Claims Management

Our skilled resources work closely with all our payer clientele, including health plans, and TPAs providing the following services.

Plan Benefits Administration

Our fully trained manpower creates benefit categories and load into software as per the client specifications. Also, we do create Benefit plan ids and load as per the plan specifications.

Providers and Contracts

We create contract classification codes that actually are attached to the contracts to pay out the claims. We perform contract set up by creating the contract templates for both par and non-par providers. We download all kinds of fee schedules / modifiers from CMS and perform maintenance. We can create provider types. We create all kinds of provider contracts and attach appropriate Benefit categories and fee schedules.

Members Enrollment Administration and Processing

We are providing data scrubbing and member demographics loading into software. We also verify data on government works portal. Our service includes posting daily enrollments files to CMS, receiving and taking action on the TRR files. We also work on disenrollment.

Claims Entry and Processing

We are providing our clients with both paper and electronic claims entry and processing. We perform claim adjustment, to correct the inaccurately paid claims. Processing refund requests and working on the claims in call center tickets. We have teams that are skilled in HCFA 1500 and UB 92 claims processing. We have the experience to migrate several insurance processes. We have good knowledge working on the reports generated by third party claims adjudication system to stop the leakages. We are skilled at Ingenix Claims Processing System

Referral Authorizations

Most HMOs require patients to get a referral from their Primary care Physician before seeing a specialist. Our services include receiving and creating the authorizations for referral requests in all forms (fax, email, telephone). We ensure loading the referrals and authorizations into designated software periodically.

Credentialing

Very few companies offer the service due to the very sensitive nature of the job. Anion has a well-qualified team that accesses CAQH website to verify provider credentials. We then follow up with the provider offices to collect the expired documents like DEA and Malpractice insurance. We ensure highest level of competency and skill set is put on this job.

Re-pricing of UB claims using third party portals

Claims which are processed using IPPS / OPPS methodology are priced through a standard third party tool. The tool provides Medicare allowable limits for all inpatient and outpatient claims.

  • It enables coding consistency and data quality.
  • Reduces compliance risks.
  • Includes edits for NCD / LCD.

Agents Credibility checks

All agents prior to hitting the market during enrollment season need a background check. We check DMV (Department of motor vehicle, DOI (Department of Insurance) and OIG (office of inspector general) portals and give the status.