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Claims Processing

Claims are adjudicated automatically by our system. Our system performs automated data checks for the following items:

  • Eligibility of insured
  • Eligibility of charge for covered services
  • Eligibility of provider and identification of network providers
  • Relationship of charge to R&C geographically specific)
  • Satisfaction of deductible and/or stop-loss
  • Application of Contractual payment rates
  • Application of appropriate co-insurance or incentive co-insurance features
  • Application of COB
  • Application of subrogation (e.g., workers' compensation, no-fault provision, etc.) where appropriate
  • Application of Medicare Documentation
  • Application or verification of required pre-certifications.

Our system is capable of identifying and separating into individual data records (by claimant), multiple practitioner visits or facility stays which can been "batched" together by a provider and submitted as a single claim.

 
 
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