Claims Management

Our adjudication and re-pricing solutions include membership eligibility and provider contract verifications, which are frequently required for claims processing. This is complemented by continuous claims assessments to verify that all entries are completely compliant with current standards.

Every year, millions of transactions pass through a technology system that must be reliable, secure, and user-friendly. Our data structure has been tested and proven successful over several years, and we focus on high accuracy and fast turnaround times for every transaction our clients send to us. Our data teams are familiar with the numerous norms and standards that are relevant to each state and county in the US.

Synthesis HealthSoft’s customizable platforms allow us to implement effective charge control methods depending on your business regulations, and we process charges for numerous specialties.

Daily reports with no pay, poor pay, and denials are addressed on a priority basis. Our goal is to keep you informed so you can make sound business decisions that will help you grow your company.  Our Quality Assurance team constantly audits data to ensure the best quality output.

Current auto adjudication rate: Professional 80% and Facility 60%

  • Claims data entry
  • Claims pricing/re-pricing
  • Claim Receipt and Data Capture
  • EDI/ANSI X12 837 Generation/OCR
  • 999 and 276/277 acknowledgements
  • Adjudication – Pre and Claim Adjudication (HCFA/UB/Dental/Vision)
  • Capitation processing
  • In-network and Out-of-network claims processing
  • Automated system engine that runs hundreds of rules to validate claims processing guidelines (e.g. eligibility, coverage, authorization, contract, duplicate, TFL, etc…)
  • Explanation of Benefit generation (paper/835)
  • Coordination of Benefit
  • Claims Post Payment Audit
  • Provider Grievances and Appeals
  • Credit balance/Refund initiation and adjustment
Salient Features
  • Built in work flow integration in all module
  • In built soft edits for data validation
  • High dollar review based on set limits
  • Linking of authorization/benefits to claims
  • Supports for Maximum Out Of Pocket including Family limits
  • Claims rules – 3 tiered –Medicare/Medicaid rules/plan specific rules
  • Integrates with Utilization Management and Member
Claims Audit
Our Claims Audit solutions are designed to help Healthcare Payers decrease or avoid inappropriate and inaccurate payments. Our business rule engines assist track correctness and identify issues before payments are made. These technologies are designed to cut billing expenses and identify coding problems. Our historical claim data is constantly running through our detection engine to guarantee all services are compliant with billing standards. Exceptions are discovered and directed through an exception management procedure.
Value Added Service
Outline the value-added services that synthesis can deliver in addition to the top three modules (member, provider claim management).
  • Premium Billing
  • DRG audit
  • Coding Audit
  • Claim re-pricing
  • Recovery Audit
  • HCC and RAF audit
  • HEDIS Audit
  • Leakage Reporting