A complete auditing and reporting application for both specific and aggregate claims, loss adjustment expenses, reimbursements and reserves.

Specific

Specific claims and 50% notifications are logged, audited and reimbursed.

  • Audit Specific claims on a detail line-by-line basis, or in aggregate
  • Track plan co-pays, deductible, and co-insurance
  • Track and automatically reduce reimbursements for Aggregating Specific and Split-Funding
  • Track individuals who are Disclosed and/or Lasered and automatically reduce reimbursements for Lasers
  • Pay Loss Adjustment Expenses
  • Account for Cost Savings achieved by case management and negotiations
  • Account for PPO Discounts by PPO Network
  • Account for charges paid by Provider to allow analysis for claims paid at each facility
  • Document and report on Pended and Denied Charges
  • Establish and manage reserves by claimant
  • Track claims by Administrator and Auditor for activity and turn-around time
  • Report claims and reserves to Carriers and Reinsurers

Aggregate

Aggregate reporting based on monthly group aggregate reports, auditing and reimbursement.

  • Manage Aggregate claims paid by multiple benefits and aggregate factors, including medical, Prescription Drugs, Dental, Vision and Weekly Income
  • Pay Loss Adjustment Expenses
  • Document and report on Pended and Denied Charges
  • Track claims by Administrator and Auditor for activity and turn-around time
  • Report Attachment Point accumulation and reserves to Carriers and Reinsurers

Claim Reimbursements

Request and pay claim reimbursements.

  • Print Reimbursement Checks
  • Print an Explanation Of Reimbursement along with each check
  • Account for voids and credit and claim refunds
  • Reimbursements are included on the claim bordereaux for Carrier and Reinsurer reporting
  • Establish claim payment authority levels by claims auditor
  • System checks for issued policies and current premium prior to reimbursement
  • Auto-referrals to alert claim management teams for trigger diagnosis and high dollar claims
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