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Industry domain brief
Healthcare & Payers
COBOLpro maps eligibility, claims, enrollment, provider, and EDI behavior for payer documentation and audit readiness.
3
Legacy estate
Systems and data surfaces to inspect
9
Workflows
Business workflows grouped by capability
3
Risks
Business impacts with control focus
4
Deliverables
COBOLpro assessment artifacts
Executive summary
Payer estates combine high-volume adjudication, PHI-sensitive data, provider contract rules, EDI transformation, and financial settlement. Small errors in benefit or pricing logic can scale quickly across members, providers, and regulators.
COBOLpro produces a governed domain brief that connects source logic to claims, enrollment, remittance, encounter, audit, and finance outcomes.
Legacy systems in scope
The source estate to turn into an operating map.
Each row is structured for executive review: where the COBOL behavior sits, what it touches, and what the documentation must prove.
Claims adjudication
Legacy estate
Claims intake, edits, pricing, COB, denial logic, payment, remittance, and NCPDP workflows
Documentation focus
Benefit, edit, pricing, denial, and payment rules with source-backed evidence
Enrollment and eligibility
Legacy estate
Member, group, plan, coverage, provider, benefits, 270/271, 834, and matching systems
Documentation focus
Coverage changes, member matching, eligibility responses, and benefit interpretation
EDI and compliance data
Legacy estate
837, 835, 276, 277, clearinghouse, encounter, risk adjustment, audit, and quality feeds
Documentation focus
PHI-aware lineage, transformation controls, reconciliation, and downstream reporting
Operational workflows
Business capabilities, not raw program lists.
COBOLpro groups source behavior around the operating workflows buyers need to preserve, explain, or replace.
01
Member and eligibility operations
- Enrollment updates and coverage changes
- Eligibility verification and member matching
- Benefits, plan, and group maintenance
02
Claims and provider operations
- Claims intake, edits, pricing, and adjudication
- Provider contract and fee schedule application
- Denials, appeals, coordination of benefits, and payment
03
EDI, remittance, and reporting
- Inbound and outbound EDI transformation
- Remittance, encounter, and reconciliation
- Audit, quality, compliance, and finance reporting
Risk and control priorities
Where legacy ambiguity becomes business exposure.
The assessment narrows risk to business impact and source-backed control evidence instead of treating documentation as a generic code inventory.
01
Payment accuracy
Business impact
Benefit, edit, contract, or pricing defects can create high-volume payment and provider abrasion risk.
Control focus
Inventory source-backed adjudication rules and tie them to provider, plan, benefit, and payment outputs.
02
PHI lineage
Business impact
Documentation evidence must be useful without weakening privacy, security, or governed access controls.
Control focus
Document sensitive data movement and transformations with role-aware, audit-friendly artifacts.
03
EDI opacity
Business impact
Claims and eligibility dependencies can be hidden inside transaction maps and clearinghouse-specific paths.
Control focus
Trace transaction flows from inbound EDI through legacy programs to outbound remittance and reporting.
COBOLpro assessment output
Concrete artifacts for continuity decisions.
Outputs are written for shared use across business, audit, architecture, application, data, and delivery teams.
01
Claims-to-remittance lineage
Evidence from inbound EDI through edits, pricing, adjudication, payment, remittance, and finance outputs.
02
Benefit and payment rule catalog
Source-cited rules for benefits, edits, denials, contracts, fee schedules, coordination, and exceptions.
03
Payer interface map
A structured inventory of clearinghouse, provider, pharmacy, finance, encounter, audit, and quality feeds.
04
HIPAA-aware evidence package
Documentation documentation organized for governed access, audit response, and planning workshops.
Domain assessment