Process Group
Claims Management
Objective
Timely and accurate processing of claims to determine the validity of the claim and the amount to be paid.
Input
- Claim
- Beneficiary identifier
- Adjustments
- Voids
- Benefit plan
- Re-submitted claims
- Claims-related policies
- Pre- authorization match
- Eligibility status
- Benefit class
- Beneficiary accumulators
- Co-insurance
- Copayments
- Deductibles
- Fee schedule
- Provider identifier
- Provider accumulators
Output
- Acknowledgement to provider of receipt of claim
- Claim identifier
- Claim status (in process, partially approved, approved, rejected, requires more information, in medical review)
- Amount approved for claim
- Explanation of Benefits
- Financial transaction to GL
- Update beneficiary accumulators
- Update provider accumulators
- Line items for claims advice
Task Set
- Registration of incoming claim
- Assign claim identifier
- Pre-process and edit claim data
- Aggregate, merge and batch claims data
- Manage claims exceptions
- Apply adjudication rules (skip to approve or reject)
- Flag for fraud and abuse
- Route for medical review
- Approve and prepare payment transaction
- Reject and assign reason code
- Update beneficiary and provider accumulators
- Determine line items for claim (confirm for proper term: advice, Explanation of Benefits statement, receipt, remittance)
Measurable Outcomes
- Claim assigned status and determination of payment
- Claims status sent to provider, beneficiary and other appropriate authorities Explanation of Benefits sent to provider and/or beneficiary
- Timeliness of claims processing
- First time claim pass rate