Study Guide
Exam 3 Study Guide
Study Guide Chapter 18: Claims and benefit administration 1. What are the purposes/importance of a claims adjudication system within managed care?
To MCO business leaders, government agencies, and others within the health insurance industry, Claims is the source of information that allows the MCO to gauge and improve its business performance and improve the health care of its members. * Enabling the MCO to meet contractual obligations to employer groups, government agencies, members, and providers. * Ensuring timely benefits administration for enrolled members including the accurate application of cost sharing features, benefit limitations, maximums, and exclusions. * Administering medical management policies and medical necessity decisions. * Improving the healthcare of its members through the development and execution of care management plans. * Providing prompt and accurate customer service to members, brokers, employer groups, and providers. * Protecting financial liability by validating eligibility, avoiding duplicate and other inappropriate claims, ensuring accurate processing, administering other party liability programs, pursuing cost-containment activities related to known or specific financial leakage, and ensuring timely productivity to avoid processing penalties and interest payments. 2. Describe the set of operational functions within claims capability.
First, receipt of electronically submitted claims through electronic data interchange and receipt of paper claims. Next, initial auto adjudication first pass then a second- attempt auto adjudication following resolution of certain suspension edits. Manual processing for claims that cannot be auto-adjudicated, check writing process. The issuance of EOB and/ or remittance advice before completing appropriate prepayment and post payment analytics. Finally, arching claim records and data. 3. Explain the core competencies and integrated components
Study Guide Chapter 18: Claims and benefit administration 1. What are the purposes/importance of a claims adjudication system within managed care?
To MCO business leaders, government agencies, and others within the health insurance industry, Claims is the source of information that allows the MCO to gauge and improve its business performance and improve the health care of its members. * Enabling the MCO to meet contractual obligations to employer groups, government agencies, members, and providers. * Ensuring timely benefits administration for enrolled members including the accurate application of cost sharing features, benefit limitations, maximums, and exclusions. * Administering medical management policies and medical necessity decisions. * Improving the healthcare of its members through the development and execution of care management plans. * Providing prompt and accurate customer service to members, brokers, employer groups, and providers. * Protecting financial liability by validating eligibility, avoiding duplicate and other inappropriate claims, ensuring accurate processing, administering other party liability programs, pursuing cost-containment activities related to known or specific financial leakage, and ensuring timely productivity to avoid processing penalties and interest payments. 2. Describe the set of operational functions within claims capability.
First, receipt of electronically submitted claims through electronic data interchange and receipt of paper claims. Next, initial auto adjudication first pass then a second- attempt auto adjudication following resolution of certain suspension edits. Manual processing for claims that cannot be auto-adjudicated, check writing process. The issuance of EOB and/ or remittance advice before completing appropriate prepayment and post payment analytics. Finally, arching claim records and data. 3. Explain the core competencies and integrated components