Complete Benefit Administration
General Features
- Ease of Use for Minimal Training Time
- Simplified Eligibility and Claims Processing
- 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
Claims, Preauthorization and Benefit Processing
- 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
Customer Servicing
- 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
Eligibility Processing
- 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
PREMIUM BILLING
- 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
PROVIDER MANAGEMENT
- 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
Group Management
- 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
Broker Management
- Broker Commission Management
- Broker Payments and Statements
- Broker Notes and Correspondence Tracking
Reporting
- 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 Turn Around Report
- Claims Cost Per member Report for Premium and Paid Claims
- Pending Clams 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 Nofications
- Claims Inventory Report
Check and Voucher Processing
- Check and Voucher Printing on MICR Printers
- Support for Printed Check or Electronic Fulfillment through RedCard
- Support for Zelis EPayments
- 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
Third Party Interfaces
- 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
Policy Management
- 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
EDI Management
- 837 Claims Import and Export
- 834 Eligibility Import and Export
- 835 Remittance Advice Processing
- 999 Acknowledgement
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