Claims Administration
CLAIMS, MAILROOM, IMAGING, OCR, ADJUDICATION, RESOLUTION AND PAYMENT
TMG Health’s application of innovative health claims technology and process improvement methodologies enable high levels of quality and rapid claims turnaround therefore reducing payment cycles. Our state-of-the-art technology also provides EDI connectivity to a wide range of clearinghouses. Our technical and production personnel fully comprehend the unique requirements posed by health claim forms, provider/member files, claim system connectivity and EDI programming.
TMG Health performs the following medical/dental/vision claims processing services:
- Receipt of paper and EDI claims from plans or clearinghouses
- Claims imaging, Image indexing, OCR and archiving
- Claims Processing and Adjudication
- Full adjudication of current year claims
- APC Pricing and DRG Grouping
- Calculate & process late payment interest
- Provider payment checks/EFT and remittance/EOP advice
- Member EOBs with appeals language
- Provide 1099 data to plan
Based on our years of experience, TMG Health has effectively implemented a quality controlled auto adjudication procedure that enables us to fine-tune our claims processes. Auto adjudication for clients allows TMG Health to achieve more timely processing and increased quality. Auto adjudication testing and implementation allows us to develop target auto adjudication rates by client.
Our services encompass the following elements/steps for health plans:
- Development of a comprehensive implementation testing plan to include extensive testing, progressive ramp-up schedule and a confirmed go-live production date.
- Facilitation of TMG Health receipt of EDI claims from clearinghouses.
- Mailroom functions: PO Boxes, envelope opening, sort, prep, date stamp and assignment.
- Receipt of additional paper documentation and/or imaged claims from Client.
- Electronic imaging of paper claims with immediate delivery to the production workflow and claims image repository.
- Claims data is passed through PROfix,TMG Health’s proprietary medical claims editor, which performs a comprehensive array of edits to validate and cross check diagnosis and procedure codes, dates of service, service line items, member and provider on-file status. This proven process enables us to accurately process significantly more claims on the first pass than traditional data or electronic methods while achieving 98+% quality levels.
- APC Pricing and DRG Grouping is performed prior to adjudication as applicable via software applications customized by TMG Health and integrated within our workflows. National APC and DRG tables are maintained.
Full adjudication of Claims includes:
- Configuration of the Facets system to meet CMS and Client’s requirements
- Finalization of claims per CMS and plan payment methodology and within CMS/State timelines
- Provider payment check runs
- Identification and maintenance of COB
- Production and fulfillment of Provider remittances/EOP and checks or EFT
Production and fulfillment of Member EOBs, PFFS and PPO claims present special challenges given the high percentage of out-of-network claims received. The ability of a claims department to pay any claim, from any provider or facility, anywhere in the nation – and do so rapidly – is a true measure of their capacity and capability as a contemporary organization.
Our specialized processes for loading out-of-network providers through the integration of our front-end data capture process and TMG’s national data base of providers and facilities, remove the bottle-necks created by this requirement. By building automated match criteria into our pre-adjudication steps, “new” provider loading for each plan requires only minutes and also ensures that no provider, even those not previously encountered at TMG, will require more than one day to load – a crucial savings in time along the claim continuum.
TMG recognizes provider expectations and the continuing escalation of claim payment timeliness. Rather than 95% of clean claims paid within 30 days as CMS requires, TMG maintains claim payment timelines including not less than 85% of all clean claims paid within 15 days (99%+ within 30 days). At the request of clients, TMG can also institute optional resources to further speed claim payment. Related to this focus, are our detailed processes to expedite claim development (whenever needed) and also our processes to obtain and maintain regional rate tables, local coverage determinations and facility rate letters to assure rapid and accurate payment of all claims originating from anywhere in the nation.