Claims Processing System
Claims Processing System
DESCRIBE YOUR ADJUDICATION SYSTEM VENDOR AND ARCHITECTURE. BE SURE TO IDENTIFY HARDWARE, SOFTWARE (INCLUDING CURRENT VERSION BEING USED, HOW LONG IT HAS BEEN IN PLACE, AND ANY PLANS FOR UPGRADES), MODULES IN PLACE, NUMBER OF TERMINALS, ETC.
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.
DESCRIBE YOUR INTERNAL SECURITY CONTROLS FOR CLAIM APPROVAL LIMITS.
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.
DESCRIBE YOUR SYSTEM’S METHOD FOR PENDING A CLAIM FOR ADDITIONAL INFORMATION.
Claims that are pending are put on “hold” in the Advantek system. Letters are automatically sent through our suspended letter program every 30 days to the member and provider requesting the additional information that is needed to process the claim. A weekly “pending report,” which serves as a system diary, is reviewed twice weekly by lead examiners and follow-up is performed if necessary. Receipt of additional information is tracked by date stamping and is attached to the original claim.
HOW DO YOU DETERMINE REASONABLE AND CUSTOMARY (R & C) LEVELS?
Advantek contracts with Ingenix (MDR), which provides R&C data including semi-annual updates.
DOES THE SYSTEM AUTOMATICALLY SCREEN CHARGES IN ACCORDANCE WITH THE INCURRED DATES IN RELATION TO THE PLAN DESIGN CHANGES?
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
WHAT EDITS AND CONTROLS ARE USED TO AVOID DUPLICATE PAYMENTS?
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:
Provider of Service
Specific Dates of Service
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.
HOW WILL YOU PROVIDE ELIGIBILITY VERIFICATION?
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
WHAT IS THE SYSTEM’S CAPABILITY FOR HANDLING MULTIPLE OCCURRENCES OF EMPLOYEE AND DEPENDENT ELIGIBILITY CHANGES?
Unlimited employee and dependent eligibility history is maintained and stored. Additionally, other Advantek system functions are date sensitive, therefore referencing the correct period of eligibility for the appropriate processing factors.
WILL THE SYSTEM GENERATE FORM AND FREE FORM LETTERS AND EXPLANATIONS OF BENEFITS (EOBS)?
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.
WILL THE SYSTEM GENERATE SEPARATE AND DIFFERENT EOB’S FOR THE BENEFICIARY FROM THE EOB FOR THE PROVIDER?
Yes, Advantek generates different formats for the Member/Beneficiary and the Provider.
WHAT IS THE PROCESS FOR NOTIFYING PARTICIPANTS OF DENIED OR DISPUTED CLAIMS?
Denials will appear on the EOB’s and will contain ERISA wording for appeal processes.
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 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.
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.
HOW WOULD YOU INFORM CLIENTS OF LEGAL CHANGES THAT COULD AFFECT ITS PLAN DOCUMENT?
Advantek has a corporate attorney and a licensed document writer who can facilitate very open communication of any legal change.