Health Claims Processing Software is widely used in the Health Payer space to automate Claims Management, Electronic Submission, Claims Adjudication, Payments and Collections.See More Claims software offer claims processing management tools and could be integrated with accounting and customer relationship management (CRM) solutions. Rules based Claims Software cater to specific business lines i.e. No Fault Auto Insurance, Workers Comp, Insurance Brokerage, FMOs, IPA, Travel Insurance, Commercial Health Insurance, Vision Insurance, Dental Insurance, Medicare Plans, Medicaid Plans, HMOs, Pharmacy Management, Radiology Management, TPA, ACOs, MSOs, BPO firms etc.

It is not possible for Claims software or The Claims Platform to cater to different or all lines of HealthCare business. Depending upon the need and size of the business, an Insurance Carrier, TPA or Health Plan should pick the software. With changing dynamics of HealthCare in America, it is recommended to go for agile, rule based and Web / Cloud based software with possible open-source coding. Also, it is important to scrutinize the Software fee, License fee, integration fee & maintenance fees etc. before picking one IT Vendor over others. We always recommend choosing Software as a Service (SaaS – Pay by use) vs. Licensed - Subscription based model.

If you are an Insurance Carrier, Re Insurance, Brokerage, Health Plans, HMO, MSO, ACO, PBM, PBA, RBM, IPA, TPA and exploring changing or migrating your IT System / Claims System or even trying to add an application to an existing system, iProjects.in could help. Our deep domain knowledge and strong relationship in the HealthCare industry will help us find the right vendor for you within your budget and needs. Yes, our services are absolutely free to you as we get paid by the Service Providers.

HealthCare Claims Software – Must have features

• Actuarial Reporting
• Adjuster Analysis Reporting
• Audit Trail
• Auto-Adjudication
• Bundling/Unbundling
• Check & EOB printing
• Check Reconciliation System Including Ability to Post Cleared Checks From Bank
• Claims Processing Including Ability to Scan, Receive via EDI or Manual Entry
• Clearinghouse Integration
• Comprehensive Claims History Display
• Coordination of Benefits, Co-Pays & Deductibles
• CPT Reasonable & Customary Pricing
• Customization Options
• Debit Card Processing
• Document Image Management System Eliminating Need to Store Paper Claim Forms
• Easy Retrieval Process Including Ability to Re-print Claim Form
• Easy to Use
• EDI Claims
• Eligibility Imports
• Friendly user interface
• Integrates with your internal systems and third-party services
• Internet Uplinks
• Links to Accounting Software
• Member/Dependent Eligibility Checking
• Multiple Plan Coverage Caps & Limitations
• Photo and document management; integrated scanning/capturing
• Positive Pay & Direct Deposit Capabilities
• Premium Billing
• Procedure Grouping
• Provider Management
• Referrals/Authorizations
• Reminders, diary, activity log
• Security Enabled
• Streamlines everyday tasks, such as letter creation and report creation, through automation
• Surcharge & Assessment Check Printing & Reporting
• Regulatory & HIPAA Compliant
• Various reports including Claims Paid by Provider, CPT, Procedure
• Voucher Printing Including Explanation of Claim Denial
• Web Inquiry Capabilities

Important questions to ask from Health Claims Technology Vendor

• Elaborate the scope of implementation support that will be provided at the time of implementation?
• Is it possible to set up specific queues for manual pends relative to different priorities such as per provider specialty / service type (code range) etc.?
• Elaborate the steps of configuration to make claims adjudication system ready for production
• Please mention the configurable items in this regard. Can we have the data structure / relations of the master tables like benefit, contract, provider, network etc.?
• Please explain the key points / items that are expected as standard outcome of discovery process. How will the Software vendor support or get involved in the discovery process?
• How does the system support the update data related to member, provider and authorization? Are their standard utilities like DTS/Stored Procedures available to handle such regular update?
• Please elaborate the data migration strategy and steps involved during data migration / conversion. This should include the data elements that needed to be migrated to start LIVE operation.
• Is it possible to set up specific queues for manual pends relative to different priorities such as per provider specialty / service type (code range) etc.?
• What is the process of feeding EDI claims into the system? How is paper claims fed into the system?
• Please list hardware/software requirement details for the system.
• What is the typical implementation time?
• What is the percentage of auto adjudication possibility based on claims edits and time taken for auto adjudication? Does the system require any auto-adjudication sub-system like iCES etc?

Leading Health Claims Technology Vendors at a Glance