Verifying patient eligibility is always the first step in successfully managing the claim Lifecycle process. If your provider clients check eligibility by phone, they will only verify patient coverage for as many patients as staff time allows. The number one reason for rejected claims is invalid or incomplete subscriber information.

ClaimRemedi solves this problem by delivering critical eligibility data to your clients in a matter of seconds using a standard web browser—allowing your clients to obtain and verify the correct subscriber information before claims are submitted. Eligibility responses can also show what your clients need to collect from their patients to cover co-payments and deductibles.

Eligibility responses are presented in a consistent, easy-to-read format. All information is organized so that your clients can quickly find what (for example, co-payment amount) they are looking for—without having to wade through several pages of randomly arranged response information. All information is displayed in a consistent format regardless of the payer.

Eliminates the need to log on and log off of multiple payer websites, each with their own unique logon and display of information formats.

Obtain real time eligibility information from payer websites without logging on to individual payer websites through our enhanced payer access solution. We access the different payer websites—but provide your clients with a single logon for all payers—and we “normalize” all information so that it is presented in the same, consistent and easy-to-read format.

Guides and prompts are displayed to ensure that different payer requirements are met when submitting eligibility requests. Does the payer require the patient’s date of birth, etc.? This includes error checking with automatic resubmission.

“Real-time” eligibility responses are returned within 3-7 seconds.

Eligibility requests can be submitted in a batch mode to facilitate the processing of information for many patients (for example, tomorrow’s schedule).

Each staff member in your client's practice can individually set up and manage their own work lists with regards to their own preferences, inputting eligibility requests, saving responses on work lists and creating reports. Supervisors can be provided with access to all work lists and reports.

Payer responses can be immediately displayed for review or automatically moved to a work list for later review.

For More Information click below:

Eligibility

At the core of ClaimRemedi's gateway clearinghouse services is a claim processor that checks claims for syntax errors and data content using your rules and edits. Where applicable, we “reformat” provider claims to ensure that they meet your 837 X12 implementation guidelines.

The Claim Processor can be located at any boundary within your overall system—prior to claims adjudication. Claim files are passed to the Claim Processor and checked for errors.

Claims are scrubbed by applying rules that are maintained in a comprehensive data engine. All rules (or edits) can be plan specific. Rules that apply only to one of your plans are applied only to claims for that plan. All code sets (CPT, HCPCS, Modifiers, ICD9, Revenue Codes, DRGs, Occurrence Codes, etc.) are maintained by ClaimRemedi and updated prior to code change effective dates. Rules can be added, deleted or changed to meet your specific requirements. Change requests can be implemented within 24 hours. All updates for off-site processing are done via web service—and are fast and “painless”.

After scrubbing, the Claim Processor returns both a “clean” claims file and an error file that identifies claims with errors along with error detail. The Claim Processor is pre-loaded with error messages that are “user friendly” and many indicate exactly what correction to make (the required value, etc.). All output files can be customized to meet your specific needs.

Rule/Edit Categories for both Professional and Institutional Claims:

• Procedure coding is checked for compliance with gender and age restrictions, inclusion of any required accompanying procedures and appropriate use of modifiers. Additional compliance checks for CCI policies and medical necessity using CPT/ICD9 crosswalk data and LMRPs can also be implemented.
• Diagnosis coding is checked for use of valid primary diagnoses, proper levels of specificity, gender and age restrictions, and the inclusion and ordering of any required accompanying diagnoses.
• All UB-04 specific codes-- ICD9 procedure codes, DRGs, revenue codes, patient status, type of visit, condition, occurrence, treatment and value Codes—are checked to see that they are correctly reported when required.
• Situational/conditional fields are checked to see if they are required and reported. Some professional claim examples— the reported diagnosis requires an accident code, accident date, date of first symptom; referring provider required because referral number is reported; date last seen required for this specialty; etc. Some institutional claim examples — the reported diagnosis requires an occurrence code; the reported revenue code requires a value code, a procedure code or covered days; date of service or patient status code required for this type of bill; etc.
• Service/procedure related fields are checked to see if they are required and reported. These include fields related to ambulance, hospice care, chiropractic, home health, podiatry, durable medical equipment and other services. For example— the reported procedure requires a date last seen, referring provider or a specific modifier(s); the reported modifier requires a prescription number; etc.
• Field values are checked for appropriateness. For example— the reported diagnosis requires a specific occurrence code(s); the reported revenue code requires a specific value code(s); the bill type requires the use of a specific code set (either HCPCS/CPT or ICD9 procedure codes) for reporting the principal and other procedures; etc.
• Coordination of Benefits (COB) on secondary payer claims is checked for accurate reporting of all required fields. For example—the total claim charges are compared with the other (primary) payer paid and adjustment amounts.
• All required fields are checked to see if they are reported, are properly formatted and contain valid 837/UB-04 codes (for example, taxonomy codes, related causes codes, condition codes, occurrence codes, value codes, etc.). This also includes plan specific “front-end” edits on subscriber IDs, group numbers, etc.

We also support both batch and real time processing. All of the above services are seamlessly integrated with our other products and services.

At the core of ClaimRemedi's solutions—we offer a complete suite of traditional clearinghouse services to your provider clients that complement our other value added services.

Connectivity to all other commercial and government payers that accept professional, institutional and dental electronic claims.

Conversion of non-837 X12 claim files—NSF professional and institutional formats, professional and institutional paper print images, EMC, and a variety of other non-standard formats. All of our outbound claims to payers are 837 X12 compliant.

Customized claim and payer specific solutions to meet your client needs. Do your providers have billing systems that are sometimes unable to correctly report payer specific required information? We know payer requirements vary and we will work with you to implement solutions on our end to fix those problems.

Print-to-paper services for professional, institutional and dental claims that are then forwarded to payers that do not accept electronic claims.

Standardized payer response reports.

Electronic Remittance Advice (ERA) processing for downloading ERAs into billing systems to facilitate auto-posting—as well as providing human readable ERA reporting tools for manual posting and other analyses.

Eligibility verification that provides fast and easy access to payer eligibility and benefit information for establishing patient coverage, co-payment and co-insurance amounts, and deductibles.

A responsive, experienced and knowledgeable support staff that will work directly with either your provider clients or with you—or both—and payers to resolve any problems.

We also support both batch and real time processing. All of the above services are seamlessly integrated with our other products and services

ClaimRemedi’s on-line editing feature takes your clients right to the heart of any errors that have been flagged by our Claim Scrubber—so your clients can correct them before claims are sent on to payers.

A powerful “point and click” edit feature allows your clients to quickly locate and correct any errors. Your clients don’t waste time trying to navigate through a claim to find the fields that are in error.

A global “find and replace” feature allows your clients to correct the same error that is repeated on several claims (for example, an invalid diagnosis code,invalid provider NPI, etc.) with a single entry.

Some errors may involve two or more fields—for example, accident date occurs before patient birth date—and either field could be in error. Both fields are presented when your clients “point and click” to edit—so that they can quickly correct the appropriate field.

Error messages are “easy to understand” and many indicate exactly what correction to make.

Your clients can choose to edit as many or as few claims in any given file. They do not need to correct all claims. They can exclude certain claims from being sent on to payers.

The security module allows your clients to control who can edit claims—as well as the type of edits they can make.

Audit reports that provide a complete audit trail of everything that was done to a claim—who changed what and when.

Other reports that show your clients the most common errors—for monitoring and training staff to reduce billing errors.

For More Information on ClaimRemedi Products with Online Claim Editing Included:

Claim Lifecycle Manager

ClaimRemedi’s claim tracking and management module provides complete claim history from claim submission through claim adjudication, and can be used to:

• Provide proof of timely filing to payers.
• Identify rejected or denied claims along with the reason for rejection/denial—and that can then be assigned by your provider clients to their billing staffs for follow-up.
• Identify claims “missing in action”.
• Perform electronic claim status inquiries to payers.
• Monitor follow-up by your clients of their billing staff — errors corrected, errors overridden, completion of follow-up items, etc.

The View Claim feature displays all payer responses for a claim—from claim submission through adjudication—in easy to understand messages that don’t require additional interpretation.

Staff assignments and notes for follow-up can be added as needed. These can either be done on an individual claim basis—or to groups of claims with a single entry.

An Auto Close feature automatically “closes” all claims that have been paid or for which the last response from a payer indicates that the claim has been accepted and no further electronic responses are expected. This eliminates the need for your clients to spend time manually closing claims that should be closed. Closed claims can always be accessed and included in any query—as needed.

Retrieve any single claim or group of claims meeting any combination of selection criteria: Staff member assigned to claim; Claim status (received by payer, accepted, rejected, paid, denied, etc.); Date uploaded, date of payer response, date of service; Payer; Patient name & account; Provider; and Batch file.

An Advanced Search feature provides your clients with access to all 837 X12 claim fields (procedure code, diagnosis, condition code, etc.) for both professional and institutional claims. Claim selection criteria for common searches can be stored as search templates and retrieved for future use.

All query results can be exported to a spreadsheet for further analysis.

Audit reports itemizing all payer responses, assignments and notes—the who, what and when—for either a single claim or a group of claims can be readily printed at any time.

For More Information on ClaimRemedi Products with Claim Management Included:

Claim Lifecycle Manager

Use ClaimRemedi’s electronic remittance advice (ERA) processing to download 835 files into your clients billing system for auto posting. Your provider clients can also print or view on-line human readable versions of your 835 files for manual posting and other analyses.

When we process 835 files, we also automatically load claim adjudication information into claim history—as the “final” event in the claim Lifecycle process. This information can then be used not only for individual claim tracking—but also for analyses of payer payment patterns, denials, reasons for denials, etc.

For More Information on ClaimRemedi Products with Electronic Remittance Services Included:

Claim Lifecycle Manager

Why spend hours of staff time manually sifting through data to generate reports you need? ClaimRemedi offers your  provider clients an abundance of embedded tools for analysis and reporting. 

• Find and quantify any information about claims.
• Measure the productivity of billing staffs.
• Generate audits itemizing all error corrections, payer responses, assignments and notes—the who, what and when—for either a single claim or a group of claims.
• Compare payments and denials by provider and type of service.
• Identify most common errors and reasons for denial by staff and by payer.
• Manage denials.
• Monitor follow-up by billing staff —errors corrected, errors overridden, completion of follow-up items, etc.

All results can be exported to a spreadsheet for further analysis.

Reports can be can be run from any computer that has web access.

Global or “wild card” searches are fully supported. Also supported are “and/or” operators, ranges of values and multiple non contiguous values.

Use any combination of selection criteria: Staff member assigned to claim; Claim status (received by payer, accepted, rejected, paid, denied, etc.); Date uploaded, date of payer response, date of service; Payer; Patient name & account; Provider; Batch file; etc.

Access to all X12 claim fields (procedure code, diagnosis, condition code, etc.) for both professional and institutional claims.

Report templates can be stored and retrieved for future use.

For More Information on ClaimRemedi Products with Analytical Tools & Reporting Included:

Claim Lifecycle Manager