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Services
Our clients are Third Party Administrators (TPA), Management Services Organizations (MSO) and Health Plans who gives highly individualized and personalized service to their clients. For them, responsiveness is critical. Growth is high for many of our TPA-clients who have earned the trust of their clients by ensuring compliance as the industry around them changes. MSO focus on providing excellent service and outstanding results to their IPA and Medical Group clients.
Claims Adjudication works closely with our TPA, MSO and Health Plan clients to provide Claims Support Services that meet their unique needs. Our Paper Claims-to-EDI Conversion Services are custom designed for each of our TPA, MSO and Health Plan clients who are over burdened by mountains of Paper Claims.
Simple and affordable, Claims Adjudication's turnkey solution for paper claims administration cuts claims processing costs, improves accuracy of paper claims adjudication, enhances productivity of claims examiners and archives paper claims for easy and convenient access anytime through an intuitive and secure web interface.
Our Healthcare Payer BPO services include:
- Claims Entry – CMS-1500, UB-92 and ADA Dental Forms
- Member Enrollment Services
- Provider Data Services
- Authorization Support Services
- Claims Adjudication
- Claims Repricing
- Customer Care Support
Benefits
- Eliminates handling of Paper Claims
- Cuts Paper Claims Processing Costs by 40%-50%
- Archive, Search, and easily retrieve paper claims at the click of a mouse
- Improves accuracy of paper claims adjudication
- Improves HIPAA and CMS compliance for paper claims tracking
- Reduces storage costs
- Improves turnaround times for processing
Overview
Claims Adjudication provides Paper Claims-to-EDI Conversion Services for Third Party Administrators (TPA), Management Services Organizations (MSO) and Health Plans who are overburdened by mountains of Paper Claims.
Electronic Claims that go through a Clearinghouse service can often account for 50% of CMS-1500s and UB-92s that our clients receive. Claims Adjudication’s Paper Claims-to-EDI Conversion Services enables Claims Administration Departments to eliminate paper and populate their Adjudication System without requiring manual data entry at their end.
Claims Entry – CMS-1500, UB-92 and ADA Dental Forms
Claims are scanned by your team and immediately uploaded to Claims Adjudication for indexing by such parameters as Patient Name, Date of Birth, Date of Service, Payer, Provider, Claim Amount, unique DCN Number, etc. Claims and attachment images are retrieved within seconds by utilizing any of the above parameters by multiple users simultaneously.
Claims Adjudication converts paper CMS-1500 and UB-92 claims into a standard EDI stream (NSF 2.0 or 837 format), similar to that which claims departments receive for electronic claims from Providers through their clearinghouse.
Member Enrollment Services
Health Plans which are growing rapidly have to deal with constantly adding and updating their Enrollments databases. Many plans take as much as 30-45 days before a new member can be enrolled. Additionally the enrollment paper forms need to be entered into the core claims system and members need to be removed on a timely basis for accurate payment of claims.
Claims Adjudication converts the Membership Enrollment forms and provides the electronic file, thereby eliminating manual data entry and reduces errors significantly at your end. Since the members are enrolled quickly, you can start collecting premium sooner!
Convert Paper Enrollments into a Electronic Format:
Claims Adjudication provides you with an electronic image of enrollment forms as well as a database of all the fields from that form to populate your Core Claims System easily. Claims Adjudication indexes and provides the electronic images of all Enrollment Forms and related attachments received.
Handle changes and Member Terminations:
Claims Adjudication's Enrollments services also processes all changes to the Enrollments forms and Member Terminations elegantly without using any additional staff at your end.
Provider Data Services
Claims Adjudication’s Provider Data Services accurately sets up new Providers, Provider Groups, and Facilities into your Claims Adjudication System. We also manage any and all changes and updates to the Provider Information, so that claims are accurately processed.
- Add and maintain pertinent information into your claims adjudication system from the provider.
- Review W9s and supporting documentation and enter required information to set up providers accurately into claims system
- Setup Provider Groups and Facilities in addition to Individual Providers
- Manage several provider attributes such as Indicative Sections, Multiple locations, addresses, payment information, tax information, Out-of-Network and additional details.
- Modify missing or incorrect provider information so that pended claims are released on a timely basis from your system.
- Removal or termination of obsolete providers
Authorization Support Services
Are the Authorizations forms received by claims department not being entered on timely basis and claims incorrectly denied or paid on the received claims because of improperly entered Authorizations?
Claims Adjudication’s Authorizations Support Services enables your departments to eliminate paper and populate their Claims Adjudication Systems with Authorization forms received without requiring manual data entry at their end.
- Claims Adjudication converts paper authorizations and attachments, and stores them for easy retrieval at any time.
- Accurately processes your authorizations using the rules and enters them into your Claims Adjudication Systems such as EZ-CAP, IDX, HealthTrio, LuminX and others.
Claims Adjudication
If the claims are pended for longer durations which increases risk of your organization for health-plan non-compliance, increased support call volume, and lower customer satisfaction.
Claims Adjudication brings you a whole variety of health insurance claims processing solutions to help you manage your claims efficiently. Claims Adjudication brings vast experience of working with healthcare payer claims systems across a variety of technologies.
Our Claims Adjudication services utilize claims professionals who are trained on multiple adjudication platforms and plan designs. Our Adjudicators have knowledge of medical terminology and also go through client specific training to learn your insurance plans, systems and claim types.
- Accurately resolve pended claims using your guidelines, state and federal regulations, and using specific health plan criteria.
- Review attachments and documentation which are received with the claim and utilize that information for adjudication.
- Correct invalid information and/or enter missing information, so that pended claims are released on a timely basis.
Claims Repricing
Claims Adjudication offers health care claim repricing services to insurance carriers and self-funded employer groups. We reprice provider bills according to pre-negotiated fee schedules and forward original bills and repricing cover sheets on to carriers and self funded groups. An integrated blend of people, technology, and intelligent processes, our claims processing system is one of the most sophisticated and efficient in the industry. As a result, clients realize significant cost savings while providing their employees access to prompt, accurate and convenient service.
Customer Care Support
Cost savings, greater flexibility, consistency and reliability of services, quality of the customer experience and customization of processes is what Claims Adjudication offers to its clients. We understand customer support and back-office processing services prevalent in the global insurance industry and services insurance providers, carriers, brokers and administrators.
Our project management methodology along with the efforts taken to understand processes has provided immediate benefits to clients. Claims Adjudication has experience in delivery of multiple complex processes involving decision-making within the insurance domain and provides support for both transaction and voice processes.
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