Advanced Claim Management

An advanced claiming solution for payers that want to improve claim auto-adjudication rates and identify the most efficient path to process claims for a higher first-pass rate and lower costs.

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Enhance Claims Processing

advanced-claim-management-significantly-improve-processing-cost

Significantly improve processing cost-per-claim by reducing manual intervention in the claim re-pricing and/or adjudication process.

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Reduce the time spent working pended claims with the ability to filter or reject transactions based on customer reference data.

advanced-claim-management-support-tangential-claim-adjudication

Support tangential claim adjudication processes with the ability to provide supplemental data.

advanced-claim-management-appropriately-direct

Appropriately direct pre-adjudicated claims to/from PPO partners for repricing services prior to delivering to a customer for final adjudication.

advanced-claim-management-identify-most-efficient-path

Identify the most efficient path for healthcare claims to be delivered to the final claim adjudicator.

advanced-claim-management-improve-accuracy

Improve accuracy by validating, augmenting, replacing, and normalizing provider submitted data. 

Improve Claim Auto-Adjudication Rates

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Network edits & enhancements

  • Delivers claims efficiently. We validate, augment, replace and normalize provider-submitted data within a claim to improve auto-adjudication and reduce time working pended claims.
  • Accesses current and comprehensive payer information. Advanced Claim Management rejects or segregates claims using payer-defined criteria, as well as identifies and rejects duplicate claim submissions.
  • Applies client-specific pre-adjudication business rules to claims to reduce manual intervention in the adjudication process and improve processing cost-per-claim.
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Claim routing service

  • Leverages hosted payer data to automatically route claims to/from PPOs for repricing services. Provides a claim to the payer that has already been repriced and is ready for final adjudication.
  • Identifies and automatically routes claims to other non-PPO entities besides the original destination for appropriate processing.
  • Creates multiple copies of claims to route to a given destination to support tangential claim adjudication processes.
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Supplemental services

  • Render electronic data onto industry-standard paper claim forms. Deliver in an electronic (PDF) format to a customer.
  • Support supplemental reporting functionality to be delivered with or without the claim.

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