Electronic Claim and Member Management for Health Management Office |
| The Task |
| To enhance efficiency of the claim processing process and aid in growth plans through increased throughput and scalability. |
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| The Challenges |
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To integrate processes related to primary care physician, the HMO and the government funding bodies (CMS / ACHA) |
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To comply with regulations on various plans including Medicare, Medicaid, and type of claims ranging from Professional, Institutional, and Dental Claims |
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To support various claim submission and processing mechanisms |
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To comply with EDI and reporting mechanisms of the various Government agencies involved |
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| The Solution |
| Binary Spectrum developed a robust platform that automates electronic claims, remittances, member enrollment, eligibility and disenrollment processes for a large HMO. |
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| The following are some of the features of solution: |
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Support for multiple integration mechanisms for Vendor interactions |
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Compliance checks and acknowledgement generation |
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Parsing and Validation mechanisms |
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Automated Workflow and Rule Management |
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Support for Real-time Messages |
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Loads the claims into HMO's database (No claim will be loaded into it, until all errors are fixed). |
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| EDI Messages Supported: |
| For Batch transactions: |
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837 P/I (professional / institutional) – Electronic Claim files |
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835 – Healthcare electronic Remittance advice request form |
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834 – Enrollment and disenrollment for Medicaid eligibility |
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820 – Electronic response files for premium Payments to insurer |
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| For Real time transactions: |
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271 / 272 – Member eligibility request / response |
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276 / 277 – Claim status request / response |
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278 – Authorization and Referrals |
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| The Result: |
| The client has scaled up the claims processing capability, and is able to do so in a timely manner while being able to deal with a variety of vendors. |
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