ADVANCED CLAIM ADJUDICATION WITH AUTOMATED PROCESSING
INSTANT ON-SCREEN REPORTING, WEB REPORTING , WEB DASHBOARDS
INTEGRATED PRE-APPROVAL AND PREAUTHORIZATIONS
RAPID AND FLEXIBLE BENEFIT PLAN SETUP
BUILT IN DOCUMENT IMAGING FOR DOCUMENT ACCESS RELATED TO PROVIDER, GROUP, AND
INSURED MEMBERS
CUSTOMER SERVICE CALL AND CORRESPONDENCE TRACKING INCLUDING ONE TOUCH SMS OR
EMAIL TO CALLER
BRITISH AND AMERICAN DATE SUPPORT
REAL-TIME WEB ACCESS PORTAL FOR INSUREDS, PROVIDERS AND GROUPS
COMPLETE HIPAA COMPLIANCE AND EDI INTERFACES
SUPPORT FOR INTERNATIONAL MARKETS AND CURRENCIES
COST EFFECTIVENESS AND A PREDICTABLE ROI
OPEN ARCHITECTURE DATABASES FOR ACCESS BY THIRD PARTY APPLICATIONS
LATEST SQL 2016/2017 64 BIT AND MS .NET ARCHITECTURE
SCALABLE TO MILLIONS OF INSURED MEMBERS
MULTI-LEVEL GROUP SECURITY WITH LOGGING OF ALL EVENTS
MULTIPLE COMPANY, MULTIPLE DATABASE SUPPORT
CLAIMS, PREAUTHORIZATION, AND CUSTOMER SERVICE QUEUES FOR MAXIMUM EFFICIENCY
AND OPTIMIZED WORKFLOW
MULTIPLE CURRENCY SUPPORT
SUPPORT FOR NON STANDARD PROVIDER CODES AND FEE SCHEDULES
UNATTENDED CLAIMS AUTO ADJUDICATION CAPABILITY
AUTOMATED WEB AD-HOC REPORTING SYSTEM
REALTIME DASHBOARD WEB CHARTS AND GRAPHS
SUPPORT FOR CUSTOM AND USER DEFINED FIELDS
BUILT -IN ELECTRONIC PRE-AUTHORIZATIONS AND SCANNED CLAIMS SUPPORT
INTEGRATED PRE-APPROVAL & CASE MANAGEMENT WORKFLOW
RAPID PREAUTHORIZATION QUEUE PROCESSING FROM ELECTRONIC OR OTHER LINKS
SINGLE SERVER OR CLUSTERED SERVER SUPPORT
MOBILE APP FOR ANDROID AND IOS ( Q4 2019)
EDI IMPORT AND EXPORT
MULTIPLE INSURANCE COMPANIES AND MULTIPLE MASTER GROUPS CAPABILITY
CUSTOM FIELDS OPTION ON KEY SCREENS
BIOMETRIC CAPABILITY FOR MEMBER ENROLLMENT AND PROVIDER CLAIMS
Broker Commission Management
Broker Payments and Statements
Broker Notes and Correspondence Tracking
BUILT -IN ELECTRONIC PRE-AUTHORIZATIONS AND SCANNED CLAIMS
837 EDI
CLAIMS WORKFLOW QUEUE FOR RAPID PROCESSING FROM MULTIPLE SOURCES INCLUDING
BATCH ENTRY, EDI AND WEB
PREAUTHORIZATION WORKFLOW QUEUE FOR RAPID PROCESSING OF PRE-AUTHORIZATIONS
RECEIVED FROM MULTIPLE SOURCES
ADVANCED CLAIM ADJUDICATION WITH ELECTRONIC PROCESSING
QUICK ACCESS TO CLAIMS HISTORY
UNATTENDED CLAIMS AUTO ADJUDICATION CAPABILITY
INTEGRATED PRE-APPROVAL & CASE MANAGEMENT WORKFLOW
ELECTRONIC CLAIMS QUEUE PROCESSING FROM ELECTRONIC LINKS OR IMPORT FILES SUCH
AS 837 OR CSV
RAPID AND FLEXIBLE BENEFIT PLAN SETUP
REAL TIME INTERFACE WITH CONTEXT WITH HEALTHCARE FIRST PASS SYSTEM FOR
AUTOMATED CLAIMS ANALYSIS OF PROPER PAYMENT FROM PROVIDER WITH RULES DATABASE
OF 3.5 MILLION RULES
FLEXIBLE AUDIT PROCESSING OF ALL CLAIMS BY EXAMINER, AMOUNT PAID, PROCEDURE
CODE OR DIAGNOSTIC CODE
RAPID PREAUTHORIZATION QUEUE PROCESSING FROM ELECTRONIC OR OTHER LINKS
SUPPORT FOR MULTIPLE PROVIDER NETWORKS AND NETWORK RANKING
ALL USER CLAIMS MESSAGES INTO SINGLE WINDOW TO ALLOW QUICKER CLAIMS ENTRY AND
REQUIRE USER TO VIEW ONE WINDOW INSTEAD OF SEVERAL WHILE PROCESSING CLAIM
SIMPLIFIED SERVICE CODES SYSTEM FOR EASY TO UNDERSTAND BENEFITS PROCESSING
FULL SUPPORT FOR NON STANDARD AND CUSTOM HOSPITAL AND CLINIC CODING
BRITISH AND AMERICAN DATE SUPPORT
FULL DENTAL CLAIM SUPPORT AND VISUAL TOOTH CHART
BENEFITS LIMITATIONS BY PROCEDURE CODE, CATEGORIES, AND TYPES OF SERVICES
BENEFIT LIMITATIONS BY AGE, GENDER, DIAGNOSTIC CODE
BUILT -IN SUPPORT FOR ELECTRONIC PRE-AUTHORIZATIONS AND SCANNED CLAIMS
INTEGRATED ACCESS TO ORIGINAL CLAIMS IMAGE AND ATTACHMENTS
AUTOMATED PROCESSING OF BENEFIT PLANS FOR BENEFITS LIMITATIONS AND PROVIDER
FEE SCHEDULES
INSTANT EOBS AND QUICK SUMMARY REPORTS
QUICK ACCESS TO PROVIDER FEE SCHEDULES
CHOOSE FROM MULTIPLE VARIATIONS OF PAYMENT METHODS
FEE SCHEDULE HOT KEY TO VERIFY RATES
ONE CLICK ACCESS TO ALL CLAIMS SUBMITTED BY PROVIDER
PRE-AUTHORIZATIONS AND REFERRALS DIRECTLY LINKED TO CLAIMS
STREAMLINED PRE-AUTHORIZATION PROCESSING QUEUE
RECEIVE PRE-APPROVALS BY FAX, SCAN, OR ELECTRONICALLY
DETAILED SYMPTOM AND DAILY LEVEL OF CARE TRACKING
TRACK REFERRALS, PRE-AUTHORIZATIONS AND COMPLETE HOSPITAL STAYS
CLAIMS RECEIVED REGISTER TO TRACK CLAIMS ALL CLAIMS RECEIVED VERSUS CLAIMS
ENTERED OR PROCESSED
PREAUTHORIZATION SUBMISSION FROM INTERNET B
TRACKING OF COMPLETE PREVIOUS MEDICAL HISTORY OR PRE-EXISTING CONDITIONS
REAL TIME AND BATCH SUPPORT FOR REDCARD, ZELIS PAYMENTS AND CONTEXT FOR
HEALTHCARE INTERFACES
ENTRY OF CLAIMS BY BATCH ENTRY, MANUAL, ELECTRONIC QUEUE OR EDI FILES
AUTOMATED CLAIMS ANALYSIS OF PROPER PAYMENT FROM PROVIDER WITH RULES DATABASE
OF 3.5 MILLION RULES (CPT CODES) (DATABASE RULES PROVIDED BY CONTEXT FOR
HEALTHCARE)
AUTOMATED CLAIMS AND DOCUMENT SCANNING
FULL SUPPORT FOR NON-STANDARD AND CUSTOM HOSPITAL AND CLINIC CODING
ONE TOUCH ACCESS TO ANY DOCUMENT RELATED TO CLAIM OR PREAUTHORIZATION
AUTOMATED PROCESS FOR CLAIMS AND PRE-APPROVALS ALLOWS HIGH SPEED TURNAROUNDS
SPECIAL RISK CLAIMS PROCESSING
SUPPORT FOR CLAIMS PAYMENT TO MEMBERS AND PROVIDERS VIA NACHA BANK EFT FILE
BUILD AD HOC, INSTANT REPORTS IN MINUTES
ADVANCED DASHBOARDS WITH CHARTS, GRAPHS AND GRIDS COMBINED
Instant On-Screen Reporting
Instant EOBs and Quick Summary Reports
Export to PDF, Word or Excel
Wizard Style Parameter Selection for All Reports
Dozens of Sub Reports and Sorting Options
Benefits Report by Service Code, Procedure Code, Disease Type
Employee Census by Subtotals by Benefits, by Location, by Nationality
Book of Business Group Summary
Claims Summary by Insured Member
Claims Summary by Provider including Top Ten Provider
Claims Summary by Amounts Paid Thresholds
Hospital Inpatient Stays Summary
Claims Detail Reports with Provider, Benefit, Reason Code filters
Claims Processing Production Report by Examiner, By Hour, By Group
Phone Call Tracking reports by Hour, by Customer Service Representative, by
Call Category
Follow Up/Reminder Reports
Inpatient Hospital Stay Census Report
Claims Paid by Month During Policy Period Report
Claims Paid Turnaround Report
Claims Cost Per Member Report for Premium and Paid Claims
PENDING CLAIMS REPORT
Account Receivable Insured and Group Reports
BILLING SUMMARY REPORT FOR INSURED AND GROUP BILLINGS
ELIGIBILITY STATUS CHANGES REPORT
HOSPITAL UTILIZATION REPORT
AVERAGE PAID BY AGE BAND REPORT
CLAIMS LAG/IBNR REPORT
SECURITY LOGGING REPORTS
PREMIUM AND ACCOUNTING REPORTS
UNLIMITED AD HOC REPORTS CREATION THROUGH WEB REPORTS SYSTEM
REAL-TIME DASHBOARD REPORTS THROUGH TPA DASHBOARD SYSTEM
AUTOMATED EMAILING AND SCHEDULING OF ANY REPORT
TRIGGERS AND AUTOMATED NOTIFICATIONS
CLAIMS INVENTORY REPORT
BUILT IN DOCUMENT IMAGING FOR DOCUMENT ACCESS TO PROVIDER, GROUP, AND INSURED
RELATED DOCUMENTS
RAPID SEARCHING FOR INSURED, CLAIM, PREAUTHORIZATION AND PROVIDER INFORMATION
CUSTOMER SERVICE CALL AND CORRESPONDENCE
SMS OR EMAIL TO RESPONSES TO CALLERS
ON-SCREEN PHONE LOG AND CUSTOMER SERVICE QUEUE
ROUTE TO SUPERVISOR CAPABILITY
ADVANCED CORRESPONDENCE LOGGING WITH ONE CLICK LINKS TO ORIGINAL DOCUMENT
INSTANT LINKS TO WORD, EXCEL AND OUTLOOK WITH AUTO FILL LETTERS AND
CORRESPONDENCE
AUTO GENERATED LETTERS WITH MICROSOFT WORD INTEGRATION AND REDCARD SUPPORT
ONE TOUCH ACCESS TO PLAN DOCS, CLAIMS AND ORIGINAL PATIENT RECORDS
SIMULTANEOUS ACCESS TO MULTIPLE PATIENT SCREENS
HANDY CORRESPONDENCE TRACKING AND POP UP NOTES AND REMINDER SYSTEM
STREAMLINED CUSTOMER SERVICING WITH MULTI WINDOW SUPPORT
UTILIZATION REVIEW AND CASE MANAGEMENT
Check and Voucher Printing on MICR Printers
SUPPORT FOR PRINTED CHECK OR ELECTRONIC FULFILLMENT THROUGH REDCARD
SUPPORT FOR ZELIS E-PAYMENTS
Voucher Reporting
Multiple EOB Formats
Cash Claims Support
One Check per Claim or Voucher per Provider
PRINTED CHECKS OR ELECTRONIC FULFILLMENT THROUGH REDCARD
Multiple Payee and Payer Profiles Insured, Group, Provider, Sub Location or
User Defined
835 EDI Export
CHECK RECONCILIATION AND POSITIVE PAY SUPPORT
Payment Check or Export to Third Party Companies like RedCard Systems
SINGLE SCREEN ACCESS TO ALL INSURED AND ELIGIBILITY RELATED FUNCTIONS
IMPORT ELIGIBILITY RAPIDLY FROM STANDARD FORMATS OR SPREADSHEETS
SUPPORT FOR SEPARATE ELIGIBILITY HISTORY AND BENEFIT PLAN FOR ALL MEMBERS OF
FAMILY
SEPARATE ADDRESS CAPABILITY FOR SPOUSE AND DEPENDENTS
BUILT IN ID CARD DESIGN AND PRINTING USING MICROSOFT WORD
PHOTO CAPABILITY FOR ID CARDS
ATTACH ANY EXISTING OR SCANNED DOCUMENT TO INSURED FILE
SEPARATE PRIMARY CARE PHYSICIAN HISTORY FOR ALL MEMBER OF FAMILY
834 EDI EXPORT AND IMPORT
EXCEL EXPORT AND IMPORT
AUTO GENERATION OF MEMBER ID AND SUBSCRIBER ID OPTIONS
Red Card – EOBS, Checks, and Letters Fulfillment
Context for Health Care – REALTIME Unbundling and Fraud Control AND EDITS
Zelis – E-payments to Providers
Authorize.Net Credit Card and ACH
COMPLETE PREMIUM INVOICING
TRACKS RETRO ADDS AND RETRO TERMS WITH AUTOMATIC ADJUSTMENTS
RATES BY GROUP, BY BENEFIT PLAN, MEMBER RELATION, AGE, AREA AND OTHER FACTORS
MONTHLY PREMIUM INVOICE TO MEMBER OR GROUP
SUPPORT FOR PPOS AND TPA/ADMINISTRATION FEES
BROKER AND COMMISSION PAYABLES
SUPPORT FOR MEMBER CREDIT CARD AND BANK CHECK PAYMENT
CREDIT CARD AND ACH SUPPORT
ANNUALIZED PREMIUM REPORT WITH PRORATION
Group Correspondence Tracking
Policy Management
Notes and Reminders Follow Tracking
Phone Call Inquiries
Group Mailing or Faxes to all Members
Subgroup/Location Support
MASTER GROUP, LINE OF BUSINESS SUPPORT
MASS CORRESPONDENCE OR EMAIL SUPPORT TO GROUPS AND MEMBERS
Full Document Support to attach Benefits, Contracts and other Documents to
Group
Master Group /Insurance company Grouping and Security
COMPLETE PROVIDER CREDENTIAL AND TRAINING HISTORY TRACKED
PROVIDER CORRESPONDENCE TRACKING
PROVIDER/HOSPITAL RATES AND FEE SCHEDULE MANAGEMENT WITH PROVIDER OR CUSTOM CODES
UNLIMITED NUMBER OF HOSPITAL CONTACTS MAINTAINED
FEE SCHEDULE SUPPORT FOR FLAT SUPPORT, PERCENTAGE FEES, AND PERCENTILE SYSTEMS SUPPORT
NON-STANDARD CODING SYSTEMS SUPPORTED AS WELL AS CPT, ICD9, ICD10
PROVIDER MASS MAILING AND CORRESPONDENCE TRACKING
AUTOMATED IMPORT OF PROVIDER FEE SCHEDULES
AUTOMATED CALCULATION OF PROVIDER FEES AND CODES
CAPITATION PAYMENT PROCESSING
AUTOMATED MAPPING FROM PROVIDER CODES TO ICD10 OR CPT STANDARD CODES
DRG MANAGEMENT
837 CLAIMS IMPORT AND EXPORT
834 ELIGIBILITY IMPORT AND EXPORT
835 REMITTANCE ADVICE PROCESSING
999 ACKNOWLEDGEMENT
POLICY HISTORY FOR EACH GROUP
SPECIFIC STOP LOSS, AGGREGATE STOP LOSS AND FULLY INSURED POLICIES
AUTOMATIC DETERMINATION OF STOP LOSS LIMITS BEFORE CLAIMS ARE PAID
SPECIFIC POLICY STOP LOSS % OF LIMIT REPORT
AGGREGATE POLICY CLAIMS REPORT
SUPPORT FOR MEDICAL, DENTAL, VISION AND LIFE PRODUCTS AND ADMIN FEES
Advanced Features of Claimscape Health Benefits System
Simplified Eligibility Processing
Integrated Scanning and Document Management
Built-In Electronic Pre-Authorizations and Scanned Claims Support
Advanced Security
Rapid Pre-Authorization Queue Processing From Electronic or Other Links
Real-Time Web Access for Insureds, Providers and Groups
Multi Level Group Security With Logging of All Events
Multiple Company, Multiple Database Support
Claims, Preauthorization, and Customer Service Queues for Maximum Efficiency and Optimized Workflow
