Medical and Prescription Drugs Claims Administration Overview

At Sun Knowledge, we give special emphasis on claims administration because we know it requires a high level of expertise, patient centric processes and attention to customer service. Through our services, we guarantee to fulfill all related objectives which a Health firm or TPA aspires for. The important ones are:

  • Provide eligible employees, retirees, COBRA continuants, and their eligible dependents with a quality, affordable health care program
  • To minimize disruption for current health care program members
  • To ensure costs are managed effectively by continuing to take advantage of enhanced cost and utilization management opportunities available in the marketplace while maintaining or enhancing quality
  • Provide enhanced communication and enrollment services for benefits
  • Responsibly manage taxpayer dollars

Medical Claims Administration

  • When it comes to Medical Claims Administration, we give you competitive advantage in the form of:
  • Provide and/or make available necessary, appropriate, and high quality medical care to each member.
  • Provide high quality, efficient program administration and services.
  • Provide specific performance guarantees which include financial penalties for non-performance.
  • Meet with the appropriate employer’s management staff to review the offeror’s health care program, present the proposed communication material, and jointly establish a preliminary implementation plan, open enrollment program, and schedule.
  • Furnish to each employee and retiree a hardcopy or electronic copy benefit booklet outlining and defining all covered services, limitations and exclusions, procedures for receiving services, schedule of benefits, COBRA, HIPAA, and other ERISA plan information requirements.
  • Furnish sufficient copies of detailed summary of benefits, limitations and exclusions for each plan offered, and network directories for each eligible employee and retiree during open enrollment periods.
  • Provide an identification card to all covered members prior to the effective date of the program.
  • Provide a detailed renewal underwriting analysis and detailed utilization data comparing current and prior years.
  • Provide a single point of contact responsible for quality control, resolving problems, and expediting services related to the overall performance of the contract.
  • Maintain a local or toll-free customer service number for covered members.
  • Provide a systematic procedure for appeal of claims, including providing resources for external reviews.
  • We maintain systems and procedures necessary or appropriate for the operation of a reasonable and appropriate Utilization Review.
  • We provide Claims Processing/Payment Services and systems and procedures, for the appropriate adjudication and payment of all claims for payment submitted to Plan.
  • We administer a coordination of benefits program on behalf of you.
  • We recommend actions for Government Program Reimbursement such as holding such claim in a pending file, or shall turn the claim if the claim becomes involved in legal action or proceedings under such laws.
  • We provide assistance in administration of a grievance and appeal mechanism for Beneficiaries.
  • We help in complying with Government Regulation with the requirements of any applicable state or federal statute, ordinance, law, rule, regulation, or order of any governmental or regulatory body having jurisdiction over the Plan.
  • We maintain professional liability insurance coverage to insure against any claim for damages arising out of or by reason of any acts or omissions directly or indirectly in connection with participation in Utilization Review, Quality Improvement or Provider Contracting Services.
  • We monitor plan eligibility for dependents, retirees, and retiree dependent; automatically notify members and terminate those no longer eligible for coverage.
  • We will accept enrollment data via facsimile transmission, in lieu of using an online enrollment system.
  • Our team member will be available for in-person enrollment meetings, providing all appropriate hardcopy enrollment materials.

Prescription Drug (PDP) Claims Administration

  • Apart from the above mentioned Medical Claims Administration services, we also provide interested party with our extra ordinary Prescription Drug Claims Administration. Here, the possible benefits include the following:
  • We have networks of Participating Pharmacies for assistance along with Mail Service Pharmacy.
  • We perform claims processing services for Covered Drugs dispensed by Participating Pharmacies, Mail Service and the specialty pharmacy.
  • We perform a standard concurrent drug utilization review (“DUR”) analysis of each prescription submitted for processing on-line by a Pharmacy in order to assist the dispensing pharmacist and prescribing physician in identifying potential drug interactions, incorrect prescriptions or dosages and certain other circumstances that may be indicative of inappropriate prescription drug usage.
  • We provide specialized prior authorization (PA) services according to your needs.
  • We process initial “claims for benefits” for Member Submitted Claims and PA requests consistent with the ERISA claims rules.
  • We have Call Center facility which is capable of providing 24-hours a day, 7-days a week toll-free telephone and Internet support.
  • We also provide clinical, safety, adherence and other like programs.
  • We follow stringent Reporting format which can happen on weekly, monthly and annual basis.
  • At no additional charge, we will provide regular prescription claims data in their own standard format(s) for disease management, flexible savings account and other “payment,” “treatment” and “healthcare operations” purposes (as defined under HIPAA).
  • We provide audit for prescription management services on an annual basis (unless additional audits are warranted).
  • We draft initial documents such as the summary plan description, Identification Cards, Enrollment Kits, Covered Individual Reimbursement Forms and Certificates of Creditable Coverage as required under HIPAA.
  • We assist in complying with the requirements of any applicable state or federal statute, ordinance, law, rule, regulation, or order of any governmental or regulatory body having jurisdiction over the Plan.
  • We maintain professional liability insurance coverage to insure against any claim for damages arising out of or by reason of any acts or omissions directly or indirectly in connection with Utilization Review, Quality Improvement or Provider Contracting Services.
  • We monitor plan eligibility for dependents, retirees, and retireedependents; automatically terminate members who are no longer eligible for coverage.
  • We will accept enrollment data via facsimile transmission, in lieu of using an online enrollment system. Furnish sufficient copies of detailed summary of benefits, limitations and exclusions for each plan offered, and network directories for each eligible employee and retiree during open enrollment periods.
  • Our team will be available for in-person enrollment meetings providing all appropriate hardcopy enrollment materials.

For your entire claims requirement, contact us today!

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