|
Feature |
Benefits |
| Authorization/Referral Management at every stage |
Member’s accessing service can be managed from a single visit to a full course of treatment. |
| Numerous criteria to make your authorizations as specific or broad as you need |
Users can create authorizations by using any combination of the
following: Member, Provider, Dates of Service, Procedure code or range of
codes, Quantity of services, Diagnosis code or range of codes,
Facility, Service Location, Place of Service, Type of Service,
Number of Visits |
| Adjudication process will automatically locate the appropriate authorization when an authorization is deemed to be required |
Whether based on the provider or facility contract, the benefit set, or if a benefit limit is exceeded the adjudication system will match the components of the service to the appropriate authorization automatically. As always an authorization can be manually assigned to a service, if desired. |
| User-defined Authorization status options |
Your organization can create as many Authorization status options as necessary.· Allows your organization to define its own process for evaluating, reviewing and approving authorization and referral requests. |
| System-calculated IBNR |
When specific procedures have been authorized, our system will automatically calculate the estimated expense. When the claim is entered in the system, the actual expenses are then reported against the estimated expenses. |
| “Mini-adjudication” performed when the Authorization is saved |
Validates that the member is eligible on the specified dates of service, that the services listed are covered and that the requested provider has an effective contract with the member’s Health Plan/Benefit Plan. · Assists Utilization Management process by giving immediate feedback to the user whether a request should be approved or denied. |
| Global Authorizations |
Global authorizations
can be established for inpatient hospital stays where both
professional and facility claims may be submitted and accumulated
against the authorization for the same episode of care. |
