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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.
The Challenges
To integrate processes related to primary care physician, the HMO and the government funding bodies (CMS / ACHA)
To comply with regulations on various plans including Medicare, Medicaid, and type of claims ranging from Professional, Institutional, and Dental Claims
To support various claim submission and processing mechanisms
To comply with EDI and reporting mechanisms of the various Government agencies involved
The Solution
Binary Spectrum developed a robust platform that automates electronic claims, remittances, member enrollment, eligibility and disenrollment processes for a large HMO.
The following are some of the features of solution:
Support for multiple integration mechanisms for Vendor interactions
Compliance checks and acknowledgement generation
Parsing and Validation mechanisms
Automated Workflow and Rule Management
Support for Real-time Messages
Loads the claims into HMO's database (No claim will be loaded into it, until all errors are fixed).
electronic claims processing and submission, health management system software
EDI Messages Supported:
For Batch transactions:
  837 P/I (professional / institutional) – Electronic Claim files
  835 – Healthcare electronic Remittance advice request form
  834 – Enrollment and disenrollment for Medicaid eligibility
  820 – Electronic response files for premium Payments to insurer
For Real time transactions:
  271 / 272 – Member eligibility request / response
  276 / 277 – Claim status request / response
  278 – Authorization and Referrals
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.
Well if you are interested in outsourcing software development or would like to find out more about our services and offerings, please get in touch with us. A senior member of our Business team will get in touch with you within 24 hours.
know how to file insurance claim through HL7 integration case studies of Binary Spectrum
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