faq's

Claims Services

1. What is your objective for claim turn around time, processing accuracy percentage, and financial accuracy percentage?

• Advantek's objective for claim turn-around time is 10 working business days or less. We strive to exceed 97% or higher for processing accuracy and 99% financial accuracy. We will be diligent in meeting or exceeding your expectations.

2. What fee schedule do you use for payment of claims?

• Advantek's flexibility can accommodate multiple PPO fee schedules based on any methodology. Our standard Reasonable and Customary (UCR) is based on current year Ingenix MDR data.

3. What are your guidelines for administration of subrogation?

• Advantek's has a contracted vendor to handle all subrogation claims. Data files are sent electronically for review and resolution. There is a staff of paralegals and attorneys that track all subrogated claims. Recoveries net of subrogation fee are promptly forwarded to you.

4. Do you provide Utilization Management services?

• Yes, currently, we are delegated for Utilization Management and reporting for many of our customers. Our UM services help ensure:



• Services are medically necessary and are delivered at appropriate levels of care.
• Authorized care follows the benefits defined in the member's plan document.
• Hospital admissions and length of stay are justified.
• Services are not over utilized or under utilized.
• Appropriate care is offered in a timely manner and is quality-oriented.
• Scheduling is efficient for services and resources.
• Costs of services are monitored, evaluated, and determined to be appropriate.

Advantek offers our UR services to prospective clients, which would allow Advantek to better support, fully integrate and control cost.

5. Who are the Reinsurance carriers that have approved your organization?

• Through various intermediaries, the following reinsurance carriers have approved Advantek:
• Anthem Inc.
• BestRe
• Hartford
• HCC Benefits
• KMG America
• Lloyds of London
• Perico Life Insurance Company
• Presidio
• Symetra Financial
• Sun Life

Auditing

6. What is your audit procedure for determining payment accuracy percentage, processing accuracy percentage and financial accuracy percentage as defined above?

• At Advantek we treat your money as our own and therefore have an extensive audit procedure in place, including a random audit of a statistically valid sample weekly.

7. Provide the results of your most recent internal performance review showing the number of claims processed, error rate for payment and processing, turn around time, etc.

• The results of Advantek's most recent internal performance review produced a score of:
• 100% of all claims paid in 10 days
• 99.7% Financial Accuracy
• 98.2% Processing Accuracy

8. Are inpatient hospital claims routinely audited?

• Inpatient claims are randomly audited for every client. With Advantek's extensive internal resources, we can provide a thorough and effective traditional hospital audit procedure, if requested.

9. What safeguards exist to protect against claim abuse and fraud?

• Random and periodic chart audits and medical record reviews are performed at Advantek to protect against provider fraud. In addition to following prospective client's policies, Advantek has established and maintained separation of duties. Second signatures are required on checks over an agreed upon amount. The Vice President of Operations also reviews 100% of check payments.

Customer Service

10. Describe your customer service process when an employee calls with a claim inquiry?

• The Customer Service Representative (CSR) will take the following steps:
• Gather member data (such as ID number, etc.) and outline the concern
• Research the issue and respond to the caller
• Take additional steps to resolve the issue, such as placing calls to provider offices
• Reprocess the claim when appropriate
• Provide explanation of benefits
• Log the call for future reference

11. What was the average speed of answer for customer service calls in 2006?

• All calls are answered within industry standards, 91.6% answered in 60 seconds.

12. How are customer service calls monitored and reviewed for accuracy?

• The Advantek Customer Service manager randomly monitors calls on a daily basis.

Claims Processing System

13. Describe your adjudication system vendor and architecture.

• LuminX is the software vendor supporting the Acclamation Systems, Inc. Luminx was founded in 1989. Luminx is an automated system designed for organizations entrusted with the responsibility of administering health and other employee benefits.

14. Describe your internal security controls for claim approval limits

• Each staff member claims are fully audited and dollar limited until the accuracy level is approved by an auditor. The dollar limit is raised as the processor achieves mastery for their level of processing. In addition, access is initially restricted to processing only professional claims, (HCFA 1500) and later allowed hospital claims (UB-92) processing.

• Advantek maintains separation of duty requirements (i.e., a person with payment authority cannot also have authority to alter eligibility.) Only the accounting department has authority to issue checks.

15. How do you determine reasonable and customary (R & C) levels?

• Advantek contracts with Ingenix (MDR), which provides R&C data including semi-annual updates.

16. Does your system have the capability to store individual claims payments and batch them together for one weekly check/draft production and distribution?

• Advantek's system is very flexible. Individual claim payments are batched together for a single check/draft. The individual payments are listed within a corresponding remittance advice, which is generated at the same time as the check.

17. How will you provide eligibility verification?

• Toll-free telephone number with message line
• Advantek has on-line access for participants and providers to support benefits and eligibility information
• Benefits and Eligibility information can be communicated to participants and providers in the following ways through Advantek:

18. Describe the procedures used for administration of Coordination of Benefits.

• The Advantek system contains an automated COB claim-processing feature. Therefore, when a COB is identified, the other insurance amounts are entered electronically into the claim detail lines, the system will automatically adjust the line item Net Amount. The system fully supports COB and TPL processing.
  
  The Advantek system also has a COB module that is accessible from the claims and eligibility modules, capable of capturing carrier information including effective cancellation dates, transfer to a new group, lapse in coverage and COB information at the employee and dependent level.

Management Reports

19. What reports are standard, Frequency?

• Management Report Packages can be customized by Advantek to support prospective clients' needs.
  
  The standard report set will be determined by the client free of charge. Ad hoc reports and additional data analysis is available at negotiated rates. We would be happy to discuss additional services available from Advantek.