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 government entity, 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 beneficiary 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 will be re-directed to appropriate service location.

Emdeon Claim Routing service links specific data on the claim to beneficiary eligibility within a group, group coverage to a PPO, procedure codes, dollar amounts, and/or provider's participation in a PPO network. The claim is automatically routed to the appropriate PPO, payer or government entity 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 government entity through Advanced Claiming.

Features

• Automated, efficient routing between government entities, payers and PPOs for re-pricing
• Applies client-specific pre-adjudication business rules to all claims
• Offers provider ID and beneficiary ID matching
• Rejects claims older than government-defined deadlines
• Identifies and rejects duplicate claim submissions
• Automated, efficient routing between government entities, payers and repricing organizations

Benefits

• Improves 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
• Improves first-pass results