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Claims
Adjudication
The
advent
of
government
regulations
such as
the
Health
Insurance
Portability
and
Accountability
Act (HIPAA)
coupled
with
increasingly
stringent
insurance
company
requirements
today
are
driving
the need
for more
efficient,
accurate
and
secure
medical
billing
and
claims
processing.
We
provide
outsourcing
services
for the
entire
gamut of
claims
processing
from
data
entry to
adjudication
for
health
insurance
companies.
We
implement
procedures
and
systems
that are
HIPAA
compliant,
to
process
and
adjudicate
medical
claims.
We are
capable
of
adjudicating
the
claims
finally
from the
captured
claim
data or
from the
data
received
from
EDI. The
claims
are
adjudicated
based on
claim
data,
information
of the
plan &
the
insured
treatment
codes
and a
host of
other
information.
Automated
Batch
Adjudication
Once the
claim
data has
been
indexed,
the
batch is
sent
through
an
automated
adjudication
program.
This
process
performs
hundreds
of
checks -
verifying
eligibility,
plan
arrangements,
allowable
benefits,
plan and
claim
limits,
deductibles,
co-ordination
of
benefits
and much
more. We
adjudicate
all
claims
before
they go
to the
examiner.
After
the
claims
in a
batch
have
been
adjudicated,
they are
automatically
distributed
to the
appropriate
“Claim
Examiner”
along
with
scanned
correspondence.
The
claim
which
meets
all the
checks
of the
adjudication
program
can then
be
released
for
payment.
Claim
Examiner
The
claims
not
passed
by the
adjudication
program
are
presented
to a
skilled,
well-trained
and
experienced
Claims
Examiner.
Such
claims
are in
the
categories
of
Review,
Adjudicate
and
Correspondence.
Review
These
claims
have
successfully
passed
through
the
claims
processing
logic of
the
adjudication
program
and have
been
adjudicated
completely.
Claims
Examiner
approves
them and
releases
for
payment.
Adjudicate
Claim
that did
not pass
through
the
adjudication
process
are
flagged
and
presented
to Claim
Examiner
for
adjudication.
Claim
Examiner
checks
the data
entered,
claim
image
and
description
of
potential
problem
and
reviews
all
information
in order
to
finish
the
adjudication
of the
claim
for the
payment.
Correspondence
Claims
which
are not
adjudicated
by the
Claim
Examiner
are
placed
in this
category.
Appropriate
correspondence
is
generated
and
“stapled”
electronically
with the
claim in
question
and
intimated
to the
provider
or
insured
to
provide
additional
information. |
