Health plans —
a member 360 that actually moves STAR, HEDIS, and MLR.
Your member lives in claims, eligibility, care management, pharmacy, and five vendor portals.
We build for the payer mix you actually run — not a textbook "health plan".
Commercial, Medicare Advantage, Managed Medicaid, and specialty lines all have different rules, measure sets, and margin pressures.
Commercial · ASO
Employer groups, self-insured, broker channel — HEDIS measures, MLR reporting, benefit transparency.
Medicare Advantage
CMS STAR ratings, HCC risk adjustment, AEP/OEP campaigns, retention, supplemental benefits utilization.
Managed Medicaid
State-specific measures, redeterminations, SDOH-led care, and network coordination.
Specialty & D-SNP
Dual-eligibles, ESRD, complex chronic and behavioral health coordination.
What breaks in a payer stack — and where the margin, members, and measures leak out.
Every payer engagement we run starts by mapping these five gaps against your current systems. Fixing them in isolation just moves the pain.
Fragmented member view
Claims, eligibility, care management, pharmacy, and portal events live in silos.
STAR & HEDIS lag
Quality measures calculated once a year.
HCC recapture drag
Risk adjustment runs on retrospective chart reviews.
UM & prior auth backlog
UM nurses and MDs drown in prior auth volume. Providers and members lose trust.
Network & contracting opacity
Provider network performance, quality, and contract performance sit in actuarial reports nobody in ops uses.
Agents designed for the roles that actually move STAR, HCC, and MLR.
Each agent is grounded on Data Cloud for Healthcare + Snowflake Health Data Cloud, with HIPAA-safe controls, human-in-the-loop approval.
Member 360 Agent
Answers benefits, claims status, and coverage questions; reconciles eligibility, pharmacy.
STAR / HEDIS Gap Agent
Continuously calculates gap lists; drafts member and provider outreach; flags at-risk measures mid-period.
HCC Recapture Agent
Surfaces suspected HCC conditions from claims, pharmacy, and clinical signals; drafts provider queries.
Prior Auth & UM Agent
Classifies incoming auth requests against medical-policy criteria; auto-approves clear cases and packages complex cases.
Four layers. One accountable partner. Built for modern health plans.
A governed architecture that connects claims, eligibility, pharmacy, care management, and member engagement through secure interoperability and AI-powered automation.
Agent Layer
AI-powered agents for Member 360, STAR and HEDIS gap closure, HCC recapture, prior authorization, and care management workflows.
Application Layer
Unified member engagement, care coordination, utilization management, case management, and digital member experiences.
Integration Layer
Secure interoperability across claims platforms, PBMs, care management systems, provider networks, and third-party healthcare applications.
Data Layer
Governed claims, pharmacy, eligibility, clinical, provider, quality, and social determinants of health (SDOH) data powering analytics, compliance, and AI.
Six reasons health plans pick us over generalist SIs and point payer-tech vendors.
STAR · HEDIS · HCC in one fabric
Quality measures and risk adjustment staged on one Snowflake-grounded architecture.
Agentforce · compliance-reviewed
Four payer-specific agents with PHI minimization, medical-policy grounding, and human-in-the-loop approval
CMS-0057 and interop patterns ready
Prior Auth API, Patient Access API, Provider Directory, Payer-to-Payer — built into our reference architecture.
Mid-period measure intervention
Gap closure happens while measurement windows are open.
Multi-LOB architecture from day one
Commercial, Medicare Advantage, Medicaid, and D-SNP on one data model.
AMS aligned to measure-year cycles
Post-go-live managed services aligned to Salesforce release cadence, Snowflake platform evolution.
Trusted by Global Technology Leaders
Delivering cloud, data, AI, and digital transformation solutions through strategic partnerships and proven execution.
- Salesforce Summit Consulting Partner
- 1,000+ Customer Success Stories
- 200+ Salesforce Certified Experts
- 100+ Industry Accelerators
- Claude Partner Network
- Claude-powered agents in production across regulated industries
- 40+ enterprise Agentforce deployments grounded on Claude
- Teqfocus runs on Claude — we are our own first client
- AWS Advanced Consulting Partner
- 150+ Active AWS Engagements
- 50+ Skilled Practitioners & Cloud Engineers
- Data & Analytics Competency + 6 Designations
- Snowflake Services Partner
- Expertise in Data Lake to Snowflake
- 50+ Customers across key industries
- 20+ SnowPro Certified Experts
Ready to modernize this operating model?
Start with one high-value workflow, prove the value, and scale with a governed Salesforce, Snowflake, and Agentforce foundation.
The questions health-plan evaluators ask first.
How do you approach STAR and HEDIS measure calculation?
Measures staged on Snowflake with full lineage — not a black box. Your actuarial and quality teams can trace any measure calculation back to source claim, encounter, or supplemental data. The STAR / HEDIS Gap Agent runs continuously so gaps surface mid-period, not after the measurement window closes.
We integrate with your certified HEDIS engine where one is in place — we don’t force a rip-and-replace.
Can you handle HCC risk adjustment for Medicare Advantage?
Yes, with continuous suspecting, not just retrospective chart review. The HCC Recapture Agent surfaces suspected conditions from claims, pharmacy, lab signals, and clinical data; drafts provider queries; prioritizes cases most likely to close in the current submission cycle.
We also integrate with your existing risk-adjustment vendor if you have one — we don’t replace it.
Are you ready for CMS-0057-F prior authorization APIs?
Yes — built into the reference architecture. Patient Access API, Provider Access API, Payer-to-Payer API, and Prior Authorization API (PARDD / DTR / CRD IGs) patterns are ready. FHIR R4 is the default interop layer on MuleSoft and Data Cloud for Healthcare.
Plus the Prior Auth & UM Agent reduces the volume reaching human reviewers by auto-triaging clear-criteria cases.
Do you work with Salesforce Health Cloud for Payers specifically?
Yes — payer-specific Health Cloud data model, objects, and workflows. Member 360, care teams, utilization management, care plans, provider relations, broker, and employer-group surfaces — all designed for payer operating models, not adapted from provider implementations.
How do you handle managed Medicaid redeterminations and state reporting?
State-specific rules modeled on Snowflake; enrollment broker integration via MuleSoft. Redetermination outreach campaigns, state quality measures, MCO reporting cadences, and enrollment-broker integration are built into the reference architecture for managed Medicaid lines of business.
What is the typical Payer engagement timeline?
First production value in 12–16 weeks; full member 360 plus agent rollout in 5–8 months. Engagements are fixed-scope and outcomes-aligned, with no ramp-up billing for Salesforce, Snowflake, or STAR/HEDIS/HCC domain learning.
Phase 1 typically targets the most painful operational bottleneck — member services, UM backlog, or mid-cycle STAR/HEDIS intervention.
Can you provide health-plan customer references?
Yes, under MSA or evaluation NDA. Named references across national MA plans, regional managed Medicaid MCOs, multi-LOB health plans, and specialty plans are available during evaluation — matched to your LOB mix and membership size.
