Claims Adjudication

MedSolutions is fully equipped to pay provider claims according to your specifications. Our sophisticated, flexible claims payment system allows for custom configuration of claims inload, adjudication, and payment processes.

We work cooperatively with claims payment departments to ensure that

• claims for procedures requiring pre-cert are paid only when the pre-cert process has been adhered to, and

• only the procedures that were specifically authorized (by CPT code) will be paid.

Data Interfacing

To facilitate the claims payment process, we are equipped to receive claims via paper or electronically for internal processing. Our preferred claims clearinghouse partner is Envoy, but we are equipped to handle additional interfaces if requested. Our claims EDI functionality is fully customizable, enabling us to integrate with our managed care client’s claims payment systems where applicable.

We receive electronic claims daily. They are automatically loaded into our claims payment system, QMACS (Quality Managed Care System), making them immediately available to our claims payment staff on-line for adjudication. Paper claims are also received and entered daily into the QMACS system.

Our claims payment system is a client/server-based application which is tightly integrated with the rest of our enterprise systems (pre-certification, provider contract management, etc.). This integration allows for strong data integrity which results in accurate and efficient claims adjudication and payment.

MedSolutions’ dedicated Information Systems staff has developed a collection of standard practices, procedures, and programs to make the entire communication process run smoothly.

MedSolutions Claims Adjudication Process

MedSolutions claims processing department functions highly efficiently based on established policies and procedures. All claims are processed within the time frame agreed upon by the healthplan and MedSolutions.

To reduce the possibility of payment errors, MedSolutions’ Finance department works closely with claims department by conducting quality assurance audits of each claims run.

All claims processors receive thorough training in claims processing procedures and in the claims requirements for each of our contracted health plans. Training is a continual process.

MedSolutions’ Claims department ensures prompt, efficient processing, adjudication, and remuneration of all claims received by MedSolutions. The department functions as a state-of-the-art information processing center to help our managed care partners reach their goals.

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