TPA Services
Print This PagePlan Administration – We administer Medical, Dental, Vision, FSA, HSA, HRA and COBRA plans. We offer HMO, PPO, EPO, POS and Indemnity versions of our Medical, Dental and Vision plans. Our FSA and HSA plans are integrated with Debit/Credit card solutions.
Claims Adjudication – We check claims for completeness and adjudicate them according to your plan. Our claims adjudication systems are built on the best solutions in the industry. We pay claims to subscribers and providers and use both EFT and paper payment methods.
EDI Claim Receipt – We receive electronic claims from warehouses, check them for HIPAA 837 compliance, notify the sender of acceptance and load them to our adjudication system for processing.
Eligibility – We collect initial eligibility electronically or on paper. We then provide ongoing maintenance for additions, terminations, and all other changes. Eligibility can also be maintained using our Employer Web Services.
Member Web Services – Our Web Services allow Members to check their eligibility, view status of claims, request ID cards and check for In-Network providers.
Provider Web Services – Our Web Service allow Providers to check member eligibility, view status of claims, submit their application for In-Network status and submit Pre-certifications.
Employer/Plan Sponsor Web Services – Our Web Services allow Employers and Plan Sponsors to add/update eligibility, view claims, and view reports.
Customer Service Call Center – We track every call by both the telephone system and our call tracking software. Our call center software is integrated with our many other systems so we answer questions quickly. We have office hours to match your, your members and your providers.
Stop-Loss Administration – We file, on your behalf, the specific and aggregate stop-loss claims as they occur and provide stop-loss reporting to both you and the carrier.
Capitation Processing and Payment – Calculation and distribution of payment to PCPs and capitated specialists. We also offer administrative services for Risk Pools.
Complex Provider Contract Solutions – If you are an existing health plan and your solutions cannot handle complex contracts easily then we allow you to setup your contracts on our pricing services and we will reprice your claims for you using your negotiated contracts.
Plan Material Creation/Distribution – We help you with designing, creating and distributing your Summary Plan Descriptions, ID cards, check layout and any other materials.
Claim Imaging – All paper claims are imaged and entered into our claims adjudication system. We also can make EDI claims look like a claim image.
Identification Cards – We help you create an ID Card that will meet your, your employees and providers needs.
Premium Billing – If you are an existing health plan you want help with your Premium Billing we can help. We use your eligibility files to create Billing Statements. We then mail and collect the premiums.
Utilization Review/Management – We concurrently review and assess your member’s use of medical care services for the appropriateness and quality of care.
Pre-Authorization/Certification – We apply this to any Medical or Dental service that you feel a pre-determination of medical necessity is warranted. We review the service before the procedure is performed in a timely manner.
Case and Disease Management – Our experts will monitor all heath related services for a member’s whose care is expected to be for a long time, or whose care is catastrophic in nature, or whose care is highly complex in nature.
Claim Repricing – We electronically integrate with any Provide Network you wish to have reprice your claims.
Claim Subrogation and Coordination of Benefits – We help you administer and in some cases recover the cost of services and benefits provided to a member where other parties are also liable.
Reporting - All of our systems are relational databases so we can report on any data you desire. We will setup weekly, monthly and yearly reports to meet your needs that are automatically sent to you. We will also send you your data in Access so your can create your own custom reports.