EBMCOnlineClaims Administration

CLAIMS ADMINISTRATION

Claim administration practices ensure timely and accurate claim processing, cost containment and compliance with government regulations such as HIPAA and COBRA.

The following teams make this happen…

Medical Review works closely with Alternative Care Management Systems (ACMS). ACMS provides clinical interpretations and insures provider billings meet industry-accepted practices and medical necessity. Services include pre-certification, case management and disease management. Pre-certification notices are transferred electronically from ACMS to EBMC’s claim processing system.
Staff Development provides staff member training on the latest claim administration procedures, regulatory requirements, technological enhancements and fraud detection.
Quality Review performs random and targeted claim audits. Administrative and training procedures are reviewed for compliance.
PPO Coordinators facilitate the exchange of repricing information with PPOs. This way plans can take advantage of the most up-to-date pricing schedules. Coordinators closely monitor PPO turnaround time and expedite claims accordingly.
Plan Building and Auto-Adjudication ensures plan parameters are correctly programmed into the claim processing system. Over 30% of claims auto-adjudicate. System edits review claims for unbundling, multiple procedures and duplicate submissions.
Enrollment verifies that eligibility information meets plan requirements. Information is coordinated with COBRA Administration and Flexible Spending/Section 125 to facilitate uninterrupted claim administration.
Out-of-Network Discounting facilitates the discounting and processing of out-of-network claims, adding further savings to the overall benefit program.

Our state-of-the-art electronic claim administration, routing and Internet-based inquiry system enhances the ability to process claims quickly and accurately, and provide online, real-time access to claim information.

Over 98% of claims transact in an electronic format. Claims are exchanged electronically between vendors such as PPOs, providers and clearinghouses. Claims sent electronically are repriced and returned by PPOs within 24–48 hours.
Claims are recorded in the system at the point of receipt and status can be monitored by providers, clients and plan participants throughout the entire claim administration process.
Claim information is viewable at www.ebmconline.com. Users view claim status, eligibility information and benefits. In addition, clients perform eligibility additions and changes.
Plan participants respond to requests for coordination-of-benefit information and accident/injury details on the website. Information is used to update claim information and reconsider claims.