Claims Administration

The claims adjudication process includes the following range of functions:
 

  • Specific and Aggregate Stop
  • Loss limits
  • On-line Eligibility and Coverage History
  • Automated Batch Adjudication
  • Automated Production of Checks and EOB forms
  • Automatic Claim Hold for Quality Reviews
  • Duplicate Payment Edits
  • Reasonable and Customary Edits
  • Automated Correspondence
  • IRS 1099 Reporting
  • Multiple PPO Contracts
  • Benefit Plan Design and Document Preparation
  • Check Payments Tied to Customer Funding Arrangements
  • Claim Edit System
  • Call Center
BMA offers the following cost containment features:
 

  • Eligibility dates prompt for pre-existing
  • Termination date can be input prior to the actual date
  • Benefits are pre-loaded
  • Prompts for Pre-Admission Review & Second Surgical Opinion
  • Tracking frequency of examiner overrides of system edits
  • Claimant and Provider prompts
  • R&C updates for all codes
  • History maintenance of deductibles, out-of-pocket and carryovers
  • Over-utilization (reports)
  • Claim dollar maximums
  • Necessity of assistant surgeon
  • Diagnostic procedures
  • Pre-Existing Conditions
  • Coordination of Benefits (COB)