ADJUDICATION

The carrier Utilization Review department would then review the claim and after their edit checks, the claim would then be adjudicated on and processed for payment. Then check and an Explanation of Benefits are sent to the provider.

During processing of claims, we determine the following aspects with excellent care:

• Benefit packages
• Payment and Denials
• Issue of referrals and authorization
• Customers care for both members and billing office

And provider reimbursement schedules are applied to determine proper claim payment. We also have our in-house software system which do auto adjudicates any possible claims. Examiners are trained to handle the more difficult claims that do not pass auto adjudication.

• Batching, Inventory Control, Claims Tracking & Entry
• Claims Adjudication & Capture of Authorization Data
• Creation of EOB’s, Payment Posting and Re-conciliation

Workflow and OCR-assisted data entry

• Telephone and E-mail Services for Provider Enquiry
• Direct and Telephone Reporting

• Maintenance of necessary systems
• Support Interfaces and Networks
• Back ups and Recovery for all Computer Operations

• Capitation Claims Reports and Lag Analysis
• Monthly Reports on Processing Activity
• Specialty wise Reporting
• Documentation of Policies and Procedures
• Monthly Charge List
• Due list
• Providers Statement
• Insurance Statement
• Business Done

Data security

Network operations