Claims Adjudication Module

The Claims Adjudication Module provides users with a comprehensive tool to adjudicate claims or utilization information being provided by both in-house and third party providers.

This module can be fully integrated with the Care Manager Module to provide completely automated updating of service authorizations based on changes/updates to SPO’s.

Claims Adjudication Module features include:

ü  Ability to create unlimited number of authorizations by customer dynamically linked to Care Manager Module SPO’s

ü  Ability to ADJUDICATE service utilization information based on Care Plan and SPO data

ü  Ability to automatically “re-generate” authorizations on a monthly basis

ü  Ability to track and view authorizations by Client, Status, Auth number etc.

ü  Ability to manage all aspects of authorizations by status, including tracking status of receipt to and from Providers

ü  Access by defined uses to view status of any authorization by clients, case manager, provider etc.

ü  Ability to accept import of data from various formats including claims, excel, text etc.

ü  Ability to dynamically add additional auths for problem resolution

ü  Ability to generate EOB report with calculation of payment due and services denied with reason

ü  Ability to identify duplicate services, services after discharge, unauthorized services, services after date range authorized