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Claims Adjudication
We reduce your claims processing costs while speeding processing
times, assuring consistency, and giving you precise control over
decisions made in the processing of claims.
We increase the efficiency of your claims processing.
Historically, the claims adjudication process had the objective of making human claims examiners more efficient. Good human claims examiners can adjudicate a claim every five minutes. They are often aided by auto-adjudication systems that can process simple claims without human intervention.
At EHP, we have reversed the historic roles of humans and information technology. The EHP system assumes that no human is required to adjudicate the claim. Therefore, it uses computers to adjudicate the vast majority of claims (95% or better). Significantly fewer people are able to produce significantly greater results. We are thereby able to reduce our customers' claims adjudication costs by 20-25%.
We think of claims processing in three phases.
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Submission of claims, encounters, and authorization requests from the originator in any form from paper to full electronic submissions (ANSI 837) and web based submission, with the internal conversion of paper submissions to electronic formats and images.
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The actual claims adjudication process which includes our "Gateway" screening of the claims/encounters to assure that the information is compatible with the five databases our system uses to adjudicate the claims/encounters (members, providers, history, benefits & rates, and rules). The information in each claim/encounter is adjudicated using the information in the databases.
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Distribution of the results of the adjudication process includes funding the approved claims and printing checks; preparing the appropriate accompanying documentation (e.g. EOBs, Remittance Advices, etc.); stuffing; and mailing.
Here's a Flowchart Showing how Claims are Processed
The process is 100% rules-based.
There is human oversight of the automated processes through Claims Auditors to assure that rule changes are properly completed and that the few issues not fully automated are resolved.
We make you HIPAA-compliant.
Our system is 100% HIPAA-compliant, and meets all privacy and security mandates of federal and state regulators.
We improve Customer Service at a lower cost.
Since the EHP system converts the entire claims adjudication process into electronic formats, your Customer Service representatives can find files faster, answer questions more consistently, and handle more calls per day. You will be able to provide more Customer Service information with fewer representatives.
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Electronic Health Plans is a leader in providing technology support
to managed care benefits administration. Our claims processing system
uses a unique auto-adjudication engine which delivers a faster, cheaper
and more accurate way to process medical claims.
