Complete, Powerful and Flexible
 | Adjudication of medical, dental, vision, prescription, short and long term
disability claims. |
| Plan set-up controlled by user. Number of plans are unlimited. |
Methodology:
| Plan or Contract structure |
| Benefit logic:
Utilizes: CPT's, ICD-9's, DRG's, HCPCS, fee schedules, CRV's and others. |
| Provider fee schedules |
| PPO fee schedules and repricing |
| Complete recall - system can report all changes, how a benefit was paid 5 years
ago as well as last month and by whom. Any adjustments are easily tracked, what buttons were pushed and what they
were thinking (almost). |
| Pre-registration optional |
| Automatic Adjudication available |
| EDI available |
| Capitation processing |
| Per occurrence tracking |
| Physician Referral tracking |
| Coordination of Benefits |
| Processor alerted to:
Pre-registrations
Pre-certs
COB
VIP
Claimant notes
Dependent notes
Family notes
Provider notes
Student status
Over % of specific stop/loss
COBRA status |
| Adding new business is simple and cost effective. You can set-up a new plan
in less than a day and be paying claims when enrollment is in. |
| Customer Service may be performed by a processor without interrupting the
claim they are working on. Press a hot key and any existing claimant's or enrollee's records are available,
answer the inquiry and hot key back into the claim in process. |
| Claim can be re-opened at any time for reprocessing up until the check is
printed. |
| EOB may be printed for any past time frame. |
| Cash Management:
 | Micro encoding (MICR) on checks is available as part of the Complete
system. |
| Logo's and signature's may be scanned in for Laser checks and EOB's |
| Bank Reconciliation-optional sending of media to bank for reconciliation
by the bank |
|
Claims Reports
| Pre-registered Report-weighted average calculations. |
| Pre-registered and Claims Pended Report |
| Enrollment Census Report |
| Processor Summary |
| Cycle Time Report |
| Claims Productivity |
| Claims Count by Date Received |
| Claims Count by Date Processed |
| Claims Awaiting Supervisor and Executive Approval |
| Pre-certs on File |
| Claims Detail History Report |
| Consolidated Paid Claims Analysis |
| Weekly Income & FICA Withholding |
| Claimant Benefits Paid Report |
| Claimant Usage by Benefit Report |
| Specific Stop Loss Report |
| Aggregate Stop Loss Report by group and/or location |
| Utilization Management Report |
| Total Benefit Analysis |
| Claims Lag Report |
| Reports of the TOP Providers, Benefits, Diagnosis
Codes, Claimants, Ages, Date ranges, etc. |
| Provider Summary Report |
| PPO Savings Report |
| PPO Withhold Report |
| COB Savings Report |
| Hospital/Patient Reports |
| Monthly check/Deposit Registers by group and/or location. |
| Exception Reporting for Incorrectly Entered or Incomplete
Claims Reports |
Any other reports not
pre-defined in the system are easily produced in various third party report generators. A data
dictionary is available for field definition.
HIPAA
Produces required notification for continuous coverage when a member is terminated and the
Group is flagged for HIPAA notification.
|