Claims Administration

Timeliness and accuracy of Medicaid claims must meet strict federal and state guidelines. Incorrect or delayed claims can negatively affect plan credibility and satisfaction of both providers and members. For example, many Medicaid MCOs experience difficulty in attracting and retaining physicians and other necessary providers to their networks due to low reimbursement rates and what the providers perceive as “administrative hassles” in settling claims.

Paying claims quickly and accurately also has an immediate impact on:

  • Contract compliance
  • Risk-based calculations
  • Pay-for-performance models at the state level, or those that the Managed Care Organization uses for its own provider network
  • Quality data fundamental to the MCO’s responsibility to meet state and/or NCQA requirements.

 

TMG Health’s application of innovative health claims technology and process improvement methodologies enables high levels of quality and rapid claims turnaround, thereby reducing payment cycles. Our state-of-the-art technology provides EDI connectivity to a wide range of clearinghouses. Our technical and production personnel also fully comprehend the unique requirements posed by state Medicaid health claim forms, provider/member files, claim system connectivity and EDI programming.

We are thus able to perform a wide range of medical/dental/ vision claims processing services for Medicaid insurers, including:

  • Configuration of the MCIS to meet client requirements
  • Receipt of paper and EDI claims from plans or clearinghouses
  • Claims Imaging, Image indexing, OCR and archiving
  • Claims data capture
  • Claims Processing and Adjudication, including:
    • Full adjudication of current year claims
    • APC Pricing and DRG Grouping
    • Claims recovery
    • COB identification, processing and maintenance
    • Claims adjustments
    • Research of pended claims
    • Calculation and processing of late payment interest
    • Production and fulfillment of provider payment checks/EFT and remittance/EOP advice
    • Provider payment check runs
    • Production and fulfillment of member EOBs with appeals language
    • Providing of 1099 data to plan
    • Finalization of claims per CMS and plan payment methodology and within CMS/state timelines
    • Subrogation (optional).

 

Claims Adjudication
Based on our years of experience, TMG has effectively implemented a quality-controlled auto-adjudication procedure that enables us to fine-tune our claims processes. Auto- adjudication for clients allows TMG to achieve more timely processing and increased quality. Through auto adjudication testing and implementation, we are also able to develop target auto adjudication rates by client.

Our adjudication services encompass the following elements for Medicaid plans:

  • Development of a comprehensive implementation and testing plan to include extensive pre-testing, progressive ramp-up schedule and a confirmed go-live production date.
  • Facilitation of TMG receipt of EDI claims from clearinghouses.
  • Mailroom functions: P.O. Boxes, envelope opening, sort, prep, date stamp and assignment.
  • Receipt of additional paper documentation and/or imaged claims from client.
  • Electronic imaging of paper claims with immediate delivery to the production workflow and claims image repository.