Sun Knowledge Inc. delivers actionable support with competent solutions for healthcare payers. We have developed tailored solutions that help insurance companies and TPA’s optimize their provider engagement priorities. Our resources are experienced and make sure that all your priorities with patient/provider details are well managed and you are able to optimize the same in the best proportions.
Database and Data Loading Support Services
Sun Knowledge handles data loading processes and manages Eligibility, Capitation, Pharmacy, Lab, MMR (measles, mumps and rubella), MOR (Medication Occurrence Report), MAO (Medicare Advantage Organization) Claims and ‘Gaps in Care’ data files.
Our DB personnel run validation checks to determine data sanctity, sanitize the data as per requirement, and finally move the sanitized and processed data to the client’s production servers.
Benefit Building Process Support Services
This claim adjudication process consists of several activities such as grouping of preset CPT/HCPCS based on the services, defining copay/co-insurance against the services based on plan SOBs (Schedule of Benefits), setting up TrOOP (True out-of-pocket cost) and benefit limits, hospital admission rules, tier utilization rules, special rules (e.g. POS based copay), excluded services, and so on.
Care Plan Process
Available in English and Spanish, we regularly carry out patients’ profiling and health risk assessment based on available health records and medications history, assigning of tiers to patients based on the assessments, reaching out to patients to obtain the most recent health condition, complexity profiling, determining and setting up care plan goals for better health outcome, medication reconciliation, discussing the care plans and agreement with patients’ PCP, sending out the care plan to the patients and PCPs, post-hospital discharge follow-up and hospital discharge & re-admission management.
Provider Verification Services
We reassess healthcare providers on continued appropriateness for practicing in the institution. Provider details are collected by contacting provider offices, with regular follow-ups in case no response is received within the stipulated time. This is a recurrent service, often conducted twice a year, during the second and fourth quarter of a calendar year. Our provider credentialing services using SQL involves using a set of pre-defined SQL queries that are used to generate reports. The reports are generated as and when needed by our credentialing team to aid in following-up with Providers to obtain validation responses. We also assist in scheduling appointments for elderly patients for different precautionary measures such as Mammogram Screening, Diabetic Eye Exam etc.
Q-Auth. Letter Generation (Front and Backend) Services
Creating various CMS-approved letter templates (intended for members/providers) in member auto-communication platform with various dynamic fields/variables, and mapping them with the database to be pulled up and auto-filled before sending the letters out to their intended recipients.
Q-Auth. Data Entry (SMG) Services
Our Prior Authorization services also include entering the ICD-10, CPT/HCPCS, POS (Place of Service), Reason for Service, level of urgency and other such data in the authorization portal, reaching out to providers’ office to collect missing information, obtaining necessary medical documentation and uploading, searching appropriate guidelines (InterQual Guidelines/Milliman Guidelines/Healthplan specific Guidelines) for the service requested and uploading them for the final medical review by the Payer.
Eligibility Verification Services
We provide extensive support in verifying the eligibility for members to log into different health plan portals. Members’ eligibility and related files received from their health plans are split and renamed during the ‘Eligibility Inload’ process. This process involves converting different files into a common proprietary format and involves running an application which is based on pre-defined SQL queries. Through this process the Option Code or Benefit Information of the health plan, or LOB, is updated.
Customer Support Services
Sunknowledge excels in providing scheduling support for members. We address questions from members regarding their appointments, authorizations and prescription refills, check referrals on file and if not, schedule appointments with doctors or follow up on pending requests, follow up on members lab reports and medical records, and remind them of their upcoming appointments.
For Payers, we address queries from members, Providers and hospitals regarding the status of the claims submitted by them, guiding them with further actions to be taken for claims re-submission or re-processing. We also do electronic data entry on claims for professionals and facilities if they have submitted paper claims, check member eligibility and updating the member’s records as necessary.
Claims Encounter Services
We expertly review claims that have been rejected by clearing house for various reasons. After review, if any claim is found to be wrongly adjudicated then we resubmit it, or archive it.
Report Submission Services
We follow a highly flexible and versatile reporting system for our customers. We run queries in SQL database and prepare plan performance summary reports on different criteria at different intervals in the approved file format. The reports include, but are not limited to, UM (Utilization Management) Summary Report, UM Denial, Appeal, Approval, Cancelled, Reopen, Referral, Auth Notification, Hospital Admission, Acute Inpatient Report, Rehab Report, Sub-Acute SNF Report, Transplant Report ER Visit Report, ESRD Report, Provider TAT, CMS ODAG, LAP, OON, SNP Report etc.
Digitizing Provider Contracts
We analyze different contracts between Health Plans and Providers, and summarize the contractual rate agreements for different services between two parties. The contractual data include Contract Effective & Termination Date, rate and capitation for Commercial/HMO/Exchange/Medicare/Medi-cal, Dual, Modifier rate, POS rate etc.
Inpatient Coordination Services
These services consist of a bunch of crucial services such as verifying the eligibility for all members, faxing hospital records/discharge summary/progress notes to IPA offices, scheduling appointments for Specialty Care, following up with hospitals and SNFs, dialysis appointment transportation through the health plans, uploading medical records from faxes into the EMR and handling calls for inpatient authorization status.
FDR Attestation Services
We also provide full support in validating FDR Attestations (First Tier, Downstream and Related Entities) from all Payor contracted providers (non-employed) for completeness. The information checked and verified include, but not limited to, FDR name, address, training date, signature and signature date.
Schedule a discussion to know more about our special services. We are right here to demonstrate the same to you without any hesitation.