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The medical software solution is designed to provide users with complete online real time data collection, processing, inquiry, claims adjudication, and reporting capabilities required to successfully compete in today's market. Requirements for a sophisticated insurance system are fulfilled with our solution while retaining the flexibility needed to process policy benefits as well as unique exceptions.
With almost three decades of experience in the design, development, and implementation of software systems for the health insurance arena, Apex Data Systems can't be beat, in fact, it is clearly our forte'. Special system modules have been designed to handle everything from basic medical only, base-plus, superimposed major medical, comprehensive major medical, short-term medical, student accident, Medicare supplements, hospitalization, and dual- and triple-option point-of-service PPO/EPO plans with negotiated rates, discounts, and per diems. From online adjudication to automated processing to electronic transmittal, processing is smooth, flexible, and efficient.
Administration Capabilities
Handling both individual and group contracts, as well as fully-insured and self-funded approaches, our consolidated administration system delivers an exceptional solution for enrollment, issue output, billing, premium collection, premium allocation, agent commissions, and financial reporting. Special highlights of our medical insurance administration software include:
Enrollment receipt and online entry log with generation of user-defined correspondence. User defined status and status description codes for use in monitoring new business and cases in medical underwriting. Ability to handle multiple health plans per person. Flexibility in defining dependent member coverage. Ability to support multiple insurance carriers on a single invoice. Flexible issue output of ID cards and certificate pages. User definable plan files that hold underwriting and administration processing rules, with availability of state overlays. State-level reporting plus reporting for division, profit center, city, county, zip, and other user definable fields. COBRA administration. Automatic adjustment and balance forward premium processing with support for both system generated and manually generated back bills and back credits. Availability of pre-authorized checking and credit card invoicing, electronic list billing, and other EFT features. Flexible agent commission processing of flat or graded commissions with generation of checks, statements, and check register.
Claims Capabilities
Processing of medical claims requires a software solution that is designed to be flexible and yet to control the accurate application of policy provisions, to be fast and easy to use, and yet designed with attention to the capture of detail. These critical features are the basis for our feature-rich claims system. The system automates the entire process, yet still allows the adjudicator to make final decisions based on documentation and facts. Claims adjudication features of our health insurance software solution include:
Support for the wide range of PPO and managed care provisions. Both policy year and plan year accumulators. Deductibles by age band, calendar year, cause, type of service, and other parameters. Coinsurance and co-pay calculations. ICD and CPT code structure support capturing multiple diagnoses and procedures. User-defined adjudication messages at the service line level. Issuance of checks, EOBs and worksheets with the ability to honor nine different benefit assignments in a single action plus flexibility to split a payment between multiple payees. Availability for batch check issuance of consolidated payments to providers for multiple claimants. User-defined not-covered codes. Pre-existing clause application and automatic processing of coordination of benefits. Claims adjustments for additional payments on invoices or refunds of overpayments. Detailed nurse/reviewer notes, and plan of care. State-related benefit overlay records that automatically engage based on the state code assigned to the insured. Free-form online claim comments. Detailed claims analysis reporting that consolidated premiums and claims for any user-requested three-year period. Calculation of reserves. Reporting of actual incurred claims, paid claims and anticipated incurred claims, all with claim dollar figures and loss ratios. Availability of modules designed especially for EDI receipt of claims and EFT payments. Security limits for each user by dollar amount. HIPAA compliance.
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