Processing of Medical, Dental, Vision, and Disability Claims
ASP’s claims processing system is a robust, state of the art claims adjudication system that has the capability and flexibility to incorporate multiple plan designs, as well as a series of different plans driven by specific contribution ratesGet a Detailed Overview of our Claims Processing
ASP’s systems are designed to process claims electronically, either through manual input of key data elements of the claim or full electronic auto adjudication processing through secure industry standard EDI protocols and methods.
The claims adjudication module of ASP’s system is specifically programmed to the client’s plan design (i.e., deductibles, coinsurance, copayments, lifetime limits, yearly limits, covered/non-covered services, etc.). The system can accept claims with prepriced, allowable charges or claims with charges that are subject to UCR limits dictated by the plan. Necessary data elements to adjudicate the claims (i.e., patient identification, member identification, date of service, CPT-4, ICD-10, provider ID) can be inputted manually or can be accepted electronically in an 837 format. It is ASP’s general practice to scan all incoming paper claims, covert them to an 837 format with the claim image appended to the 837 record, and auto adjudicate them through the system.
Eligibility of members and dependents is updated daily. The claims adjudication module automatically verifies patient eligibility in the claims adjudication process.
Although ASP’s typical “first pass” rate on auto adjudicated claims (i.e., those claims that are processed and paid without human intervention) is 62%, the system is programmed to automatically pend claims for processor review in a number of circumstances, including:
- possible duplicate claim
- ineligible member or patient
- possible other party liability (coordination of benefits)
- work-related injuries
- accidental injuries (possible subrogation)
- claims over a stated dollar limit (e.g., hospital claims with charges exceeding $50,000)
Check runs for processed claims are run on a weekly basis. Check EOB’s and member EOB’s are electronically forwarded to a third-party provider which prints, stuffs and mails the material to providers and members. Images of all provider and member EOB’s are maintained on a secure web site for a period of seven years. Under this process, both the incoming scanned image and the outgoing Explanation of Benefits statement(s) are stored electronically and are easily retrieved.
Disbursement reports and check registers are generated by the system. The benefit checking account is reconciled on a monthly basis through an automated bank reconciliation process once an electronic file is received from the Fund’s banking financial institution. Claim information and claim history is maintained on the network system indefinitely.