The Claims Processing Module is a significant addition to the Managed Care Module.  It provides an organization with the ability to adjudicate claims payment according to specific detailed benefits and rate rules.  Easy access to provider information allows reliable resolution to claim disputes.

Administrative Benefits:

• Financial planning

  • Use as a budgeting tool

  • Track Accounts Payable

  • Track the value of outstanding authorization

  • Review IBNR claims

• Contract Management

  • Monitor profitability

  • Evaluate pricing and renewal strategies

  • Monitor contract utilization

  • Renegotiated contracts

• Standard online reports

Clinical Benefits:

• Produce EOB Reports
• Process of appeals and grievances
• Monitor turn around time on claim payments
• Update utilization in client benefit records
• Services providers through an online view of claim status

Reimbursement Benefits:

• Manage cash flow

• Pay providers based on contract type/provider type

• Develop user defined adjudication rules

• Produce error reports

• Adjust claims

• Use of integrated check writer

• Process denials

• Produce EDI

CLAIMS PROCESSING

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