Claims management
TMG Health is backed by over 30 years of successful claims management experience. Our claims management system processes more than 40,000 claims a day, 365 days a year - resulting in a satisfied provider or member every time. Because over one-third of these claims are Medicare, our technical and production staffs fully comprehend CMS, NCQA and HEDIS and state requirements. TMG Health's development of unique technology and production methodologies allows for the provision of high accuracy and rapid turnaround coupled with significant savings. Our investment in state-of-the-art technology enables us to interface with any client system while accommodating claims in both paper and electronic environments.

 

Claims Processing

Why outsource your claims to TMG Health?
Quality, efficiency and technology are key in health insurance claims processing. That’s why so many clients rely on TMG Health’s Claims Services Division for outsourcing support.

Whether it’s claim imaging and OCR claims data capture, full claims adjudication processing or system conversion support, we have the solution for your claims processing needs. We have provided claims service solutions for more than 30 years, with clients such as large Blue Cross plans and multi-state Medicare plans. And we have a special expertise in processing Medicare and Medicaid claims/encounters and referrals.

Commitment to Excellence
Long-term, personalized relationships combined with innovative technology and processes sets TMG Health’s claims processing apart from the rest. Our experienced claims staff processes 40,000 claims a day, over 10 million a year and we guarantee 24 – 48 hour turnaround cycles from paper to EDI, with 98% percent claim accuracy.

Our Technology
TMG Health's development and application of unique technology and production methodologies allows for higher accuracy and rapid turnaround coupled with significant savings. Our investment in state-of-the-art connectivity technologies enables us to interface with a range of managed care claim systems while accommodating claims in both paper and electronic environments.

The TMG Health E-TransAct solution provides an innovative and highly productive approach to managing interactive eligibility, authorization, referrals, benefits verification, claims status and claims/encounters. Designed to meet the requirements of our customers and facilitate a more efficient and effective operations by transforming paper to EDI.

Features of our health claims technology include:

  • Leading Edge Data Capture Technology (Imaging, OCR, Auto-Keyboarding)
  • High Speed Claim Data Correction
  • Software Based EDI Suspense Resolution
  • ProFix™ Claim Edit Processing
  • Customized Software ApplicationsOCR Integration and Implementation

An example of our innovative use of technology is in the integration of OCR into claims processing. Rather than using off-the-shelf technology, our OCR engines are tuned to health data, with superior machine and handwriting recognition capability. All claims flow through our proprietary ProFix™ claims editing system to maximize quality, eliminate false positives and increase pass through rates. The result is superior claims data and higher auto-adjudication levels.

Our wealth of claims management experience allows us to offer a complete array of claims services, including:

  • Mailroom (receive, prepare and sort)
  • Claims Pre-Processing (Data Entry)
  • Complete Claims Adjudication
  • Imaging Services
  • Optical Character Recognition (OCR)
  • Provider Remittance and Checks
  • CMS Compliant Explanation of Benefits (EOBs)
  • Coordination of Benefits (COBs)
  • Electronic Data Interchange (EDI) with Insurers
  • Claim Management Reporting
  • Encounter Data Reporting to CMS
  • CMS Compliant Interest Calculation and Payments
  • Compliance with all State and Federal Regulatory Requirements
  • APC Priority
  • DRG Grouping

The Bottom Line
One concern when outsourcing claims processing is the ability to quickly learn processing status. We utilize Internet-based technology to communicate with our clients and providers. Our Internet-enabled reporting allows you to view claims status individually or in aggregate, ensuring that you can track workflow on a real-time basis.

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