| Claims
Processing Modules |
| |
| An
overview of claim processing using Paragon21 |
| |
|
Paragon21
automates procedures, beginning with the verification of
eligibility and ending with the generation of Cheques, remittance
advises, and/or correspondence.
This
section provides an overview of the highlights in the procedure
for processing a claim using Paragon21.
|
|
Among
other things, Paragon21 automates the procedures for:
 |
Registering
claims.
|
|
Verifying
eligibility.
|
|
Maintaining
a history of past benefits.
|
|
Mapping
procedure codes to benefits.
|
|
Comparing
charges to Reasonable and Customary charges.
|
|
Identifying
duplicate charges.
|
|
Calculating
payable benefits.
|
|
Corresponding
with claimants.
|
|
Corresponding
with service providers.
|
|
| Significant
Strengths |
|
|
Provides screens that
follow the logical workflow for processing Hospital (HC21 form)
or Ancillary claims (Fund designed form).
|
|
Collects and maintains
data in an on-line, real-time eligibility database.
|
|
Allows the user to
log and control the mail count as new claims are received.
|
|
Allows an alphabetic
search for claimant or dependent eligibility records using only
the first few characters of the last name and/or other information
(member number etc.)
|
|
Simplifies the procedure
for locating a claimant record and the claimant’s historical
information.
|
|
Streamlines the procedure
for entering and processing a claim.
|
|
Provides system responses
(edit/validations) when additional information is required from
the assessor.
|
|
Provides on-line access
in every phase of the claim processing activity including access
and validation with: Surgical Codes, DRG codes, Medical Benefits
Schedule, MIMS, ICD-9 codes and Providers contracted items.
|
|
Allows automated random
selection of claims for auditing and quality control.
(The system places the claims in ‘suspended’ mode until
they are approved and released by a supervisor and/or manager.)
|
|
Provides log reports
and on-screen information that graphically represents the amounts
paid between the incurred date and the paid or completion date.
|
|
| Registering
a Claim |
|
Paragon21 allows the users with the appropriate security level to
log claims. With this
arrangement, one or more persons can be registering claims while
others are processing claims.
When a member number
is not known, you can search by the name or part of the name and
an alphabetical list of members can be displayed.
On the Claim Log
screen, the user specifies the type of Claim (e.g. Hospital, Medical
or Ancillary). This
causes a screen to be displayed that allows the user to enter information
into the system in the same order as it appears on the claim form
(when possible).
|
| Claim
Format |
|
After the claim type is identified, the claims format (e.g. HC21
form for Hospitals) Benefit Line Input screen is displayed where
the user can:
|
Enter information in the same order as it appears on the
Claim form received from the provider. |
Once the user
has entered the information, the system:
|
Automatically maps the procedure code with the appropriate
benefit.
|
|
Automatically accesses the appropriate benefit pricing information,
Reasonable and Customary amounts, and benefit calculation specifications.
|
|
| Coverage
History Display |
|
From the claimant’s record (when there are benefit exclusions or
irregularities), the system displays a coverage claims history record
containing a breakdown of the coverage and limits available to the
claimant.
|
| Condition/Episode
History Update |
|
The Condition (episode) History Update screen allows the user to
describe the episode and assign an ICD-9 /ICD-10 Diagnosis and/or
DRG Code to the Claim. If
the diagnosis or DRG Code is not available, the user can select
the option to display a list of diagnosis and DRG codes.
The assignment of
a condition/episode codes allows the user to:
|
Group all charges related to a certain condition/episode
together. |
|
Generate reports sorted by condition/episode.
|
|
| Benefit
Limits |
|
Based upon the claims history, the Limits Inquiry screen displays
the Limits available for each person in the membership and when
additional funds will be available based on the type of cover.
In
addition, the user can specify whether the benefit is assigned and
whether the claim is for a pre-treatment estimate. When a pre-treatment estimate is processed, the system performs
the same calculations as it would for a claim but the system generates
a Pre-Treatment Explanation of Benefit form without an accompanying
benefit cheque.
|
| Provider
Identification |
|
Once the claim is
registered during the processing cycle, the provider associated
with the claim can be identified.
This procedure is the same whether or not the provider is
participating in a provider contract arrangement.
Entering the provider’s
registration number can identify an exact provider record and type.
If the exact information is not available, a list of providers
can be displayed by entering partial information, such as the first
few letters of the provider’s last name, type of provider and postcode
or Suburb. From the list of providers, the correct provider for the claim
can be selected.
When several providers
use the same company number (e.g. Medical Centres), the individual
provider can be identified by name, telephone number or address.
|
| |