Claims Adjudication is Simple with CHS Claims

Claims Adjudication for medical, dental, vision, prescription, short and long-term disability claims.

• Available for on-site license or as a hosted application (ASP).
• Microsoft technology: SQLServer database with a Windows front end.
• Acclaimed Customer service staffed by health care claims experts with a minimum of 12 years’ experience in the field. Support calls are logged with status available via the internet.
• Plan set-up enables unlimited numbers of plans with:
  • Plan or contract structure
  • Procedure-driven logic using CPTs, HCPCS, fee schedules and more
  • Provider or PPO fee schedules or discounts
• Plan copy and modification feature enables quick setup of plans.
• Auto-adjudication using benefit codes built using business rules based on over 25 variables from both the claim and the claimant records made available to the adjudication engine.
• Inbound claims can be scanned images, EDI or paper.
• HIPPA EDI 5010 transaction sets.
• Capitation processing can be enabled.
• Per occurrence tracking.
• Primary Care Physician referral tracking
• Easily handles the Coordination of Benefits.
• Hotkey between claims and customer service without interrupting claims processing.
• Ability to reprint and mail EOBs as originally presented.
• Processor alerts include:
  • Pre-registrations
  • Pre-certifications
  • Coordination of Benefits
  • Notes on claimant, family, dependent or provider
  • Student status
  • Over percent of Specific Stop Loss
  • COBRA status
• A claim can be reopened at any time for re-processing up to the time the check is cut.
• EOBs can be reprinted at any time.
• Recall capability to show how a benefit was paid in history, including processor information.
• MICR encoding, logos, and signatures on checks.
• Optional bank reconciliation of checks via Positive Pay and similar features.

Specific to Dental Claims

• High Auto-adjudication (98-99%)
• Tooth chart with history and alerts for conflicts, including quadrant history.
• Dental pre-treatment estimates.
• 1^st, 2^nd and 3^rd year tiered dental benefits through plan design.
• Dental PPO and schedules.
• HIPPA EDI for dental claims (837D)
• Optional real-time payment of regular and dollar-based dental plans with various payment gateway interfaces.

PPO network and Re-pricing features

• Unlimited PPOs per plan
• Providers can belong to any number of PPOs
• Out-of-Network claims can be set up to automatically price-based on non PPO, if the plan permits
• Accommodates various PPO Pricing Structures
  • Discounts
  • Per Diems
  • Discounted rates by CPT
  • Fee Schedules
  • Re-pricing by PPO vendor prior to receipt by plan
• HIPPA compliant EDI for inbound re-priced EDI claims.
• Re-pricing fee and UCR Schedules can be loaded on the system in advance of effective date. The date-driven logic will re-price based on date of service.

Enrollment and Eligibility Features

• Manual and electronic formats for loading enrollment. HIPPA 834 or proprietary file formats.
• CHS WebAccess allows members/employers to change some information and then, on approval, upload it to the CHS system enrollment.
• Eligibility can be checked with a single simple inquiry via CHS WebAccess or interactive voice response.
• Multi-tiered coverage and rates
• Table Rating capability
• User-defined coverage codes

▪ Pre-registered and Claims Pended Report

▪ Enrollment Census Report

▪ Claims Productivity and Processor Summary

▪ Claims Count by Date Received

▪ Claims Waiting Supervisor and Executive Approval

▪ Pre-Certifications on File

▪ Claims Detail History Report (with 100+ different extractions/combinations)

▪ Consolidated Paid Claims Analysis

▪ Weekly Income & FICA Withholding

▪ Claimant Benefits Paid Report

▪ Claimant Usage by Benefit Report

▪ Claimant Accumulator Report

▪ Specific Stop Loss Report

▪ Trigger Diagnosis Report for Stop Loss Carriers

▪ Aggregate Stop Loss Report by Group and/or Location

▪ Claims Lag Report

▪ Reports of the TOP (i.e., Providers, Diagnosis, Claimants, Age, Dates, and more)

▪ Provider Summary Report

▪ PPO Savings Report

▪ PPO Withhold Report

▪ COB Savings Report

▪ Monthly Check / Deposit Registers by Group and/or Location

▪ Overridden Claim Lines Report