ACS began designing and developing our own claim adjudication system in 1985. In designing our system, we wanted to make certain our expense tracking capabilities were flexible, understandable, and meaningful. The features described below allow us to process claims quickly and efficiently, while concentrating on ways to manage our client's health care expenses.
Eligibility - Once the specific parameters of your plan are loaded into our system, individual records will be established for each participant. Our claim system automatically checks date(s) of service against date(s) of coverage so benefits cannot be paid before the date of coverage or after coverage termination, even for COBRA participants.
Usual and Customary - Benefit determination will be made using Usual and Customary guidelines based on information provided by Medicode and updated semiannually. A norm of 85th percentile is loaded for Usual and Customary unless the client wishes a different level.
Pre-Existing Monitoring - Our system will display an alert for any claimant who may be subject to the pre-existing condition limitation. The examiner will then request medical records if necessary and an outside opinion is available through a peer review. All examiners are routinely audited by supervisors.
Claim Filings and Inquiries - A Benefit Submission Form is required only with the first claim each year. Once the required information is loaded into our system, we require only the itemized bills, name of Plan Sponsor and social security number of the participant. Our claims department is divided into teams. Each team is assigned specific clients and is responsible for claims processing and communication with plan participants and providers. Claim inquiries are handled directly by the claims examiner who processed the claim or the claim support personnel assigned to each team. We conduct internal audits of our examiners to monitor their accuracy and timeliness.
Coordination of Benefits (COB) - ACS makes every effort to identify claimants who have duplicate coverage. ACS follows the COB guidelines established by the National Association of Insurance Commissioners (NAIC). Other insurance information is automatically displayed on the screen during the adjudication process reminding the examiner that other insurance is available for the claimant.
Duplicate Claim Audit - Our claim system is designed to detect duplicate claims based on the provider identification number and type of service.
Claims Turnaround Time - The average claims turn around time for a "clean" claim is three to five business days. This time lag can be monitored by means of the Funding Invoice which shows the Incurred Date, Received Date, and the Posted Date of each claim processed for payment.
Verification of Benefits - ACS has designed "BeneFAX", a customized facsimile transmittal for benefit or eligibility inquiries. In addition, we are currently developing the required HIPAA EDI Transaction Standard for "Eligibility For A Health Plan" (also referred to as "270/271").
Subrogation - ACS has dedicated professionals who monitor claims which have been identified for subrogation. Subrogation permits the plan to recoup expenses that were caused by a negligent third party. ACS does not receive any of the recovery for the administrative work involved. Subrogation recovery services are covered under our administrative fee.
Home© ACS Benefit Services, Inc. [Update 12/01/2001]