure API — with a full audit trail — without leaving Sigma.
Four personas — Risk Adjustment Manager, Claims Analyst, Pharmacy Analyst, and Quality Analyst — each see only the data their role authorises, enforced through Sigma’s Row-Level Security. The same platform serves every payer function from a single governed workspace.
This solution is built natively on Sigma not retrofitted. Sigma is the only BI platform that eliminates the extract layer entirely, querying Snowflake live at billion-row scale. For life sciences, that means PV Scientists get Grade 4 SAE signals the moment they are recorded not at the end of the week. The GxP ready writeback layer means every action taken in Sigma is traceable, governed, and audit ready. And the AI Agent means a Pharmacovigilance Scientist can query 1,143 adverse event records in plain English
without SQL, without a data team, and without waiting.