About Healthcare payers

Healthcare Payer organizations can benefit from PCH in their core business segments like member enrollment, Provider data management, claims processing, adjudication, analytics, storage, and communication.

In addition to member enrollment, Provider enrollment, and Provider data management, PCH is integral to the credentialing and contract management processes.

PCH supports the claims front-end process and produces clean claims for adjudication. In the adjudication process, PCH increases the auto-adjudication rate and makes payments more accurate.

PCH provides unified communication services at each stage of the process to update all parties on claim status and facilitates the storage of documents for future reference.

PCH's data analytics solution reduces exposure to fraud, waste and abuse throughout the claims lifecycle. Additional mobile app solutions simplify the claims process and increase Member and Provider satisfaction by enabling easy access and full visibility.

How IT Works

Member Enrollment Services and Healthcare Exchanges

  • Quote to card | Secure, web-based plat form for effectively managing healthcare enrollments and documentation |Member Installation

Provider Data Management

  • Credentialing | Contract management | Installation

Claims Processing

  • Mail Room- Sorting, Scanning, Data Capture | Platform (PCH) - Single channel for Paper & EDI | Data verified & pre-claim edits → Clean-claim | Real-time notification & visibility of any deficiencies & status of claim | Client-specific validation

Adjudication

  • Clean claims | Business Rules Integration | Pre Edits | Authorization | Contract Fee Schedule | Remittance/Payment |Explanation of benefits / liabilities mailed | Exception management | E-presentment of denials

Payments

  • Paper or electronic transactions and Lockbox (Payment Hub) | Manage reports | Adjustment | Daily deposit log | ERA conversion

Unified Communication Services

  • Presentment | iCRM |Live or Virtual Agent Outreach & Follow-up | FAQ Print & Mail - Claim,EOB, Correspondence|Alerts & Notifications

Storage/Archival

  • Active Record Management | FlexiblePhysical Delivery Schedule |Scan on Demand |Online Ordering | Inventory Control

PAYER

PAYER

Provider Data Management

  • Credentialing | Contract management | Installation

Claims Processing

  • Mail Room- Sorting, Scanning, Data Capture | Platform (PCH) - Single channel for Paper & EDI | Data verified & pre-claim edits → Clean-claim | Real-time notification & visibility of any deficiencies & status of claim | Client-specific validation

Adjudication

  • Clean claims | Business Rules Integration | Pre Edits | Authorization | Contract Fee Schedule | Remittance/Payment |Explanation of benefits / liabilities mailed | Exception management | E-presentment of denials

Payments

  • Paper or electronic transactions and Lockbox (Payment Hub) | Manage reports | Adjustment | Daily deposit log | ERA conversion

Unified Communication Services

  • Presentment | iCRM |Live or Virtual Agent Patient Outreach & Follow-up | FAQ Print & Mail - Claim,EOB, Correspondence| Alerts & Notifications

Storage/Archival

  • Active Record Management | FlexiblePhysical Delivery Schedule |Scan on Demand |Online Ordering | Inventory Control

Member Enrollment Services and Healthcare Exchanges

  • Quote to card | Secure, web-based plat form for effectively managing healthcare enrollments and documentation |Member Installation

Provider Data Management

A universal platform to manage providers to ensure provider information is up to date by effectively managing provider updates.

Document Aggregations

Provider related documents are gather from different modes - post box, web upload, Print Driver Intake (PDI), email, EDI, mobile. Physical documents are aggregated through mail room and scanned and converted to electronic formats.

Extraction & Routing

Data capture for extracting data from unstructured document by OCR, Auto Correction Engine (ACE) and compare OCR to extract the relevant text. Text files containing enrollment information are print to enrollment form as image. Some amount of data is keyed in to complete the extraction process.

Enrichment

Captured data are enriched and validated through configurable business rule engine to ensure correctness of provider details.

Decision

Provider updates are process per the request like demographic updates, network changes, fee schedule, credentialing, etc.

Business Communication & Dashboard

Provider status is tracked through dashboards and gets the required reports. After successful processing provider updates are apply to payers system Customers will get to know the status of the provider details through our integrated communication service.

Storage, Archival & Retrieval

Provider documents are stored in a secure environment for future use. These can be retrieved for further enquiries.

Claim Processing

Claim Aggregations

Claims intake from different modes - post box, web upload, Print Driver Intake (PDI), email, EDI. Paper claims aggregated through mail room and scanned for electronic format.

Extraction & Routing

Data capture for extracting data from unstructured document by OCR, Auto Correction Engine (ACE) and compare OCR to extract the relevant text. Text files containing claim information are print to claim form as image. Some amount of data is keyed in to complete the extraction process.

Enrichment

Captured data are enriched and validated through configurable business rule engine with respect to details such as member, provider and service

Decision & Business Communication

Claims which are not satisfied the rules are rejected and information sent through print and mail communication or electronic presentment. Claims are routed to resubmit and for reprising for credibility.

Output, Shipment & Dashboard

Clean claims are sent in a batch and get acknowledged. Dashboard and reporting is available to track the different claims parameters like TAT, Quality, etc. Customer interaction is managed thorough communication interface.

Storage, Archival & Retrieval

Processed claims are stored in a secure environment for future use. These can be retrieved for further enquiries.

Adjudication

Faster, more accurate adjudication process designed to minimize the need for manual intervention and maintain customer satisfaction.

Payer Gateway-Submissions

Claims are received as EDI, paper, or from clearing house submissions. Intakes are acknowledged by the workflow and cleaned up for further processing

Pre process

Basic data validations are done in this stage to check member, provider details, medical coding details, etc. With these data get transformed and enriched.

Pre Adjudication

This stage is assist with integrated business rules to validate member eligibility, provider status, service line authorization and valid medical codes for the services. Member benefits, liability, provider contracts, fee schedule are check to ensure the accuracy of the charges.

Adjudication

Client specific validations are carried out for referrals, authorizations for the procedures are checked before the claims get paid. Claims are re-priced or routed to review in special cases and get adjusted accordingly. Pay or deny the claims are decided in this stage based on rule engine decision or manual review for special cases.

Payments & Communication

Payments are getting settled to the provider through paper or electronic form. Providers get paid quickly. Explanation of Benefits and Electronic remittance advice is generated and communicated to providers through electronic presentment in portal.

Dashboard &Reporting

Dashboard and reporting is available to track the different adjudication parameters like paid claims, pending claims, paid amount, TAT, Quality, etc.

Storage, Archival & Retrieval

Processed claims are stored in a secure environment for future use. These can be retrieved for further enquiries.

Payments

End-to-end payment solutions supporting electronic and paper transactions, lockbox, customer service and presentment services to payers ensures streamline payment process

Payment channels

Portal offers different payment channels like mobile, tablets, SMS, online portal and payment modes like check, EFT, ACH for better user experience.

Bill payments

Efficiently managing and helping bill payments for payers. Portal supports multilevel approval process for payments. Overall reduces paper process.

Exception management

Auditing and reconciliation are done to ensure the payers payment accuracy. Any payment exception arise during the process are managed and processed efficiently.

Technology & Security

Proprietary technology with configurable business rules for business specific payments. Security mechanism and security standards are in place to manage payments in highly secured environment.

Presentment

Payment related communications are managed electronically and also in print and mail formats. Any payments will get e-bills as acknowledgment. Respective user will get notifications about the transactions through portal and other hand held devices.

Unified Communication Services

All payer related communications are integrated within the portal. Intelligent communication and presentment for automated engagement and response though any media channel (SMS, Chat, Voice, Print, Email, Mobile, etc.).

Customer Interaction Management

Live or virtual agents connecting members and providers with payers for communication related to their business process. These agents will help customers in place of payers for business related interactions.

Dashboard & Reporting

Payers can track all their services through our intelligent dashboards and get any business reports for better decision making.

ePresentment

Welcome packages are sent to new members through presentment or via email. Bills related to transaction are presented to the user on screen and can be saved. Any status regarding processing of the claims are presented via portal to members and providers.

Print & Mail

Any communication need in print format can be done with our automated print and mail facility.

Alerts & Notifications

Triggers are configured for the services to send alerts and notifications for business continuity. Periodic remainders are rolled out for any kind of updates.

BoxOffice

Secure and compliant on-premises and/or cloud-hosted data archival for real-time data visibility, document management and reporting for all payer services.

Real time data

All process related data are stored and retrieved dynamically for quick processing and can be archived for later use.

Profile Management

Data access can be managed based on roles and assigned permissions accordingly. Activities are tracked to eliminate any unauthorized access.

Security & Compliance

All payer related data are stored in highly secured environment and follow healthcare industry compliance and certified by security organization. Our storage is equipped with two step verification, encryptions and anti breach architecture to ensure higher security to the data and no data loss.

Actionable Intelligence

Stored data can be accessed for future analysis and can able to improve intelligence out of them.

4.4 Mn+

Enrollment Annually

10 Mn+

Claim Transaction/annum

12 Mn+

Adjudication /annum

5 Bn+

Images Stored online

HealthcareVALUE ENHANCERS

Rapid and seamless member enrollment and provider data management

Increase in first pass rate of claims passed through PCH

Claims lifecycle view for the real time status of the claim

Global inventory management tools

Early view and comprehensive reports with intelligent dashboards

Revenue integrity solution to minimize the loss

Shorter installation period

Integrated unified communication services

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