Claims Processing

The RIMS/Trizetto’s claim payment system delivers advanced functionality and technology, as it is the most comprehensive, technically advanced system available that automates the healthcare claims payment process, including:

Plan Administration
Claims Entry
Claims Inquiry
Claims Processing
Duplicate Claim Editing Rules
Electronic Claims Receipt
Enrollment/Eligibility Processing
EOBs and Checks
Fund Accounting
Maintaining Accumulators
Provider Maintenance
Re-Insurance Tracking
Our state of the art claim processing system has modules specifically designed for referral tracking and medical management. It also includes programs to detect unbundling and provider fraud. In addition we have seasoned claim personnel trained in manual detection of potential fraud. RIMS automatically coordinates benefits when appropriate.
Claim Adjudication
The GISC claim system allows for both benefit and eligibility checks along with benefit determination. The edits built into our system allow us to:
Detect reasonable & customary abuse.
Detect Fraud.
Detect Physician overcharges.
Detect and avoid duplicate payments.
Identify services inconsistent with diagnoses.
Establish claimant status for COBRA, COB, retirees, students, etc. to comply with customers specific exclusions and overrides.
Verify eligibility, benefit plan,waiting periods, pre-existing condition provisions and timely filing limitations.
Interpret claimant, service and provider data to determine service eligibility.
Provide a variety of reports to help the customer analyze their plan using service provider and ICD-9 code data.

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