Claim Adjudication involves reviewing the provider’s claims to determine the appropriate payment. We support TPAs/Payers by utilizing automated software and conducting In-depth Medical Reviews to assess the Medical Necessity for Utilization Reviews of the claims. Our team of skilled Coders/Auditors remain vigilant about payer rule updates concerning eligibility, allowable amounts, exclusions, and riders, keeping our BRD (Business Rules Development) engines up-to-date for optimal cost savings in claim settlements.
We also aid payers and TPAs in consolidating claims and related data for accurate indexing/sequencing to accelerate the adjudication process. Our Credentialing and enrollment services facilitate providers’ successful enrollment with the plan.
In-depth Medical Reviews include evaluating coding compliance, provider documentation, and conducting reimbursement audits. Additionally, we offer program development and audit assistance to entities and subcontractors working with Medicare Administrative Contractors (MAC), Recovery Audit Contractors (RAC), Medicaid Integrity Contractors (MIC), and Zone Program Integrity Contractors (ZPIC).
Our programs and services enhance profitability and ensure that all authorized claims are efficiently collected and processed for the correct entitlements.