I-CAPS

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LET US SHOW YOU HOW TO TRANSFORM YOUR CLAIM PAYMENT SYSTEM
INTO AN INTELLIGENT SOFTWARE PROCESS


HIGHLY INTELLIGENT CLAIMS PROCESS

A claims administration solution that transforms a claims payment process into a highly intelligent cost containment solution. Smart processes that think and make the right decisions. A responsible reimbursement system for pricing and editing claims to detect improper coding by physicians. Over 130 clinical coding rules are seamlessly integrated within one common coding compliance framework. Integrating payment rules and correct coding policies to help to contain the rising costs of health care.

COMBINING SMART SOFTWARE AND DATA

I-CAPS is an information management solution that combines proven software with pricing, coding policies, rule sets, and databases into one complete fully-integrated knowledge-based process. Proven fully functional software for claims processing and clinical coding edits that can reduce administrative costs and improve internal processes. It combines intelligence with defensible clinical data base rule sets. A complete information solution from one reliable vendor with smart software plus knowledge bases that have been designed to work together within one integrated process. I-CAPS eliminates the need to purchase obsolete UCR pricing data and the need to purchase separate clinical edit processes, sparing you the extra expense of software integration.

FULLY INTEGRATED CLAIMS ADMINISTRATION

I-CAPS is an administration system that supports the complex delivery models within managed care. It combines smart software with defensible coding conventions and policies for a fully integrated knowledge-based process. I-CAPS represents a comprehensive foundation that automates all key operational areas within the claims administration environment including membership and enrollment, mailroom, claims adjudication, provider network management, utilization review, customer service and compliance. It represents an architecture that ties all pieces of a modular system easily together into one common process to elevate the claims process to new heights. I-CAPS allows administrators to design, build, and administer plan models that dynamically respond to plan sponsor needs and the continuous changes within health care.  Thus, allowing them to take advantage of the latest communications protocols.

DEFENSIBLE PAYMENT POLICIES

The pricing and coding methodologies utilized are fully defensible since they have been developed in accordance with methodologies recommended by the National Correct Coding Initiatives and the Health Care Financing Administration's Bureau of Program Operations. Coding conventions conform to those defined in the American Medical Association's (AMA) CPT Manual, in national and local policies and edits, in coding guidelines developed by national societies, in analysis of standard medical and surgical practice and in review of current coding practices. It can be used to support both Medicare and private payment environments and designed to detect improper coding and eliminate inappropriate reimbursement in physician bills.

MANAGED CARE CAPABILITY

Fully integrated managed care components to address all forms of integrated health care delivery including, HMO, PPO, POS, as well as Medicare and Medicaid programs.

  • Ability to handle triple option plams
  • Capitation payments based on gender age bands
  • PPO network and pricing
  • Full UR integration
  • Multiple referral option
  • Provider measurement
  • Clinical encounter management
  • Provider channeling

FULLY FUNCTIONAL SYSTEM

I-CAPS is comprised of a totally-integrated series of online, real-time program functions which address the entire claims processing cycle:

  • Mail Room Registration
  • Claims/Encounter Entry
  • Eligibility and Enrollment
  • Electronic Data Interchange (EDI)
  • Coding Compliance
  • Billing and Accounts Receivable
  • Automatic Claims Adjudication
  • Flexible Claims Denial and Pending Mechanism
  • Coordination of Benefits (COB)
  • Automated Pricing
  • Anesthesia Pricing
  • Customizable Explanation of Benefits (EOB)
  • Automated Correspondence
  • Claims Management/Customer Service
  • Payee Accounting
  • Comprehensive and Flexible Reporting

I-CAPS processes claims for all lines of insurance including:

  • Medical/Surgical Behavioral Health
  • Dental Disability
  • Prescription Drug Vision

REPLACES OBSOLETE AND MEANINGLESS PRICING OF CLAIMS

Built in pricing utilizing a resource-based relative value scale (RBRVS) fee schedule that reflects the physician resources required to perform the service. This methodology was adopted by Medicare in 1992 and since then by most major payors for payment of fee-for-service medicine. This system is replacing the previous reasonable charge mechanism of actual, customary and prevailing charges and fast becoming the standard payment methodology within the health care industry.

OTHER KEY FEATURES OF I-CAPS

  • EDI - Batch Adjudication
  • Interactive claims entry allowing for multi-line entry for UB-92 or HCFA 1500 claims.
  • Batch with an On-Line Adjudication Process
  • On-Line Messaging Windows
  • Claim Log and Eligibility Log Files
  • Problem Claim Routing System
  • Automatic Letter Follow-Up
  • Data Management for Analysis and Reporting

FAST AND EFFECTIVE CLAIMS ENTRY

The claims entry process is a single-screen process which incorporates advanced design features which combine ease of use and entry speed. The I-CAPS design achieves a perfect balance between a multiple-screen entry through the use of a unique windowing approach to provide high levels of claims throughout.  I-CAPS entry process represents a logical and highly-organized claims workflow and integrates pricing, network management, editing and adjudication in one sequence. A multi-line entry screen provides for up to 48 claim service lines and claims can be adjudicated on either an interactive or batch basis. Pop-up windows are used throughout the process to provide for retrieval of necessary information. Single key strokes allow for the handling of special situations as well as single key interrupt capability throughout the entire process.

FULL CONTROL THROUGH MANAGED AUTOMATION

Although I-CAPS is a fully adjudicating system, the claims reviewer maintains complete control throughout the entry and processing of a claim. The operator can pend a claim, deny a claim, override a claim and make a number of action decisions based on the claim information supplied and the system interaction with the advanced knowledge databases. Decisions that must reside within the computer remain within control of the system. However, the operator guides and manages the process and has the ability to vary from the cycle to handle unexpected conditions and exceptions.

A CONVERSATIONAL SYSTEM

I-CAPS provides a user-friendly conversational interface between the system processes and the user. The messaging system incorporates on-line help text and continually informs the user regarding the processes taking place. The conversations between the system and the user provide guidance and allow for questions and answers. The system tracks and informs as it processes.

TOTALLY AUTOMATED ADJUDICATION

I-CAPS lets you review, enter, process, approve, hold, release, pay, pend and deny claims in an automated yet managed fashion:

  • Automatic referral application
  • Automatic preferred network pricing and discounting
  • Automatic benefit calculations based on individual plan provisions, appropriate deductibles and co-payments
  • Handles all methods of U&C pricing including MDR, HIAA, RVS and RBRVS
  • Automatic penalty calculations based on UR rules
  • Automatic eligibility tracking and checking which can be tailored to suit a plan's needs
  • A duplicate claims checking mechanism in which the Administrator selects the criteria for the duplicate claim checking process
  • Features which allow you to manage the claims processing flow based on plan design and limits

PLAN FLEXIBILITY

I-CAPS is designed to handle multiple plans and multiple lines of business with virtually no limitations regarding the plan design and benefit types. Due to the wide flexibility of the system, an administrator can tailor plan features according to plan needs - not the system's. Benefit structures are easily defined and loaded in the system through a simple table-load process.  When your plan benefits change, the administrator can easily make the system changes needed without the requirements of programmer intervention.

CLIENT-SERVER IMPLEMENTATION

I-CAPS utilizes the IBM AS/400 client server technology and relational database model. The I-CAPS data base architecture includes a case management design which allows for the implementation of an episode of care analysis and payment system.

COMPLETE CONTROL AND SECURITY

Access of all of the functions within I-CAPS can be secured through the security administration system. I-CAPS allows for the controlled access of all system functions and the administrator can establish user-security profiles with variable levels of authority. The user-security set-up establishes:

  • Sign-On Information
  • Passwords
  • Correspondence Identifications
  • Claims Processing Classification
  • Clearance for Procedures
  • Security Levels and Limits

BUILT-IN COST-CONTAINMENT FEATURES

The system is designed to accept the expansion of plan features that include cost-saving forms of health care. New billing methods and peer-review features to accommodate:

  • Full Integration of Claim Audit
  • RBRVS Pricing and Editing
  • Preferred Hospital Billing Arrangements
  • PPO (Preferred Provider Organizations)
  • Multiple Reimbursement Arrangements
  • Concurrent Review Programs
  • Pre-Authorization Programs
  • Mandatory Second Surgical Opinion
  • Stop-Loss Reporting
  • Auto Hold for Review Mechanism

AUTOMATIC DETERMINATION OF ELIGIBILITY

Auto eligibility determination is built within the claims process. On-line eligibility maintenance and inquiry capabilities add efficient access and allows the user to add, modify or view information regarding employee/dependent eligibility. If an employee changes groups, locations, or terminates and is rehired, all previous eligibility information is maintained.

PENDING AND DENIALS

The I-CAPS system allows for the pending or denial of a claim at any point during or after claim entry. The administrator can establish appropriate pending and denial codes along with their associated letter text and these codes represent the mechanism which triggers the automatic generation of letters and/or special text on the EOB's. Pended claims can be easily released and do not require any re-keying of data.

INTEGRATED WITH ACCOUNTING SUBSYSTEMS

I-CAPS supports all major accounting needs of a Fund Administrator. Online updating from the check production subsystem to a check reconciliation subsystem interface to plan funding.

ADDRESS THE ENTIRE CLAIMS PROCESS... START TO FINISH

The I-CAPS system integrates a broad base of functions into several components. The components or modules, as they are called, utilize a consistent set of software design standards, which provide the highest possible levels of compatibility, reliability and maintainability. Modules are configured, priced and licensed based on a clients particular needs.

PAYMENT ADJUSTMENTS

The post payment adjustment function is used when an incorrect payment was made to a subscriber or a provider. One simple step to update all accounting and claim records with complete audit trail. This provides an automatic process for updating of the accumulators. The process ties back to the original claim and creates the necessary adjustment records and replacement claim lines as required.

COMPLETE CLAIMS MANAGEMENT AND CLAIMS AUDIT

I-CAPS is designed to allow the user to completely manage the claims status; tracked and maintained through our unique logging system:

  • Receive Claim Adjust Claim
  • Enter Claim Reconcile Claim
  • Hold Claim Deny Claim
  • Pre-Certify Pend Claim
  • Review Claim Delete Claim
  • Release for Payment Undelete Claim
  • Manual Override

HOLD FOR REVIEW

A claim, once entered can be routed automatically through to the payment process or it can be held to await further review. The system provides a hold mechanism, which based on tailorable settings will automatically prevent the claim from being paid until it is reviewed and approved. The claims management hold features can be based on clinical coding audits, dollar limits, claim cycles, stop-loss limits and selected security options and operator profile settings. Review reports are automatically printed and routed to individual auditors.

MAIL ROOM/PRE-REGISTRATION

A mail room module is available which allows the logging in of claims prior to the claims examination process. Claim folders and documents can be easily managed and claims for a particular subscriber can be consolidated, eliminating many unnecessary steps and speeding up the claims process.

ONLINE NOTES

An online note system is standard and allows for the creation of an unlimited amount of notes and text which can be associated with each unique plan; provider or dependent. The notes can be displayed automatically during the claims process. Notes are available for providers, subscribers, and individual family members. The system automatically maintains a complete and detailed record of every claim which has been entered into the system, paid or not paid, along with a claim log that tracks all changes to the claim disposition and all key claim events. This valuable claims repository can then be warehoused into meaningful information packets for measuring plan performance.

CHECK AND EOB PRODUCTION

When claims have been approved for payment they are immediately available for payment. The claims administrator can request a check production run and pay a group of claims within a plan by indicating the operator and the fund. Payments can be combined by subscriber or provider and then consolidated for block payments. As a result, the I-CAPS system minimizes the number of checks necessary for printing. An Explanation of Benefit (EOB) is produced which provides a complete explanation of the claims amounts submitted, considered, denied and paid. The format is subject to a number of tailoring options which customizes the EOB to a plan's special needs.

The check production and EOB production module provides for complete management and can:

  • Reprint Check Information Maintains an Interface to the Fund Accounting Module
  • Print Individual or a Group of Checks Check Reconciliation 
  • Maintain Check Numbers Updates the Check Register
  • Updates the Fund Balance Checks can be split for split payment and can be sent to an alternate payee when required.
  • Interfaces in the check process allow for the transmission of check data (InstaMed) for electronic payment on check printing (ABF)

ONLINE CORRESPONDENCE GENERATION

I-CAPS provides a centralized correspondence generation system, which can be entered from any point in the system to send letters to providers, insurance companies, and subscribers.

REPORTING MODULE

I-CAPS captures detailed data about every aspect of every claim: the medical condition, treatment, insured, provider charges and all special elements of data related to specific benefits. A series of predefined reports with built-in flexibility are available which can assist in tracking and controlling costs and managing fund resources. These reports have been designed to analyze plan performance, payment history and utilization.

TOTAL BENEFIT ADMINISTRATION

Each of the I-CAPS modules can be easily integrated within one master framework to perform the advanced and specialized functional process for dental, medical, prescription drug, disability, and mental health. These subsystems have been designed to take full advantage of the AS/400 relational database. Each module uses the I-CAPS relational database and I-CAPS process and avoids redundancy and duplicate processes.

EASY TO INSTALL

On-site installation management coupled with a parameter-driven design assures a quick startup.  When computerized history is available, a customized claims history load program can be provided which simplifies the crossover and eliminates the need for operational startup at plan anniversary date.  Plan models can also be set up and copied, eliminating much keying and setup time in the multiple plan environment.

EASY TO LEARN

Your claims examiners do not have to be insurance experts to use I-CAPS. The claims process screens, although standardized, can be tailored to accommodate the uniqueness of each individual benefit. A windowing system is used during the processing of a claim, which creates a logical and step-by-step sequence. When a new examiner first uses the system, the entry sequence can take a more direct path and would involve fewer steps. In other words, it gives the claims examiner the option to select the claims processing sequence best suited to his/her experience level and individual preference.  It educates your user through its extensive database of knowledge.

EASY TO USE

One single keystroke interrupt capability exists to allow a processor to leave the claim processing function in the middle of a claim to perform a different set of online tasks such as:

  • Letter Generation 
  • Look-Up/Alpha Scan 
  • Patient Inquiry 
  • Billing Question 
  • Provider Look-Up With No Loss Of Data

EASY TO MAINTAIN

A flexible approach for managing the plan benefit parameters which gives the Plan Administrator complete control over the benefit database.  That approach is carried through for the data management of the system codes, employee, payee, claims, message and pricing tables.


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