Processing of the provider’s claims for determining appropriate amount to be paid against the claim is an important aspect of Claim Adjudication. We help TPAs/ Payers to process the claims by using automated software as well as conducting Complex Medical Reviews to determine the Medical Necessity for Utilization Reviews of the claims. Our team of expert Coders/Auditors keep a constant eye on the changing rules of payers with regard to eligibility, allowable amounts, exclusions and riders and keep our BRD (Business Rules Development) engines up-to-date to ensure maximum cost savings in Claim Settlements.
We also help payers and TPAs to consolidate claims and claims data for appropriate indexing/sequencing for a faster adjudication process. We offer Credentialing and empaneling services for successful enrollment of providers with the plan.
Complex Medical Reviews include assessing coding compliance and provider documentation and reimbursement audits. Additionally, we provide program development and audit assistance to entities and subcontractors working with Medicare Administrative Contractors (MAC), Recovery Audit Contractors (RAC), Medicaid Integrity Contractors (MIC), and Zone Program Integrity Contractors (ZPIC).
Our programs and services increase profitability and ensure that all authorized claims are collected and processed to the appropriate entitlements.