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

 

 

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 claimantís 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 Ďsuspendedí 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 claimantís 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 providerís 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 providerís 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.  

   
 

For more information or to organise a demo of the Paragon21 Package,
Please contact projectmanager@paragon21.com.au
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