Web Authorizations/Pre-certs

A provider can request an authorization for a service or referral by logging in on the web. The provider enters the pertinent subscriber, diagnosis, provider, place of service, and procedure codes as well as the date range for which the authorization is requested. The benefit plan of the employer group is used to automatically set the authorization/pre-cert limits on the dollar amounts and number/days of the services requested. Each service is marked as approved or pended for approval based on parameters set in the benefit plan.

An authorized person can view all approved and pending authorizations. They can mark as approved all pended authorizations. They can pend any authorizations that were automatically approved. They can automatically generate a form letter to send to the provider with a request for additional information. They can flag the authorization as valid only for the listed services. They can add notes to it.

When the authorization is approved electronic acknowledgement is automatically sent to the provider. After the authorization is approved, the provider who made the request for authorization or the subscriber can at any time view the status of the authorization, the limits, and any applicable notes by again logging in to the web page.

A provider can request additional services for an open authorization. The provider logs in to the authorization web page. He lists all his open authorizations for a particular patient. He selects the appropriate authorization. Then he adds the additional services to the list of services already entered for that authorization. Those services are either marked as approved or pending approval in accordance with the business rules for the benefit plan.

Authorizations can also be used to communicate and manage requests for transfers and for long term managed care or treatment plans.

Adjudication

Uses common coding conventions including CPT, ADA for dental, UB-82 and 92 revenue codes, HCPCS, ICD9 diagnosis codes, and NDC (National Drug Codes). Providers can send claim information using XML, ANSI X12, or a flat file format. They can send the information by e-Mail, CD-ROM, DVD, floppy disks, or cartridge tape. When received the records are translated to the claim upload file format. For EDI transactions a 997 functional acknowledgement is automatically generated and sent to the trading partner.

Up to four providers can be entered per claim, each connected to a particular service line or lines.

Adjudication of Electronic Claims requiring Authorization

When a claim is received electronically the authorization file is checked. If the claim requires an authorization and the authorization isn’t found, or unauthorized services have been rendered, or limits have been exceeded then the claim is pended for review by an adjuster. If everything is in order, a claim number is automatically generated, and the claim is approved and marked for payment. Multiple authorizations from multiple providers for the same medical incident or occurrence can be combined into a single claim.

Adjudication of Manually Entered Claims requiring Authorization

When a claim is manually entered, a list of open authorizations for the member is displayed. When the adjuster selects the appropriate authorization/authorizations, a claim number is generated and the claim, patient, provider, and service information is automatically transferred to the claim. If an authorization isn’t found the claim is adjudicated in accordance with non-participation rules.

The adjuster can override any calculated amounts as required.

Treatment Plans/Managed Care

An authorization for services to be rendered over a period of time (e.g. treatment plans) can remain open for multiple claims with the balance of limits being deducted each time a claim is processed on that authorization. The provider and/or subscriber can view the remaining service balances on the web.

Adjudication of Electronic Claims not requiring Authorization

Records in the claim upload file are extensively checked using edits for completeness, code consistency, and accuracy. Possible duplicates are checked based on service rendered and date of service. Any exceptions found are put into an exception table/tables with the reason for the exception. These records are, in coordination with the provider, corrected and reloaded into the claim upload file. This insures the data integrity of the claim database while at the same time making it easy to find and correct exceptions.

Manual Adjudication/Review of Claims not requiring Authorization

Co-payments, out of pocket amounts, payment percentages, non-covered amounts and other deductions are automatically calculated for each detail line as soon as the service code and number of times/days for a service are entered. Cob information can be calculated and collected for each line as it is processed. The adjuster can override any calculated amounts. Totals for deductibles, plan limits, current payments, etc. are viewed on the maintenance screen as soon as each detail line is entered.

An adjuster can be alerted to key employees. The adjuster can view subscriber, member, provider, and claim notes. The adjuster can automatically generate form letters and mailing labels for checking student status, claims inquiries, and other purposes.

Claim detail lines may be deleted until the claim is sent to the payment file. Then reversal transaction, recovery, and financial adjustment claims maintain a complete audit trail.

Customer Service/Claim History

Adjusters may handle customer service without interrupting the claim they are working on. Summary history can be displayed for all claims for a patient or patients with the click of a button with the latest claim shown first. Each claim line shows the claim number, provider, service dates, service type, status, and payment amount. The adjuster can double click on a summary line to display a claim’s detailed information. The adjuster can then return to the original location in the claim being processed.

Reminder

A follow-up date is assigned to a claim by the adjuster when the claim is pended. A reminder screen prompts the adjuster about claims needing action or review.

Web Based Service Inquiries

Minimizes service call inquiries by providing necessary information to subscribers and providers. A subscriber can log in to his/her account to find out the status (open, adjudicated, paid) of a claim and the payment profile for services rendered. A provider can pull up a summary list of claims for which they are the provider. Detailed status and payment information is available by double clicking on the claim summary line. A Provider can filter claims by patient number, member number, or patient name.

Claim Payments/EOBs

Checks the premium payment paid-through dates and user-defined grace period when determining claims eligibility. When a group falls behind in payment by user-defined rules, claims from that group are adjudicated, but not paid until cash is applied to the account balance.

Can support either in house check printing or writing to a payment file for payment by a service bureau. Pre-printed check stock can be utilized or MICR encoded checks on blank safety stock.

Multiple claims for the same incident and payee can be combined per check. Each claim service line can have up to two designated payees. EOB’s can be combined on a single page with checks with a separate form generated for non-payments. EOB’s can be printed separately from checks. EOB’s may be reprinted at any time for any claim in history. Checks and EOB’s are designed with member and provider addresses printing for standard window envelopes.

As each check run is posted, each claim detail line is updated with the payee code, the check number(s), check amount(s) and check date. Payment and adjustment amounts are subtracted/added from the trust fund and/or reserve accounts.

Payments can be directed to the individual provider, to the group practice, or to an alternate payee at either the practice address or a billing address as defined in the provider’s record.

COB/Medicare

Coordination of Benefits and Medicare payments are automatically tracked. Claims can be pended from the claim screen and an EOB can be generated with an explanation as to the information necessary to release the claim reducing the need for letter writing.

It uses ICD-9 diagnosis codes, CPT, ADA, and HCPC procedure codes, and UCR processing for medical, dental, HCPC, anesthesia, and outpatient procedures. The parameters used to adjudicate include, but are not limited to procedure, diagnosis, pre-existing conditions, place of service, provider type and specialty, patient age and sex.

The system checks for duplicate services rendered by service and service dates. It pends claims for pre-existing conditions, for being over a certain dollar limit, for red flagged providers or employees, and for cosmetic and elective procedures, accident related claims, and over-age dependents.

If the member belongs to a PPO, and utilizes a PPO provider, the PPO fee schedule for that benefit is used. If a non-PPO provider is utilized, the non-PPO fee schedule is used along with any penalties that need to be assessed and the claim is pended for review. For a manually entered claim, the adjuster will be given the option to take or not take a penalty.

If the patient has been assigned a primary care physician and the PCP was not utilized, the system checks a list of physicians in the PCP’s call group that are eligible to provide care when the PCP is unavailable. If the physician is on the list the claim is paid as if the PCP was utilized. Otherwise, the claim is adjudicated as a non-PPO compliant claim and pended for review.

Billing parameters, premium rates, administrative fees, and other parameters can all be maintained and varied by employer group, location, class, and individual benefit plan.

Care Management

Uses HEDIS Prevention and Wellness Indicators combined with data from a variety of sources (e.g. member enrollment, prior carriers, claims, labs, case management) to identify potentially high risk and high cost members who could benefit from treatment plans that avoid preventable, dangerous, and costly medical events. The pre-cert/authorization and claims systems can then be used to capture the proposed, authorized, and actual treatment plan, down to the procedural level. With this integrated system there is no unnecessary duplication of data entry or storage.

Makes it easy for online review of inpatient, outpatient and large cases based on user-selected criteria including dollar amounts, age, sex, length of stay, location, provider type, diagnosis code, and procedure code.