claims

Claims Adjudication is Simple with CHS Claims

Features:

  • Adjudicates 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 Coordination of Benefits.
  • Hot key between claims and customer service without interrupting claims processing.
  • Ability to re-print 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.
  • 1st, 2nd and 3rd 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

Reports available from CHS CLAIMS™

Additional reports can be generated using Crystal Reports. A CHS data dictionary facilitates do it-yourself reporting. Reports are exportable to various formats including Excel (.xls) and Adobe
(.pdf) compatibility.

▪ 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

800.524.2327
200 W Douglas Ave, Suite 360
Wichita, KS 67202
Monday - Friday:
8am to 5pm

©2019 Complete Health Systems. i3™ is a trademark of Complete Health Systems, LC. | Site design and development by Baseline Creative.

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