CASE STUDY
Scaling Complex California Claims Through a Trusted Partnership
How Imagenet extends internal capacity, improves turnaround, and supports regulatory requirements for a large California Medi-Cal health plan.
OVERVIEW
A large California Medi-Cal health plan serves a high-volume member population statewide across multiple plan types, while operating within one of the most complex regulatory environments in the country. As a public-sector health plan, it must balance scale, accuracy, and compliance while maintaining continuity across established systems and workflows.
This case study highlights how Imagenet supports representative California Medi-Cal claims engagements by extending adjudication capacity in a controlled, compliant manner—helping protect turnaround time and governance within demanding claims environments.
THE CHALLENGE
Medi-Cal health plans face a uniquely demanding claims environment:
High and fluctuating claim volumes
Complex claim categories requiring manual review and specialized handling
Tight prompt-pay requirements and compressed operational timelines
Regulatory change without proportional increases in funding or staffing
Having already partnered with Imagenet to streamline inbound mailroom operations—including claims submissions and other time-sensitive documents—this engagement expanded to extend that foundation into adjudication.
Its objective was operational resilience: a trusted partner that could flex with demand, operate within existing workflows, and help protect turnaround time and compliance as complexity increased.
THE SOLUTION
Building on an established partnership that began with inbound mailroom and document intake operations, Imagenet expanded its role to provide embedded, onshore claims adjudication support designed to flex with demand while adhering to plan-specific rules, SLAs, and compliance requirements.
What Imagenet delivered:
Pending-claims adjudication support within existing claims platforms.
Coverage across professional, outpatient, and inpatient claim types (including higher-complexity categories requiring manual review).
Time-sensitive special project support—such as retro contractual changes—to address inventory surges and operational deadlines.
A delivery model built for rapid resourcing, consistent QA, and real-time operational alignment.
Continued upstream support through Imagenet’s multi-channel intake capabilities, including OCR-driven data extraction, digitization, intelligent routing, and secure document archiving—helping ensure cleaner data, faster processing, and stronger audit trails.
How the model worked:
Imagenet operated inside existing systems and workflows (no platform replacement).
Teams maintained frequent operational touchpoints—supported by structured quarterly business reviews led by Imagenet leadership—to align priorities, review performance trends, and adapt quickly to shifts in volume, complexity, or policy requirements.
Direct access to Imagenet operational leadership supported responsiveness and long-term stability.
RESULTS & IMPACT
The partnership delivered outcomes California health plans care about: compliance confidence, operational flexibility, and safe capacity expansion.
Turnaround Time (TAT) Improvements
30 Days
California prompt-pay requirement for clean claims (state requirement).
~15 Days
Average clean-claim turnaround time supported through the Imagenet partnership.
When clean claims exceed state prompt-pay timelines, health plans may be required to pay interest and can face penalties if delays become systemic. Through Imagenet’s embedded adjudication support model, this engagement supported average clean-claim turnaround performance of approximately 15 days—helping protect regulatory performance while mitigating provider and member abrasion.
Impact highlights:
Sustained prompt-pay performance: Supporting regulatory compliance while managing increasing claim complexity.
Expanded support as trust grew: The engagement expanded over time to include additional claim types, higher-complexity work, and special projects—without requiring added internal headcount.
Operational resilience: The ability to flex capacity and address inventory surges while maintaining established governance and QA expectations.
What It Takes to Safely Manage Complex Claims in California
California health plans operate in one of the most demanding claims environments in the country—defined by regulatory complexity, compressed timelines, and high expectations from members and providers.
As claim volume and complexity increase, plans need partners that can safely extend internal adjudication capacity without disrupting existing systems, workflows, or governance models.
Key capabilities to look for include:
Rapid, flexible resourcing to absorb volume spikes and time-sensitive projects.
Deep familiarity with California-specific regulatory requirements.
Ability to operate within a plan’s existing claims platform, processes, and SLAs.
Strong training, quality assurance, and continuous improvement disciplines.
Experience supporting health plans that must balance speed, accuracy, and accountability.
The right partner brings more than additional capacity—they deliver the operational rigor and adaptability required to protect turnaround time, accuracy, and compliance as complexity grows.
Don’t Let Complex Claims Put Compliance at Risk
See how Imagenet helps California health plans scale adjudication capacity, protect prompt-pay timelines, and handle high-complexity claims—without disrupting existing systems or workflows.