Claims Processing System
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 and 99% financial accuracy. We will be diligent in meeting or exceeding your expectations.
CONFIRM YOUR FLEXIBILITY FOR CLAIMS PAYMENT OVERRIDE. WHAT IS YOUR RECORD KEEPING SYSTEM FOR OVERRIDES? HOW ARE THEY TRACKED?
Advantek’s process and procedure accommodate authorized payment override. These overrides are flagged in our claims processing system and are tracked.
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.
WHEN CLAIMS FALL OUTSIDE YOUR SERVICE AND PRICE GUIDELINES, WHAT IS YOUR PROCEDURE PRIOR TO PAYMENT?
If Advantek receives a claim for services rendered that are outside our service and price guidelines for a covered enrollee, we will first determine whether this is a covered benefit under the terms of the plan. If the service would qualify for payment, we will pay the R&C rate for the service in the particular geographical area.
WHAT ARE YOUR GUIDELINES FOR ADMINISTRATION OF SUBROGATION?
Advantek 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.
DESCRIBE YOUR PROCEDURES FOR REPORTING, FILING AND RECOVERY OF SPECIFIC AND AGGREGATE STOP LOSS CLAIMS. WHAT IS THE PROCESS FOR RESOLUTION OF DENIED CLAIMS?
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-9 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.
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 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.
Advantek would like to extend our UR services to prospective clients, which would allow Advantek to better support, fully integrate and control costs.
Through various intermediaries, the following reinsurance carriers have approved Advantek:
American United Life
Lloyd’s of London
Mutual of Omaha
Sun Life Financial