 Claims processing is the core of payer systems. The eCAMS claims engine is flexible yet tuned for performance in the most demanding environments. Secure on-line Web access puts the power of managing your Medicaid or commercial payer processes in the hands of business staff, not IT. Easy to use and manage edit/audit and business rules features ensures the reliability of the claim data and that claims are processed in accordance with rules, regulation and law. Claim data is automatically validated against other integrated systems such as member, provider, reference and other systems as necessary. eCAMS implements an asynchronous model of claims processing using a series of system monitors and processing agents. Every claim adjudication cycle is broken into logical steps performed asynchronously.
eCAMS claims engine features:
- Claims pricing for institutional, professional, dental, long term and crossover claims
- Proactive fraud and abuse prevention with implementation of pattern detection rules in the rules engine
- Clinical editing with support for CCI edits and integration with external clinical editing tools such as Claim Check®
- Comprehensive mass adjustment functionality with features such as system initiated adjustments and impact assessment
- Powerful pricing engine with features to support numerous pricing methodologies, including DRG, APC and performance-based pricing
- Reimbursements for providers, including capitation and fee-for-service. Fee for Service Professional and Dental claims are reimbursed by fee schedule, by report and acquisition costs
- Capitated claim and claim adjustments for both individually and for large volumes of claims
- Reduces defects and increases accuracy in implementing claims business rules
- Greater insight into business operations and policy changes with features supporting auditing, reporting and analysis and version control
See also:
Benefit Plans Design & Implementation
Provider Self Service & Management
Member Management for Holistic Insight
Financial Integration
SOA Integration
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