Complete Claims Processing and Billing Solution

Complete, Powerful, Flexible

Claims Processing and Payment Software Solutions
  • Adjudication of medical, dental, vision, prescription, short and long term disability claims.
  • Plan set-up controlled by user.
  • The Number of plans is unlimited.
"140,000 members, 1 full time processor,
98% auto-adjudication rates!"

Plan or Contract Year 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 on-line repricing
Complete recall - system can report all changes, how a benefit was paid 5 years ago as well as last month and by whom.
Pre-registration (optional)
Automatic Adjudication (optional)
Capitation processing
Per occurrence tracking
Physician Referral tracking
Coordination of Benefits
Processor alerted to:

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 Inquiries may be performed by a processor without interrupting the claim they are currently processing.
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's may be printed for any past time frame.
Cash Management:
Micro encoding (MICR) on checks is part of the COMPLETE System.
Logo's and signature's may be scanned in for Laser checks and EOB's

Customer Service Module with phone log and progress tracking capabilities.
Pre-certification tied to claims for easy monitoring.

Examples of Claims Reports
Pre-registered Report
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
Claims Awaiting Supervisor and Executive Approval
Pre-certs on File
Claims Detail History Report
Consolidated Paid Claims Analysis
Weekly Income and 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 from the SQL database. A data dictionary is available for field definition.

HIPAA Features

Produces required notification for continuous coverage when a member is terminated and the Group is flagged for HIPAA notification.
HIPAA Privacy Reporting
HIPAA EDI Translator (optional) with X12 transaction sets

Enrollment and Eligibility

Run In
Bringing in new groups is a cinch. Even when you need to accommodate a run in period for the new group.
The Complete Health Benefits Administration System has built-in programs to handle Run-Ins and to bring new business on at a moment's notice.

Flexibility and Simplicity
Employers can enter and update their files at the host location via internet.
Employees can work from any location via internet.
Information can be received electronically from other sources.
Can receive data from other systems such as a payroll or policy tracker.
Eligibility checking with a single, simple inquiry for providers and employers.

For more information or details about CHS's Complete Claims System, please see our Contact page.

Complete Configuration Specs