Claims Management Software

“An EDI (Electronic Data Interchange) feature to load encrypted claims files sent by providers.

Claims received thru this platform will be instantly processed (and awarded per inbuilt rules) unless otherwise indicated for human intervention.

EDI file decryption is done with a password chosen by the provider.

A simple claim-capturing interface with controls to minimize user capturing errors.

Amount to award is calculated and allocated by the system, shortfalling if benefits are no longer available.

Claims can be automatically rejected for different duplication scenarios.

User is given limited options to change the benefit allocation from a sub-list of applicable benefits, but the system automatically selects the most appropriate one.

ICD-10 codes are pre-loaded into the system and the user can pick one for each claim line and for the whole claim (diagnosis).

Modifiers are built into the system to automatically determine the maximum payable amount.

Member reimbursement claims capturing.

Member Pre-authorization and Member treatment pre-funding

Flagging of claims based on their status

Grey – awaiting capturer verification

The system uses the table above for mapping and thus determining what status the member is in at a specific date. This is also dependant on the status of the principal member.A member is changed to another plan by capturing a ‘Joined’ event to the new plan.The system automatically calculates the waiting period depending on whether late-joiner or regular-joiner

Amber – on hold pending human adjudication. May have a problem detected by the system of a user
Red – Rejected

Green – Ok and ready for payment

Provider’s own ref number for their own claims are captured in the system

Printing of claim form

Use of hash total to detect capturing errors.

Generating, emailing and printing a pre-authorization letter.

Generating, and sending a pre-authorization SMS.

A checklist is used to monitor/assess the activities around each claim (workflow).

The steps in the checklist are customisable
Claim Correctly Captured.

Claim Stamped.

Clinical Data Verified.

Final Authorisation.

Adjudication & Award

Patients readmission rate:monitor the number of patients who are coming back.

Related Services’ History.

History of Same Diagnosis.

Benefit Exhaustion History.

Parent Benefit Exhaustion History.

Global Limit Usage History.

An individual claim line can be flagged, and a whole claim can also be flagged. The whole claim’s flag monitors handling of the individual lines. If claim is rejected, then the individual claim lines do no access or hold benefits.

Clinical data can be captured, even though it is generally not included on standard paper claim forms, including:

Date/time of admission and discharge.

Next of kin in the case of an accident.

Per-claim audit trail: For every claim, the system records and shows the trail of users who changed it, including the date/time and location (computer) used

Claims navigator feature lists all claims according to the following criteria

Dates treated/received/captured/paid.
Payment Batch.
EDI File
Paid only
Unpaid only
Current Member’s History
Current Provider’s Claims
Current Member AND Provider
This Whole Family
Payment Flags: Pay – All OK, Pay – On Hold, Awaiting User Decision and Rejected.

Capturing accuracy: Hash Total Mismatch, Capturing Checked and Capturing Not Checked.

Current user’s own claims: Captured by me, My UnChecked Claims and Capturing Not Checked.

Other navigator features: Bulk deletion, Bulk movement to a different provider and Bulk setting of payment decision and Searching for a specific claim by system assigned number or provider’s reference.

Data Capturing Session (Capturing by Batch) – this speeds up capturing of a batch as the common details of the entire batch are entered only once and automatically set for each new claim in that session.

Each computer can be optimised either in favour of claims or membership.

Shortfalls and rejection reasons are edited using this feature.