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Payer Platforms

We have an in-house team of technical resources that have a deep understanding of Payer administrative processes, workflows, and customization of business rules. This team has leveraged its domain and technical expertise to design and develop proprietary Claims Management and Claims Processing Platforms. We have the following payer software applications, which can be customized to suit your specific requirements.

  • A claims processing platform for claims adjudication
  • Separate modules for Enrollment, OCR, Call Management, and UM
  • Built-in CMS pricer, NCCI, and LCD edits with provider and back-end interfaces
  • Full view of the business through standard and customized reports
  • A DRG-based coding audit platform
  • Built-in workflow, web-based application
  • Host of system validations and ability to accept custom validations
  • Prompts on possible DRG codes to aid auditors during audits
  • Identifying Dx codes with CC and MCC conditions to locate documentation adequacy for these codes
  • Built-in Medicare pricer to identify financial impact on changing the submitted codes
  • A Medicare pricing module
  • Identifies the appropriate amount per Medicare for all claim types
  • Interface for contract loading based on a percentage of the Medicare amount
  • Interface capabilities for bulk updating of the appropriate amount
  • Reduce or eliminates manual entry by using OCR
  • A platform for verification of the output and allows users to generate an output in HIPAA compliant 837 format
  • Built-in edits to eliminate errors
  • Built-in audit workflow customizable queue creation process
  • Self-indexing of images
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"By utilizing your services, we are able to focus more on our client and strengthen our core delivery."

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Provider Solutions

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Claims OCR and Audit Platform

This platform reduces or eliminates the manual efforts by doing an OCR process on the image files of the claims, thus providing a platform for verification of the output that allows users to generate output in HIPAA Complaint 837 Format.

It is a synchronized processing with the validation of output against pre-set rules and master data, thus importing Master Data through front-end or the template. It has a built-in intelligence with an in-built Audit Workflow and a user-friendly HCFA-like audit screen. It splits the issues into Errors and Warnings, which are color-coded accordingly with customizable queue creation process. This also does self-indexing of images. The output can be taken in HIPAA complaint 837 format or XML format, which is faster than data entry.

Price Fast – CMS Pricer

Our Medicare Pricing software that identifies, in bulk, the correct amount allowed as per Medicare for Physician as well as Facility claims. It provides an interface for loading contracts if they are based on a percentage of Medicare allowed amount and provides interface capabilities for bulk updating of allowed amount into any Claim Processing System that allows such access. It is user-friendly wizard for uploading data and canned reports on exceptions and has easily customizable backend processing.

HoCAS Claims Audit Platform

Our DRG-based Coding Audit Platform is a user-friendly wizard for setting up templates and for the input of files. This system supports creation of multiple templates of input, with in-built workflow and is an agnostic application. It is a web-based application with A-synchronized mode of processing, with no client side requirements. It has the ability to accept custom validations and prompts on possible DRG codes to help auditors do better audit of medical records thus identifying Dx codes with CC and MCC conditions and aids for verification of documentation adequacy. It also has an in-built Medicare Pricer to help the auditor identify financial impact on changes to the submitted code.

Velocity Claims Processing System (CPS)

An end-to-end Payer tool, the Velocity Claims Processing System is our proprietary Claims Administration Platform. This software has the features to process the claims that are data entered (paper claims) or uploaded (EDI claims) into the payer application in use, and offers unmatched flexibility. Our skilled resources have a deep understanding of payer administrative processes, business rules and workflow during all stages of Claim Adjudication.

Velocity has separate modules for Enrollment, OCR, Call Management, and Utilization Management. It also has in-built CMS Pricer, NCCI, and LCD edits. Velocity has both provider and backend interface that supports standard and on-the-fly customizable reports.

  Features and Benefits

  • Manage your workflow
  • Claims Processing platform which helps to manage the workflow during all stages of Claim Adjudication
  • A front end web access, allowing for multi-stage claim processing
  • Hybrid architecture – available on ASP model, claims are reviewed at multiple stages with an option to hold the payment at any stage
  • Helps minimize manual intervention
  • Built-in rule engine and edits/checks, integrated with Document Management System/EDI with fully functional DRG and OPPS modules
  • Electronic file upload capability
  • Robust reporting capabilities
  • Built-in Medicare statutory reports with query builder features for building ad hoc reports, and supports HIPAA formats for claims and membership upload