EHP Technology

EHP's technology reverses the historical relationship between people and computers in the process of health care administration. Rather than claims examiners using the system to help process a claim, computers auto-adjudicate claims, only asking for help from senior Claims Audit specialists when information is missing.

EHP Administrators is able to perform its services in a cost effective way because of our Managed Care System. Key elements of the system include:

Use of a very efficient rules-based engine to define the various benefit structures and medical guidelines which must be applied to the adjudication and utilization tracking of claims & encounters.
Our system is designed to allow maximum scalability.
Our software was developed with the keystone of maintainability, including extensive documentation.
Our complete workflow management system facilitates the methodology needed to support a computer-based claims examination function.
EHP delivers real time medical authorizations and encounter processing today and our system is designed to support real time claims adjudication over the web.

The EHP Claims/Encounter Process

EHP requires that claims data be in electronic format so that all information is consistent and retrievable. Paper claims/encounters are converted into electronic form and processed.

The EHP Gateway Process

Once received electronically, claims/encounters are subjected to a process which validates the claim for consistency and accuracy to obtain key information needed to complete the adjudication process

The EHP Auto-Adjudication Process

Gateway screening of claims assures that the information is compatible with the five databases our system uses to adjudicate claims (members, providers, history, benefits & rates, and rules). Claims passing the gateway process go directly into the EHP Auto-Adjudication engine. There, the specific information contained in each claim is examined using the criteria programmed into the rules database, and each claim is adjudicated using the information in the databases.

Based on the information it receives, the system determines the allowed price for each service (either internally with contract rules or fee schedules, or externally with automatic electronic interfaces to PPO's for repricing) and the appropriate benefit rules. It then checks claims history for duplicates, maximums, deductibles, COB information, case-related data and other information needed to process the claim, and computes the payment on the claim. The system also determines whether a pre-authorization was required, and reads and checks files to see whether one was obtained.

Claims Adjudication Rates

The company has developed software that auto-adjudicates (without human intervention) in excess of 95% of all medical claims that are submitted to it electronically, and 99%+ for simple HCFA claims.

The EHP Output Process

After claims adjudication is complete, support documents are created for the customer. They include Explanations Of Benefits (EOBs) for patients, Remittance Advisories for providers, and Checks/Electronic Funds Transfers (EFTs) for benefit payments to patients, insureds, or providers.