CompuClaim’s EDI Eligibility Determination Services

EDI Eligibility Determination Services

CompuClaim offers hospitals, medical providers and others a comprehensive set of eligibility determination tools to find unknown third party patient insurance eligibility and help you capture health insurance claiming revenue you are missing. Our tools include the following services:

Batch Scheduler:

Upload your patient schedule to CompuClaim and we will send ANSI 270 insurance verification requests to all the applicable payers. We retrieve the responses and provide you the information to decide the appropriate action on day of visit: denial of service, collection of co-pays or deductibles, or a payment program.

Current eligibility offerings by other services are great for office-based providers but do not address the needs of hospital-based or emergency providers who render services in advance of verification. These groups have seen declining revenues due to an increasing number of uninsured patients and higher enrollment in low paying Medicaid programs.

CompuClaim provides two unique services to increase revenues in these areas!

Coverage Finder

Many patients that present as “self pay” actually have insurance, and for some providers 25% or more of their patients have coverage but are either not aware or are hiding the fact they have coverage! But how do you find it? If you can find it, how long will it take? What will it cost? CompuClaim Coverage Finder is the answer. Just upload basic patient demographics into CompuClaim’s Web portal and we will automatically query applicable payers. We will return insurance information when we find it. Coverage Finder increases your revenue, improves your accounts receivable, while eliminating manual tasks, timely filing issues, and collection agency costs.

TPL Finder

Growing Medicaid enrollment, with its lower reimbursements, are affecting provider revenues. But many Medicaid patients actually have private insurance, or Third Party Liability (“TPL”), that would provide higher reimbursement. The last study performed by the GAO in 2006 found the national average at 13%, with many states exceeding 20%. Current estimates are 18% nationally! Because Medicaid is a “payer of last resort”, all state agencies go through a subrogation process, querying payers on all their claims. When TPL is found, the private carriers reimburse Medicaid for the cost of the claim. Good for the Medicaid agencies, as they save millions through subrogation reimbursement. Good for payers, as they save millions by reimbursing for services at lower Medicaid rates. Who pays these millions? Medical providers like you!

CompuClaim TPL Finder recovers this lost revenue of higher TPL reimbursement for medical providers who take Medicaid patients. Upload all your Medicaid claims and CompuClaim will automatically query payers to see if other coverage exists. When TPL coverage is found, simply rebill the TPL payer as the primary and Medicaid as the secondary. TPL Finder increases revenues in your Medicaid population!

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