Managed Care Claim Management

About Managed Care Claim Management

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Managed Care is a health care system with administrative control of a constellation of health services, encompassing early intervention to control price, volume, delivery site and intensity of health services provided. The intention is to maximise the health of the insured, as well as the value of health benefits given, eliminate redundant facilities and services and to reduce costs. Managed care healthcare scheme use tiered referral system, starts from primary care physician who acts as a gatekeeper for secondary services, such as specialized medical care, surgery, and physical therapy.

AdMedika Managed Care Claim Management Services unique approach combines physician-guided care with technology-driven efficiency to achieve better results for our clients. We aim to deliver quality, cost-effective healthcare by monitoring and recommending utilisation of services, as well as controlling the cost of those healthcare services. We incorporate our years of proven best practices to built highly efficient service delivery workflows that incorporate physician oversight, keep costs at minimum while raising the bar on client service and results and encourage health care providers to collaborate with our professional medical advisers.

Patient Workflow

  • Outpatient Primary Care
  • Outpatient Secondary Care (Specialist)
  • Inpatient / Maternity

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Key Benefits

key benefits
Members
  • Cashless treatment
  • Leverage quality & convenience
  • Accelerate service speed
Costs
  • Cost Containment
  • Accelerate claims processing time
  • Transparency of costs
  • Efficiency of reports
Compliance
  • Prevent fraud
  • Reduce claims processing errors
  • Cost analysis accuracy
  • Comprehensive and accurate report

EDC Receipt Sample

  • Outpatient Receipt
  • Inpatient Receipt
  • Billing Confirmation Receipt
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Reporting

AdMedika Claim Management service can generate comprehensive reporting that can simplify the process of analysis and decision making. In addition to standard reporting scheme, we can also generate customized reports in accordance with the needs of our client’s business processes. Reports can be provided on a monthly, weekly and daily basis. And will be sent through email and can be accessed directly via FTP.
Below are some of our Managed Care Claim Management reports

  • High costs inpatient care
  • High costs outpatient primary care
  • High costs outpatient secondary care
  • Referral count and details
  • Provider reports
  • Degenerative diseases
  • Chronic diseases
  • Care patterns based on member's group
  • Care patterns based on member type
  • Care patterns based on member's age
  • Disease patterns based on member's group
  • Disease patterns based on member type
  • Disease patterns based on member's age
  • Transaction report based of type of care
  • Claim transactions report

Claim Verification Workflow

We handle thousands of claim documents on daily basis and every each of these documents may consist up to dozens of papers. The Claim Verification process is the most crucial steps in our claim management service. We focus on maintaining the highest quality, best-trained and most professional claim analysts in the industry and we only hire claim analysts with medical or public health educational background.

Reception & Registration

Claim documents are registered into our system while we check for the completeness and double check the document coherence with existing data. After that the documents will be scanned and sorted and then be ready to be verified.

Verification

Before the verification process starts, the documents will be double checked for completeness. The process start with verifying of treatment and drugs are according to the health benefits and limit, check for claim excess. After all the documents are validated, the claim verification reports are generated and it’s ready for the next process.

Splitting

Make copies of the claim documents and sorted by payer, provider, diagnosis and treatment.

Delivery

Sent the verified claim documents to its payers. The report and scanned copies of the documents can be sent through emails or it can be accessed through FTP access.

PT. Administrasi Medika
Telkom Gambir, Gedung C, Jl. Medan Merdeka Selatan No. 12, Jakarta Pusat 10110 - Indonesia
021 3483 1100   021 3483 0101   Contact Us   Find on map
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