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Claims Tools |
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Web-enabled automation of Denial letters;
Claims Auditing and Automated Interest Calculation eliminate
many previously labor-intensive manual tasks. |
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Denial
Letters: Claim denial letters are generated
by designated staff members using a simple, one
step process. Once submitted, a match for the member’s
health plan and appropriate language is found
and a corresponding denial letter containing all
ICE approved denial reason codes, ERISA language
and health plan demographics is composed. |
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Claims Audit:
Analyzes processed claims, identifying all errors
in accordance to the client’s business
rules. Audit rules may include verification of financial
responsibility for services, member eligibility,
bundling/unbundling and many more. Reports are available
for analysis of audit results and review of
automated calculation of interest, determining penalties
on untimely claims. |
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Mass Fax |
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Broadcast faxing streamlines the process
of communicating with the provider network. A web-based
filtering interface is used to designate a distribution
list and if needed, a single transmission is available.
Attachments, fax cover sheets and notes can be added to
each document. |
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Fax-It |
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Mass faxing that is designed specifically
for authorization status submissions. The system is scanned
at
predefined intervals and approved, modified or denied
authorizations are automatically faxed out to
designated providers. The letters are customized to the
MCO’s specifications and may include information
such as member’s PCP, authorized provider or referring
physician. Logs of outgoing faxes are created
and can be referenced at a future time. Images of the
authorization are stored within the log and can be
viewed at anytime. |
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Code-It |
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This web-enabled version of Ingenix’s
Medicode ICD-9, CPT, and HCPCS reference data is available
for
claims staff, UM and other departments. Easy access to
code searches and bundling/unbundling programs
increases the reliability of the decision making process
while shortening the search time and eliminating the
need for use of expensive reference books purchased annually.
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QI |
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Quality initiatives can be challenging
and process intensive. User-defined indicators such as
asthma,
postpartum visits, well child visits, pharmacy utilization
patterns, etc. are used as search keys for data mining
and tracking. Reports are then generated and automatically
broadcasted to the relevant providers. |
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Eligibility Pre-Processing System |
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Analyzes incoming eligibility data.
Comparisons are made between new and existing eligibility
data to
identify member adds, changes and terminations. Pre-defined
business rules are applied and a clean file
is produced, thus maintaining accurate eligibility information.
Pre-processing also affords an immediate
cursory review of all incoming records, enhancing reconciliation
of capitation and eligibility data. |
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Encounters |
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Assists with the submission of encounter
transactions to the health plans and clearinghouses. Records
are compiled monthly for submission and the data is then
validated in accordance with a health plan's
rules. Using a web-enabled interface, the staff reviews
and corrects all records. This process increases
the number of encounters submitted as well as the accuracy
of the data submitted. |
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Eligibility |
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View all eligibility information, at
a glance. Member effective and/or termination dates, co-pay
information
and Primary Care Physician data are some of the fields
that may be displayed. |
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Authorization |
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View approved, modified, or denied
services including all clinical information supporting
these status
assignments. |
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Provider |
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Provider information such as demographics,
hospital privileges, languages and health plans is available
at a
glance. Advanced filtering capabilities allow for searches
by zip code, specialty, or name. |
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Claims |
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This web-based claims look-up feature
displays information related to a decision made for a
claim’s status.
Staff members utilize this module for efficiency and ease
in answering claim status inquiries and requests
for adjustments. Links are available to view the provider,
member, and authorization used in the claim
adjudication process. |
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Reports |
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The Re-Crystallize technology web-enables
and standardizes the report libraries, using pre-defined,
flexible
filters. Reliability of data and accuracy of reports are
increased when web-enabled, as data cannot be
modified randomly. The design of the operating environment
is such that running these reports does not
impact the performance of a client’s system. |
