Detailed Claims Processing

Detailed Overview of the Eldorado HealthPac Claims Processing System


ASP utilizes HEALTHpac, the industry standard in comprehensive health benefits management claims adjudication systems that has been subjected to over 30 years of continuous development.

Features include:

  • Claims Input via EDI, Scanning and Manual Entry
  • Medical, Dental, Vision, Rx and Disability Claims Management
  • Advanced Dental Logic (Tooth Chart, Surface and Service Tracking)
  • Multi-option & Coordination of Benefits & Processing
  • Aggregate and Specific Tracking
  • Contract Management
  • Fund Accounting
  • Automated Workflow
  • Auto-adjudication
  • Medicare Supplement
Primary processing features include:
  • PPO Repricing of Professional and Facility Claims
  • Automatic Adjudication
  • Patient Encounter Tracking
  • Capitation Processing
  • Integrated Case Management
  • Output Routing System
  • Basic Reimbursement Schedules
    • Insurer, Government, Employer Contracts
    • Per Diem Rates, Per Hour Rates, Percent-Off
  • Global Fees
  • Fee for Service, ICD-9, ICD-10, CPT-4, HCPCS Codes and others
HEALTHpac’s calculation logic determines the allowable reimbursement of a claim within the context of an episode of are. It identifies episodes by examining indicators:
  • Interim Bill
  • Certificate Number
  • Procedure Codes
  • Patient Control Numbers
  • From and Through Dates
  • Provider Specialty
  • Procedure Code Ranges
  • Diagnosis Code Ranges
  • HCPCS Code Ranges
HEALTHpac Calculates Contract Allowables Based on:
  • Per Case
  • Per Diems by Date of Service
  • Stop-Loss Provisions
  • CPT-4 and ICD-10 Level Exceptions
  • A Specific Contract by Important Contractual Clauses (such as Service, Diagnosis, Place of Service, Procedure)
  • Number of Visits
  • Percent of Charges
  • Volume Discounts
  • Results of Cumulative Contract Payments

HEALTHpac supports virtually any usual, customary and reasonable (UCR) pricing database. Examples include Ingenix’ medical, dental, anesthesia and HCPCS modules; PHCS/HIAA, RBRVS, ADP; as well as specific user-created fee schedules.

HEALTHpac’s letter generation utility allows easy communication with eligible employees and care providers. The processor may create ad hoc letters, letters requesting additional information or medical reports, and denial letters. Letters may be generated on-the-fly or automated through the batch adjudication process. In addition, there is a complete online, viewable history of all eligible employees’ correspondence.

Claims may be received electronically, scanned using OCR technology, or input manually from facsimile or hard copy HCFA 1500 and UB-92 claim forms.

Reasonable and Customary Expense Limits

ASP’s claims adjudication system automatically adjudicates the claim under pre-defined reasonable and customary expense limits if that option is activated. Further, claims may be adjudicated on the basis of any number of criteria, including, per diem rates, per hour rates, percent-off, global fees, fee for service, ICD-9, ICD-10, CPT-4, HCPCS codes, per case rates, per diems by date of service, stop-loss provisions, CPT-4 and ICD-9 level exceptions, specific contract by important contractual clauses (such as service, diagnosis, place of service, procedure), number of visits, volume discounts, or results of cumulative contract payments. In addition, claim extracts from the system permit detailed and robust reporting of all medical expenditures.