Advantek staff runs queries monthly for each stop-loss contract year. Each query is set at 25% and 50% of the attachment point (deductible). Reports are reviewed and patients are identified for 50% notification to the stop-loss carrier. Patients are also identified who have exceeded the deductible and required information is sent to the carrier for reimbursement. Files are maintained for each patient in addition to internal tracking logs for each carrier year. We also identify claims based on ICD-10 criteria.

Appeals are filed for all denials based on contract language. However, we currently have a very low denial rate and generally receive reimbursement for 100% of filings.

The Cost Containment Department handles all aggregate stop loss tracking.

Through various intermediaries, the following reinsurance carriers have approved Advantek:

• American United Life
• Gerber
• HCC Benefits
• HighMark
• KMG America
• Lloyd’s of London
• Mutual of Omaha
• Optum Health
• Presidio
• Sun Life Financial
• Symetra
• Westport

Yes, currently, we are delegated for utilization management and reporting for many of our customers. 

Our UM services help to ensure the following:

• Services are medically necessary and are delivered at appropriate levels of care.
• Authorized care matches 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.

This is a comprehensive program designed to assist members with chronic illnesses.

This program can be tailored to focus on specific diseases. Unlike Case Management, the goal of Condition Management is to intervene early in the course of manageable diseases such as diabetes, hypertension, asthma, high risk pregnancy, etc.

The results of Advantek’s most recent internal performance review produced a score of:

• 100% of all claims paid in 10 days
• 98.99% Financial Accuracy
• 99.42% Processing Accuracy

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

• New 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 only processing 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.

The claims module of Advantek’s system is date sensitive and will reference the appropriate historical period for support files, corresponding to the claim’s date of service.

Our system allows for the capture of history for:

• Member’s Eligibility Plan Assignments
• Plan Level Benefit Adjudication Rules
• Provider Contract History, & Provider Pricing History
• All Pricing Support Files

The Advantek system currently checks for duplicate claims (during the manual, auto adjudicate or electronic claims process) by comparing the following elements from a new claim against claims previously entered into the system by:

• Member
• Provider of Service
• Specific Dates of Service
• CPT Code

Benefits and Eligibility information can be communicated to participants and providers in the following ways through Advantek:

• Toll-free telephone number with message line
• Advantek has on-line access for participants and providers to support benefits and eligibility information

Advantek’s system supports a fully integrated Letter Module for the following letter types: Member, Group, Provider and Claims. The system has the capability of generating Letters/Correspondence on an individual basis, or ‘in mass’. The system will keep a historical record of all letters generated.

The system also has the capability to produce EOB’s by selecting the desired selection criteria.

The Advantek system contains an automated COB claim-processing feature. Therefore, when a COB is identified, the other insurance amount is also 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.

he 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 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 are available at negotiated rates. We would be happy to discuss additional services available from Advantek.

Advantek is flexible in its banking arrangements based on prospective client’s needs.