| Claim
Administration Services |
 |
Mailroom/Scanning
|
|
OCR/DE data capture
|
|
Paper to EDI conversion
|
|
Clearinghouse Services:
Validation of member and
providers information 837,
270/271 etc.
|
|
Full claims inventory/workflow
reporting
|
|
|
| Policy
Administration Services |
| |
Eligibility Tracking and
Verification
|
| |
Initial and ongoing enrollment
of groups and members/benefits
|
| |
Ongoing maintenance of group
and member demographic data
|
| |
Coordination of benefits
including TPL/COB
|
| |
Provider access to eligibility
and benefits
|
|
|
| Utilization
Management Services: |
| |
Referral Processing
/authorization services
|
| |
Full prior
authorization/pre-certification
review process with auto
approval or review of all
requests for referral
authorization
|
| |
Regulatory compliant
auto-generated notices/letters
sent to providers/patients
|
| |
Quality and Utilization
Management
|
| |
HCC/RAF coding support
|
|
|
| Claim
Adjudication Services: |
| |
Claims Payment
|
| |
Adjudication of claims based
on eligibility/ benefits/
authorizations/ fee schedules
|
| |
Repricing
|
| |
Generation of checks and EOP/EOBs
|
|
|
| Customer
Service: |
| |
Customer Service to Members
and Healthcare Providers
|
| |
Appeals and Grievances
|
| |
Review and tracking of all
member grievances, responses,
and intervention
|
| |
Full member services including
member outreach in the
resolution of concerns and
other activities
|
| |
Customer services reporting /
trending by product, provider,
etc.
|
|
|
| Provider
Network Development
& Management |
| |
Credentialing support
|
| |
Provider record/database setup
and maintenance
|
| |
Contract setup and maintenance
|
|
|
| Capitation
Administration: |
| |
Capitation file maintenance
and payment processing
|
| |
Integrated capitation and
eligibility reporting
|
