We provide outsourcing services for the entire gamut of claims processing from data entry to adjudication for health insurance companies. We implement procedures and systems that are HIPAA compliant, to process and adjudicate medical claims. We are capable of adjudicating the claims finally from the captured claim data or from the data received from EDI. The claims are adjudicated based on claim data, information of the plan and the insured treatment codes and a host of other information. Our approach to claims adjudication is straightforward - utilize a skilled group of offshore professional claims adjudicators, a US-based operations group, and a team of experienced IT professionals to deliver extraordinary service to Healthcare payers.
SSS ADVANTAGE:
- Eliminates handling of Paper Claims
- Cuts Paper Claims Processing Costs by 40% to 50%
- Archive, Search, and easily retrieve paper claims
- Improves accuracy of paper claims adjudication
- Improves HIPAA and CMS compliance for paper claims tracking
- Reduces storage costs
- Improves turnaround times for processing
SSS Claims Adjudication Workflow:
- STEP 1: Claims Entry – CMS-1500, UB-92, and ADA Dental Forms
- STEP 2: Member Enrollment Services
- STEP 3: Provider Data Services
- STEP 4: Authorization Support Services
- STEP 5: Claims Adjudication
- STEP 6: Claims Repricing
- STEP 7: Customer Care Support
Professional Adjudicators
All SSS professionals are trained on multiple adjudication platforms and plan designs. Our adjudicators are highly educated people with knowledge of medical terminology and who are proven analytical problem solvers. New adjudicators are trained in an intensive five-week program covering the U.S. healthcare industry and claims adjudication. The program is administered by senior level U.S. based claims adjudicators who also serve as claim auditors.
Client Specific Training
Certified claims adjudicators go through client specific training to learn the client’s insurance plans, systems, and claim types. SSS works with the client to create a detailed project plan, verify the requirements, and determine the critical success factors that need to be met. In addition, a comprehensive communication plan is developed to define the communication channels and to review status, issues, and amendments to plans. A dedicated Project Manager manages the entire process. During client specific training, our operation begins with full supervision and 100% claim review until the team in training becomes proficient and earns client certification.
Automated Batch Adjudication
Once the claim data has been indexed, the batch is sent through an automated adjudication program. This process performs hundreds of checks - verifying eligibility, plan arrangements, allowable benefits, plan and claim limits, deductibles, coordination of benefits, and much more. We adjudicate all claims before they go to the examiner. After the claims in a batch have been adjudicated, they are automatically distributed to the appropriate “Claim Examiner” along with scanned correspondence. The claim which meets all the checks of the adjudication program can then be released for payment.
