Emdeon Advanced Claiming

Emdeon Advanced Claiming identifies the most efficient path for healthcare claims to be delivered to the final claim adjudicator.

Emdeon pre-adjudication services apply predefined payer or PPO business logic to all targeted incoming claims originated by EDI or paper-based processes. By hosting and automatically updating payer and provider data, Advanced Claiming can execute a wide range of business rules at a group or member level as claims are processed by Emdeon. Advanced Claiming customers typically experience a higher first-pass rate, reducing manual intervention in the claim re-pricing and/or adjudication process, significantly lowering processing cost-per-claim. For customers with multiple adjudication systems, pre-processed claims can be re-directed to appropriate service location.

Emdeon provider data cleansing helps solve one of the biggest problems in healthcare - provider data inaccuracy. Through our database of correct, current and comprehensive information on more than 6.5 million provider records, Emdeon can validate, augment, replace and normalize provider data within a claim to help improve auto-adjudication, increase payment and reporting accuracy and reduce the time spent working pended claims.

Emdeon Claim Routing service links specific data on the claim to member eligibility within a group, group coverage to a PPO, procedure codes, dollar amounts, and/or provider's participation in a PPO network. It also enables Emdeon to determine Capitation Division of Financial Responsibility (DOFR). The claim is automatically routed to the appropriate PPO or payer for processing in a format specific to the re-pricing or adjudication system without manual intervention. Once re-priced by the PPO, the claim is then delivered to the payer through Advanced Claiming.

Features

• Validates, corrects and replaces provider data
• Flags suspect providers
• Automated, efficient routing between payers and PPOs for re-pricing
• Applies client-specific pre-adjudication business rules to all claims
• Offers provider ID and member ID matching
• Rejects claims older than payer-defined deadlines
• Identifies and rejects duplicate claim submissions

Benefits

• Enhances the efficiency of the payment cycle
• Reduces manual intervention during claim adjudication and re-pricing
• Lowers processing cost-per-claim
• Speeds claim payment settlement cycle
• Increases first-pass results
• Improves payment and reporting accuracy