Members Management

Members Database

Cover/Product Database

Group & Individual Contribution Billing

Agency Administration Module (Optional)

Customer Service Notes System

Correspondence Module Features

Claims Processing Modules

Claims System Versatility

Claims Administration & Assessment

Claims System Summary

Reasonable & Customary Charges

Electronic Claims Processing

Dental Claims Module

Pharmaceutical Processing Modules

Claim Adjustment & Cheques Cancellation

Cheques & Remittances Advice

Report & File Generation



Claim Administration and Assessment
Performed in a fully automated, on-line, real-time mode
Paragon21 Claims Modules performs claims assessment in a fully automated on-line, real-time mode.  The assessment process pulls together all pertinent information to perform the benefit calculation.
Significant Strengths  


Supports alternate care delivery systems including Provider/Hospital/Medical

Assesses a broad array of covers and benefit options including hospital, medical, dental, optical, well being therapies and non-PBS pharmaceutical claims.  

Provides base system security, which allows Health Funds to control and limit access to inquiry screens, update functions, databases, and members’ information.  

Provides separate screens for registering/login a claim and processing a claim.  

Automates eligibility and coverage verification.  

Flags a warning message when the charge appears to be a duplicate of a previously submitted claim line.  

Processes ‘per cause’ benefits.  (The system automatically calculates the benefit based upon the number of occurrences or services.)  

Accepts unlimited line items and unlimited provider/s on a single claim.  (The system processes an infinite number of claims for one individual on the same day.)  

Supports multiple Reasonable and Customary (R&C) tables of charges.  (The system automatically verifies submitted charges against the R&C tables.)  

Supports and manages complex benefit tables so claims can automatically be assessed.  

Allows a claim supervisor/auditor to randomly select claims for auditing.  (The system places the claim on hold until the supervisor releases it.)  

Eliminates the need to memorise or look up clumsy codes.  (The system automatically determines the benefits based upon the procedure code provided on the claim form.)  

Bulk payment processing provides the ability to combine multiple payments for the same provider on a single cheque.  This provides savings on postage and supply costs plus eliminates much of the time spent working with multiple cheques.



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