Claim Processing

• Claim Processing is a multi-step process of processing the claim submitted by the Provider or the Beneficiary. Two ways to submit a claim:

a) Hard copy format (entered manually into system)

b) Electronically (EDI or DDE)

For Hard Copy format: Image of hard copy format is captured for audit and archival purpose using imaging, micro-filming or intelligent character recognition (ICR/OCR); assigns a control number to each claim; claim information is manually entered or using ICR technology; then claims is submitted to the shared system.

A. Validation and Sorting

i.Stamps the date of receipt on paper claims

ii.Image paper claims and attachments (stores the copy)

iii.EDI translation is performed on electronic submission. Translates into flat file.

iv.Automated process is performed for initial format validation check.

v.HIPAA compliance edits are performed.

vi.A back up copy of electronic files is created for audit and archival purpose.

vii.Sorting of claim is done.

viii.A control number (unique) is assigned to each claim.

ix.Claims are sent into shared system into batches.

x.Any claim that doesn’t pass the edit is rejected back to the Provider.

xi.Beneficiary and Provider data is checked on the claim against the data in the corresponding beneficiary and provider data in files. If the Provider or Beneficiary data is not matched with the data on the file, the claim is rejected.

xii.Incomplete claims are returned to submitter for correction and resubmission.

xiii.Complete claims are ready for batch processing and moved to next processing stage.

xiv.Claims with invalid data are denied.

B. Adjudication

Automated batch processing

i. Completeness

ii. Valid submittals

iii. Valid values and

iv. Data consistency

v. Apply rules and guidelines to check for duplicate and suspensions and valid Provider and Beneficiary eligibility.

vi. If suspensions are generated or further investigation is required, the claims/adjustment undergo further manual processing

vii. Rejection may be generated by line or by claim; if some parts of claim are acceptable, that part of the claim may be paid.

C.

Pricing and Remittance Advice:

• · Once the claim/adjustment is complete, it goes through pricing and is then sent for verification.

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