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Our feature-rich claims system delivers complete online, real-time claims processing and user inquiry functions for individual and group coverages like medical, dental, vision, prescription drug, critical illness, long-term care, long-term disability, weekly income, life, and AD&D contracts. Basic hospitalization, Major Medical, Base Plus, dual and triple-option PPO/EPO, and other variations of medical plans are all handled for groups and individuals. Our solutions handle the complete process from enrollment maintenance through issuance of checks and EOB's while keeping human intervention at a minimum. Claims are worked entirely on the system using complex calculations and accumulations from highly detailed plan files. The system structure allows for electronic claims submittal or integration with imaging applications as alternatives to hard-copy input. In our software design, we have kept the system easy to use and understand, while putting as many tasks as possible to clerical level staff, thus freeing-up more time for the adjudicator to handle mission-critical events, and have developed logic paths which enable the system to make decisions based on user-defined parameters.
Eligibility
Our claims system may be implemented with our fully consolidated administration module, or as a stand-alone solution, which includes integrated eligibility maintenance. During claims adjudication, the system checks the most current, up-to-the-minute enrollment and policy data for quick, accurate verification. Eligibility information and claim history is maintained for each individual on the database and can be accessed independently or automatically during claims adjudication. Eligibility records include effective and termination dates, paid-through-dates, preexisting codes, waiver codes and other reporting fields. Age parameters for benefit eligibility, reductions and terminations which are maintained in the general plan files are monitored, and each claimant's age information is maintained in their own master records so that specific data can be displayed as each submitted claim is processed.
Flexible Claims Receipt and Tracking
All claims records involving an insured and dependents of that insured, are maintained through sequenced records with submittal numbers relating to the Explanation of Benefits (EOB). Claims received may be immediately inventoried to the system and are ready for inquiry or payment. In addition to a simple inventory entry, a fully detailed pended claim action may be created for further action. When claims mail is received, it is immediately placed into a pending status in the system. There is no time lag or lack of information about when the claim materials were received and the approver to whom the matter has been assigned. Notepad features are available throughout the claims system for free-form entry and diary-type notes.
Integrated Pending and Claims Correspondence
Claims pended for additional action or information are maintained online for inquiry purposes. They are readily available for customer service and adjudication. Online inquiries detail all claims data captured to date. Claims may be pended using user-defined reason codes. Our extensive claims software solution includes a complete and sophisticated correspondence and pending system which automatically produces form letters for additional medical histories, claimant data, and other information. The pending module allows for letter quality standard forms and custom letters to be generated by the system. These are user developed and maintained so output can be personalized to the needs of the user. Specific data is merged into these letters from the database or entered as freeform user input. The system automatically generates up to nine follow-up letters in a single series, and on the schedule set by the user, so that the follow-up process can be unattended. In addition to letters, forms for special purposes may also be generated, such as for Duplicate Coverage Inquiries, Dental pre-estimates, and others. The pending system also incorporates a complete management review system including reports which show elapsed time on non-processed mail in addition to listings of claims awaiting a response for additional information, and complete analysis reports on lag time.
Feature-Rich Plan Files
For claim screening purposes, our consolidated systems store General Plan files for eligibility and underwriting functions and Claim Plan files for the automated adjudication process. Both files are configured to allow complete user inquiry for customer service and hospital or other outside verification purposes. Since the systems offers online adjudication, benefit levels and ineligible amounts which are developed as part of the claim plan files are handled automatically so there is no need for claims analysts to denote such elements. At the same time, the system offers the flexibility for "not covered items," such as personal items on a hospital bill, to be entered by the processor. During processing, the system makes the appropriate calculations and allocations based on the plan file information. Plan files used to determine specific benefits contain all of the essential elements used for calculations. These files indicate which particular benefits accumulate together toward deductibles, stop-loss, or maximums. Plan files are driven by user-defined service codes, which are designed to allow definitions of each type of service by carrier or book of business. Changes in plan benefits and parameters can be maintained as part of eligibility history by the end user, and calculations are based on the plan in effect on the claim-incurred date. Control of plan building, code tables, eligibility, etc., is in the hands of the user with appropriate security, and does not require any programmer intervention.
Accumulations
Accumulation records are maintained automatically during the claims adjudication process. Accumulations may be held at an overall plan level for the insured or family, or at the specific benefit level or type of service. As part of the accumulation tables, our systems maintain current and prior year data by plan year or calendar year, for deductibles, coinsurance, maximums, numbers of visits, carryovers, and each of the many other plan parameters established by the user. Accumulations are automatically updated by the claims process and for flexibility, can be directly accessed with the proper security, for maintenance of transfer of benefits provisions or for other purposes. This flexibility is especially valuable in any takeover or conversion process.
Reasonable & Customary and other Coding Features
Our claims systems have been designed to use major, standardized coding tables including ADA codes, CPT codes and ICD operation and procedure codes, as well as user-defined structures. The usage of R&C processing, the data, and the appropriate tables are user determined. The claims module has been designed to maintain two separate databases; one configured for HIAA-type data and the other for Ingenix or ADP RVS-type records. The structures are a standard part of the system and may be loaded either by direct data entry, or automatically via electronic media. Customized data developed by PPO's, EPO's, or other provider organizations can also be accommodated.
User-Definable Coordination and Integration of Benefits
In order to handle a full array of contractual provisions, both coordination and integration are supported within the claims adjudication system. To offer the greatest level of flexibility, both COB and integration parameters are user-definable including overall applicability, reimbursement percentage, and application of credit reserve. Calculations of benefits are handled automatically with the capture and application of credits and debits as appropriate. Other carrier data is maintained along with full mailing addresses, and Duplicate Coverage Inquiries (DCI's) are also generated as part of the system's standard correspondence features. Fast, simple, hands-free COB processing and maintenance allow current and future claims actions to be handled automatically.
Forward-thinking Provider & Network Maintenance
Flexibility and functionality in the areas of provider and network maintenance are crucial to administering successful cost-containment health programs. The ability to effectively partner with the provider community is key to any managed care program. As part of initial set-up, and on an on-going basis, provider records may be electronically fed to the system for use with your medical, dental, vision, and other health plans. This electronic load can include network relationships and multiple fee schedules or discount arrangements. As an option, and with proper security, providers may be entered on-line while the claims approver is entering other claim information for calculation. Separate menu options also exist to allow entry by claims assistants. The system allows for multiple PPO/EPO relationships, networks and contractual deals. Tracking and utilizing special contract relationships and discounts or schedules is automatically handled during the adjudication process. Offering the flexibility to handle clinic-type situations, multiple providers may be retained under a single Tax Identification Number along with a unique sequence. Since the system offers multi-carrier support, current and prior year payment accumulations are maintained by provider and payor, for tax reporting purposes. The system offers both generation of 1099's and IRS electronic submissions. For report selections, provider records also contain information such as provider type, medical specialty, and problem indicators.
Provider Deals
Our health claims solutions allow complete processing of multiple PPO/EPO arrangements in conjunction with the provisions of the plan. The systems allow for any number of PPO and/or EPO networks for national/international coverage and further maintains specific payment provisions on each provider, even individual providers within a clinic situation. Each provider may have multiple network relationships and each relationship may carry its own discount or repricing features. Examples of the types of pricing features include dollar or percentage discounts from fee for service, a scheduled allowance per procedure, a per-diem, variances based on place of service, an allowance not to exceed a specified percentage of URC, plus quick pay discounts, and others. These repricing features are used to determine the eligible expense. The claims systems then further allow for plan provision variables at the point of service based on the provider's participation within a network. For example, the plan may allow a greater coinsurance reimbursement for use of a network provider or a low per-visit copay. All calculations are handled automatically for the user in a single pass without the need for any user investigation. Of course, complete on-line inquiry to all records is also available.
Multi-Carrier Check and EOB Issuance
Claims checks and worksheets or EOB's are automatically generated as part of the complete adjudication process. The system supports the automatic assignment of check numbers and output can be printed on multiple formats per the user requirements to allow for multiple carriers or various currencies. Up to nine separate checks, each with the ability to issue split-payments to multiple payees, can be issued with each EOB. Payments may be made to the insured, an assigned provider, a beneficiary, or other entity. Multiple split payments are available on all product types and check formats. Batch payments to providers are also available based on user preference. Special payment registers are available on batch checks as an addition to the standard check registers.
The systems allow for denial and not covered reason codes, predetermined by the user, to be defined on the EOB worksheet output. This process maintains conformity within a user's processing organization, and gives management control over the language used for messages on the EOB. Based on security authorization, freeform notes are handled through the pending module as documented correspondence.
Adjustments
As part of our claims systems, online adjustment processing for the correction of and historic maintenance of overpayments (refunds) and underpayments is available. Checks issued for incorrect amounts and those that simply contain misinformation not relating to dollar amounts can, with proper security access, easily be updated and adjusted. New checks are generated if necessary and all claim history records are cross-referenced accordingly. History is maintained and augmented. The system updates check files, employee/policyholder and dependent claim history, provider records and other pertinent files. Refunds and additional payments on previous actions can be reviewed as a part of history while the integrity of the original transaction is completely maintained. These actions also show appropriately on check registers and reconciliation reports for overall financial accuracy.
Inquiry
Users may make their own determination as to the level of hard-copy materials they will maintain for history. Retrieval of claim files for claims adjudication, hospital verifications or customer service inquiries is not required. Online inquiry details all claims adjudication actions, claims checks, claim status, benefit levels, accumulations, and other elements. The individual claim history shows each claim submitted and the outcome of processing, in detail.
Claims Calculations and Auto Adjudication Capabilities
Apex Data Systems' claims solutions have been developed with the guideline of combining automatic adjudication with user flexibility. The claims processing does not require manual overrides for any of the plan designs built as part of the plan files. The system does, however, allow for appropriate overrides, thus offering the full flexibility of a manual procedure. Such manual overrides are recognized by override codes and user security access. Security provides that overrides can be held for supervisory review and release.
All eligibility and claims history is available for online inquiry purposes. This means that the system can support paperless claims adjudication and customer service responses. The inquiry process is simple and efficient with the employee/policyholder, dependent and provider inquiry available by name or by ID number. While most users maintain hard-copy documentation, microfilming and/or imaging are viable alternatives. The system also offers the flexibility to accommodate electronic transfer of data in accordance with the user's specifications, including such information as eligibility files, accumulation records, PPO schedules and updates, names and address records, R&C data, and claims billings in the form of UB-92 or HCFA-1500 formats. Based on the user's needs, custom interface programs can also be developed by the staff of Apex Data Systems.
A number of key fields are available to identify and track claimants and their claims submittals. These include name, social security or ID number, claim number, dependent sequence within family and claim submittal and set numbers. Claim specific numbers are automatically assigned by the system at time of processing. Other special coding is available for reporting purposes including such user-defined fields as division and profit center.
Processed claims may be pended "with calculations" but without making a payment, even when part or all of the claim is eligible. The user may apply the pending status, for example, while gathering additional information, or may be assigned automatically by the system, for example, when allowances are in excess of processor security levels. Pending reports show all claims that are pended, along with a reason code and a system or user defined pending reason description.
During the claims adjudication process, the system automatically controls provisions such as benefits and benefit periods, and displays extension status codes and dates. The system not only chooses the appropriate plan record for adjudication, but also applies appropriate eligibility dates for greatest control and accuracy.
The system has been designed, however, to provide the user with complete flexibility. In various functional areas, user overrides may be allowed, based again on the user security codes. Such overrides appear on management reports for complete audit control.
Some of the special features of our claims solution are:
- Initial data entry and verification performed by claims assistants excluded from the approval step by system security.
- Immediate capture of even incomplete claims by entry into the system in a pended status.
- User-defined and selected correspondence generated to gather additional information desired.
- Automatic checks for potential duplicate submittals and possible pre-existing conditions.
- Tolerance test of number of inpatient hospital days on each claim, against admission and discharge dates.
- Special preferred provider discount calculations for prompt payment.
- Identification of charges in excess of R&C for both surgical and non-surgical procedures.
- Eligibility with history of breaks in coverage or plan changes.
- Eligibility verification down to the specific named dependent coverage level.
- Computation of plan or benefit year deductible, carryover and inside plan limits.
- Identification of potential COB situations and calculation of COB claim payment.
- Diagnostic code recognition.
- Tax deductions and interest payment.
- Beneficiary maintenance for multiples at the primary, secondary, and tertiary levels.
- Batch payments to providers.
- PPO and EPO Dual and Triple Option point-of service processing.
- Repetitive payments for disability claims with the user-defined review periods (up to 12 months).
- User-defined disability cause code field, enabling reporting by cause of sickness or injury for all plan types.
- Freeform notepad and claims comments screens, allowing staff to document important notes or activities and to flag as urgent for subsequent automatic review.
Reports
As part of the overall functionality of our systems, Apex Data Systems believes that reporting is crucial to a complete claims management system. Therefore, our solution offers a wide array of standardized base system reports, many of which can be generated using the flexibility to sort and select data in a variety of ways via user-friendly prompts and responses.
In addition to the base system reports, our systems can also make use of independent ad-hoc report writers. Ad-hoc reports can be produced and maintained by the user, so that with our full suite of reports and an ad-hoc report writer, you can meet all your reporting needs.
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