Procedure of obtaining prior approval from the payer(insurance company) before the healthcare provider offers services to the patient.
Determines the amount of reimbursement that the healthcare provider will receive after the insurance company clears the dues.
UM is a process that evaluates the efficiency, appropriateness, and medical necessity of the treatments, services, procedures, and facilities provided to patients on a case-by-case basis.
Essential Value Adds
Ensuring that the events of the patient encounter are captured accurately, and the electronic health records properly reflects the services that were provided.
Credentialing process validates that a physician meets standards for delivering clinical care wherein the insurance verifies physician’s education, affiliations, licenses, certifications, training, malpractice and any adverse clinical occurrences.
Referral is the process of sending a patient to another practitioner (ex. specialist) for consultation or a health care service that the referring source believes is necessary but is not prepared or qualified to provide.
HEDIS® is a set of standardized performance measures developed by the NCQA to objectively measure, report, and compare quality across health plans.
Reconciling the payments received from the insurance payer to each individual claim. Once payments are posted, any secondary claims can be created and submitted.
Tracking and managing unpaid claims ensuring that no time is lost on pursuing every reimbursement possibility.