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     {"id":403,"date":"2022-07-27T15:46:45","date_gmt":"2022-07-27T15:46:45","guid":{"rendered":"https:\/\/cr8dynamic.us\/?page_id=403"},"modified":"2022-10-12T10:36:51","modified_gmt":"2022-10-12T10:36:51","slug":"claims-management-software","status":"publish","type":"page","link":"https:\/\/cr8dynamic.us\/index.php\/claims-management-software\/","title":{"rendered":"Claims Management Software"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"403\" class=\"elementor elementor-403\">\n\t\t\t\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-960faf7 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"960faf7\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-39710b4\" data-id=\"39710b4\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-c10c05c elementor-widget elementor-widget-text-editor\" data-id=\"c10c05c\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.6.7 - 03-07-2022 *\/\n.elementor-widget-text-editor.elementor-drop-cap-view-stacked .elementor-drop-cap{background-color:#818a91;color:#fff}.elementor-widget-text-editor.elementor-drop-cap-view-framed .elementor-drop-cap{color:#818a91;border:3px solid;background-color:transparent}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap{margin-top:8px}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap-letter{width:1em;height:1em}.elementor-widget-text-editor .elementor-drop-cap{float:left;text-align:center;line-height:1;font-size:50px}.elementor-widget-text-editor .elementor-drop-cap-letter{display:inline-block}<\/style>\t\t\t\t<div class=\"elementor-element elementor-element-3207b42 elementor-widget elementor-widget-heading\" data-id=\"3207b42\" data-element_type=\"widget\" data-widget_type=\"heading.default\"><div class=\"elementor-widget-container\"><h3>Claims Management Software<\/h3><p>&#8220;An EDI (Electronic Data Interchange) feature to load encrypted claims files sent by providers.<\/p><p>Claims received thru this platform will be instantly processed (and awarded per inbuilt rules) unless otherwise indicated for human intervention.<\/p><p>EDI file decryption is done with a password chosen by the provider.<\/p><p>A simple claim-capturing interface with controls to minimize user capturing errors.<\/p><p>Amount to award is calculated and allocated by the system, shortfalling if benefits are no longer available.<\/p><p>Claims can be automatically rejected for different duplication scenarios.<\/p><p>User is given limited options to change the benefit allocation from a sub-list of applicable benefits, but the system automatically selects the most appropriate one.<\/p><p>ICD-10 codes are pre-loaded into the system and the user can pick one for each claim line and for the whole claim (diagnosis).<\/p><p>Modifiers are built into the system to automatically determine the maximum payable amount.<\/p><p>Member reimbursement claims capturing.<\/p><p>Member Pre-authorization and Member treatment pre-funding<\/p><p><b>Flagging of claims based on their status<br \/><\/b><\/p><p>Grey \u2013 awaiting capturer verification<\/p><p>The system uses the table above for mapping and thus determining what status the member is in at a specific date. This is also dependant on the status of the principal member.A member is changed to another plan by capturing a \u2018Joined\u2019 event to the new plan.The system automatically calculates the waiting period depending on whether late-joiner or regular-joiner<\/p><p>Amber \u2013 on hold pending human adjudication. May have a problem detected by the system of a user<br \/>Red \u2013 Rejected<\/p><p>Green \u2013 Ok and ready for payment<\/p><p>Provider\u2019s own ref number for their own claims are captured in the system<\/p><p><b>Printing of claim form<br \/><\/b><\/p><p>Use of hash total to detect capturing errors.<\/p><p>Generating, emailing and printing a pre-authorization letter.<\/p><p>Generating, and sending a pre-authorization SMS.<\/p><p>A checklist is used to monitor\/assess the activities around each claim (workflow).<\/p><p>The steps in the checklist are customisable<br \/>Claim Correctly Captured.<\/p><p>Claim Stamped.<\/p><p>Clinical Data Verified.<\/p><p>Final Authorisation.<\/p><p>Adjudication &amp; Award<\/p><p>Patients readmission rate:monitor the number of patients who are coming back.<\/p><p>Related Services&#8217; History.<\/p><p>History of Same Diagnosis.<\/p><p>Benefit Exhaustion History.<\/p><p>Parent Benefit Exhaustion History.<\/p><p>Global Limit Usage History.<\/p><p>An individual claim line can be flagged, and a whole claim can also be flagged. The whole claim\u2019s flag monitors handling of the individual lines. If claim is rejected, then the individual claim lines do no access or hold benefits.<\/p><p>Clinical data can be captured, even though it is generally not included on standard paper claim forms, including:<\/p><p>Date\/time of admission and discharge.<\/p><p>Next of kin in the case of an accident.<\/p><p>Per-claim audit trail: For every claim, the system records and shows the trail of users who changed it, including the date\/time and location (computer) used<\/p><p><strong>Claims navigator feature lists all claims according to the following criteria<\/strong><\/p><p>Dates treated\/received\/captured\/paid.<br \/>Payment Batch.<br \/>EDI File<br \/>Fund<br \/>Paid only<br \/>Unpaid only<br \/>Current Member&#8217;s History<br \/>Current Provider&#8217;s Claims<br \/>Current Member AND Provider<br \/>This Whole Family<br \/>Payment Flags: Pay &#8211; All OK, Pay &#8211; On Hold, Awaiting User Decision and Rejected.<\/p><p>Capturing accuracy: Hash Total Mismatch, Capturing Checked and Capturing Not Checked.<\/p><p>Current user\u2019s own claims: Captured by me, My UnChecked Claims and Capturing Not Checked.<\/p><p>Other navigator features: Bulk deletion, Bulk movement to a different provider and Bulk setting of payment decision and Searching for a specific claim by system assigned number or provider\u2019s reference.<\/p><p>Data Capturing Session (Capturing by Batch) \u2013 this speeds up capturing of a batch as the common details of the entire batch are entered only once and automatically set for each new claim in that session.<\/p><p>Each computer can be optimised either in favour of claims or membership.<\/p><p>Shortfalls and rejection reasons are edited using this feature.<\/p><\/div><\/div>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Claims Management Software &#8220;An EDI (Electronic Data Interchange) feature to load encrypted claims files sent by providers. Claims received thru this platform will be instantly processed (and awarded per inbuilt rules) unless otherwise indicated for human intervention. EDI file decryption is done with a password chosen by the provider. A simple claim-capturing interface with controls [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"om_disable_all_campaigns":false,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0},"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/cr8dynamic.us\/index.php\/wp-json\/wp\/v2\/pages\/403"}],"collection":[{"href":"https:\/\/cr8dynamic.us\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/cr8dynamic.us\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/cr8dynamic.us\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/cr8dynamic.us\/index.php\/wp-json\/wp\/v2\/comments?post=403"}],"version-history":[{"count":22,"href":"https:\/\/cr8dynamic.us\/index.php\/wp-json\/wp\/v2\/pages\/403\/revisions"}],"predecessor-version":[{"id":600,"href":"https:\/\/cr8dynamic.us\/index.php\/wp-json\/wp\/v2\/pages\/403\/revisions\/600"}],"wp:attachment":[{"href":"https:\/\/cr8dynamic.us\/index.php\/wp-json\/wp\/v2\/media?parent=403"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}