Claims Adjudication

Sunknowledge has been a pioneer in the claims process outsourcing arena, with proven demonstrable experience in insurance claims adjudication. We implement procedures and systems that are HIPAA complaint, to process and adjudicate medical claims. Our customers are attracted to our remorseless pursuit of quality (we offer 99%+ accuracy at claims level). Our processing timelines comply with CMS guidelines. Sunknowledge claims adjudicators are trained in several industry standard claims adjudication software and can adapt to any claims adjudication system within a short period.

Highlights

  • Verification of all keyed fields in case of claims that are not submitted electronically
  • Determination of member eligibility and coverage
  • Primary insurance verification
  • Determination of timely filing limit of claims
  • Confirmation of provider status (participating / non-participating).
  • Checking authorization notes for instructions and applying authorization status to claims
  • Identification of duplicate / corrected / interim / final submissions
  • Determination of DRG
  • Apply case-rate / per diem to services within the purview of the case-rate / per diem contract
  • Determination of correct allowable
  • Ensuring that co-pay, coinsurance, deductible and OOP are accurately
  • Calculated and applied as per the benefit plan
  • Use of appropriate remark/adjustment codes
  • Real time audits
  • Customized reporting
    • Inventory Report
    • Quality report
    • Production report
    • Pend report
    • Skip Report

Are You Looking for streamlined medical billing assistance?

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