Claims And Utilization Management Services
1. Claims And Encounter Management :
- Receive paper or electronic HCFA 1500;
- Adjudicate claims in accordance with Plan’s policies and procedures;
- Audit Adjudicate claims by using Virtual Examiner claims review software;
- Prepare Pre-check run review report;
- Maintain claims processing compliance;
- Generate standard claims reporting package available for online access;
- Generate payment thru Check run printed on-site or thru ACH debit;
- Coordinate Third Party Liability and Reinsurance recovery;
- Provide Reinsurance carrier with large claim information on a monthly basis or at time of admission
- Maintain latest current fee schedules according to provider contracts and Plan Benefit
2. Utilization Management/Quality Assurance :
- Provide review and authorization including Medical Director review in applying clinical and Plan Benefit approval guidelines for authorization of services by providers. Notify providers and employees of action taken online, by fax, by mail and or by secure email;
- Allow submission of referral requests using CERECONS web-based application;
- Allow review of referral status review using CERECONS web-based application;
- Implement “paperless” referral processing and approval process to speed authorization turn around times;
- Apply Virtual Auth Tech to processing of all referral requests;
- Assure that authorization approval processes are performed in compliance with Health Plan and governmental guidelines;
- Provide Case Management of all hospital admissions, SNF admissions and complex or costly out-patient care as identified thru QM Meetings and Virtual Examiner Case Management reporting;
- Aggressively screen for and coordinate care for potential TPL cases;
- Schedule and manage utilization and quality meetings;
- Provide monthly reporting in compliance with specified dead-lines;
- Review and as appropriate, make recommendations regarding the structure and functions of the group’s utilization and quality management plan;
- Provide concurrent and retrospective review of medical procedures in accordance with policies and Plan requirements;
- Provide data regarding the use of outpatient and inpatient services by provider;
- Respond to Plan participant grievances
Eligibility Management And Management Information Service
1. Eligibility Management :
- Maintain and update a current eligibility list of Plan enrollees under all Plan agreements and provide the primary physicians with eligibility lists (“e-list”) in a timely manner;
- Provide employees with member eligibility cards
- Provide updated reports in a timely manner showing total member enrollment;
- Verify eligibility on claims and referrals based on the most current information provided by Plans;
- Provide telephonic support for member and provider inquiries
General Monitoring of GROUP Compliance with the requirements, terms and conditions of Plans:
- Advise and assist GROUP to timely and appropriately meet the requirements and standards of Plans, governmental agencies and other third parties
2. Management Information Services :
- Utilize computerized managed care information system as operational platform for all managed care processes including Eligibility, Referral Authorization, Capitation, Claims adjudication and payment, case management and Provider administration.
- Provide Online data access for processing of and review of referrals, claims and eligibility
- Comply with all HIPAA guidelines relating to information security and data transaction monitoring
- Support access of online eligibility and claims referrals.
Online And Computerized Management Services
1. Eligibility & Capitation Services
Services Include:
- Eligibility
- Web based Verification
- Member Search & Lookup
- Co-pay & Benefit Verification
- Online E-list
- Search & view
- Complete list print capability
2. Claims & Encounter Web Enablement
Services Include:
- Electronic Claims and Encounter Submission
- Online Claims Status Review for physicians
3. Referral Web Enablement
Services Include
- Electronic Referral Submission
- Auto-referral Customization
- Remote Medical Director Access & Approval
- Online Referral Status Review
- Provider Office Print Capabilit
4. Executive Decision Support
Services Include:
- Executive Financial Information
- Capitation Summary
- Medical Claims Expense Summary
- Trend Information
- YTD PMPM and % for membership, Claims and Referrals by PCP and by facility or physician specialty
- Utilization Information
- Specialty and Physician utilization by PMPM and % of claims for each PCP and specialist
Out- Of- Network Negotiations
In response to the escalating health care costs the company has developed an out-of-network secondary network
Benefits:
- Discounts on non-network claims that would normally be paid at retail.
- Claims data is sent through our various secondary network providers for network repricing.
- The discounting of out-of-network claims reduces the out-of-pocket cost to the plan participants
Administrative fee is usually a percentage of savings (30%) however; the transplant network is usually a flat access fee which is generally an allowable charge under the Stop Loss policy
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