Emdeon Advanced Claiming identifies the most efficient path for healthcare claims to be delivered to the final claim adjudicator.
Emdeon Pre-Adjudication Services apply predefined payer or PPO business logic to all targeted incoming claims originated by EDI or paper-based processes. By hosting and automatically updating payer and provider data, Advanced Claiming can execute a wide range of business rules at a group or member level as claims are processed by Emdeon. Advanced Claiming customers typically experience a higher first-pass rate, reducing manual intervention in the claim re-pricing and/or adjudication process, significantly lowering processing cost-per-claim. For customers with multiple adjudication systems, pre-processed claims can be re-directed to appropriate service location.
Emdeon Claim Routing service links specific data on claims to member eligibility within a group, group coverage to a PPO, procedure codes, dollar amounts, and/or provider’s participation in a PPO network. Claims are automatically routed to the appropriate PPO or payer for processing in a format specific to the re-pricing or adjudication system without manual intervention. Once re-priced by the PPO, claims are then delivered to the payer through Advanced Claiming.
Features
- Automated, efficient routing between payers and PPOs for re-pricing
- Applies client-specific pre-adjudication business rules to all claims
- Offers provider ID and member ID matching
- Identifies and rejects duplicate claim submissions
- Automated, efficient routing between payers and PPOs for re-pricing
Benefits
- Improves the efficiency of the payment cycle
- Reduces manual intervention during claim adjudication and re-pricing
- Lowers processing cost-per-claim
- Speeds claim payment settlement cycle
- Improves first-pass results
