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| Payer
Services |
Adjudication, Utilization and Credentialing
 With
improving follow-up capability of care providers
due to global delivery; payers need more quality
resources to avoid inaccurate reimbursement.
R Systems works as dedicated partner with the
payer providing high quality SLA-driven claims
customer support and adjudication service utilizing
a mix of offshore and onshore staff. |
Claims
entry, Duplicate Check, Critical Error Correction
and Adjudication
We can help benefit administrators like carriers,
TPAs, ASOs in customizing the adjudication rule
engine and utilize offshore service for improved
manual adjudication for claims that cannot be
auto adjudicated.
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This includes:
- Entering claims data with verifications
- Duplicate checks
- Collecting missing piece of information
from providers’ office
- Attending 837 conversion errors,
- Manual adjudication based on policy directives.
- Managing processes like secondary insurance
claims, claims with attachments complying
with the payer’s policy guidelines
- Checking for member eligibility, provider
status, coding compliance, inclusions and
exclusions etc.
- Payable calculation and check processing
- Backlog handling / pend management
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Pre-cert
and Utilization Management [Authorization]
 The
utilization management team is capable of handling
Intake of Authorization Requests, Duplicate
Checks, update pre-authorized referrals, run
checks on Member Eligibility, Provider Participation,
Patient Demographics, Cost Shifting between
hospitals and free standing facilities.
For Pre-certification of Inpatient procedures
requiring clinical decision-making, decision
support is provided by our overseas CGFNS certified
nurses, which is subsequently validated and
endorsed by registered nurses under the concerned
state.
The concurrent review team attends to request
for hospital / SNF stay and coordinates discharge
processing.
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Case management,
Disease management and Global OB programs
To avoid major expenses on high-risk members,
we in R Systems, are experienced to run Case
Management and Disease Management programs.
This involves patient education, periodic communication,
drug monitoring, counseling and utilizing community
resources.
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Provider
Credentialing, Provider education and Provider
Data Upkeep
Provider credentialing process involves checking
records for new providers collected through
field reps and verifying it online. Locating
the correct provider contract is critical to
success of any carrier. Millions of healthcare
dollars are paid out every year in terms of
duplicate claim payment, payment to wrong provider
or against wrong tax id of the same provider.
Provider data upkeep team calls up provider
offices to verify provider data collected through
field reps, and accordingly update the provider
contracts in the system.
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