Claims Management

Data Marshall Claims management encompasses the entire claim life cycle for their clients.

A key offering of Data Marshall is the Claims Adjudication services that we render for Insurance companies, Health plans & Third party administrators (TPAs). Data Marshall performs claim data entry, pre-adjudication edits, claims adjudication and re-pricing. We process travel claims, HSA claims, consumer driven health claims, encounter claims and RX invoices for our partners.

Verification is conducted for benefit plans, provider networks, physician referrals and provider matching. All family and individual deductibles and pre-existing conditions are verified.

Features

  • Manual adjudication of claims, as well as basic edit fixing.
  • Claims received on a daily basis and processed within a TAT of 24 hrs.
  • Claim-level analysis with respect to group/provider specific payment guidelines while following the service specific contractual terms before it is approved for the payment.
  • 360 degree analysis of the claims, in addition to a thorough review of claims processing & payment rules.

Approach

  • Edit Review
    1. Focus on the specific claim.
    2. Fix the reason for auto adjudication rejection.
    3. Verify out of pocket expenses & fee schedules.
  • 360 Review
    1. Focus on Inter-linked billed claims Ex: Primary & Assistant surgeon, Mother & new born.
    2. Review Benefits & billing procedures.
    3. Member & dependent eligibility verification.
    4. Medical necessity review.
  • Value Add
    1. Focus on a group of claims in relation with Member & Provider.
    2. Verify Billing for Carve outs.
    3. Check for fraudulent or inconsistent billing practices.
    4. Alert the insurance carrier of the trends observed, and seek further inputs.

case studies

Claims Adjudication for a growing TPA located in Wisconsin.

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Claims Reconsideration for an Established IPA in East coast.

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