AdMedika Claim Management

adclaim AdMedika’s Claim Management Services called  AdClaim   , are conceptualized on the fact that paper-based medical claims process proved inefficient, lacks transparency and prone to abuse and fraud. Our proven methods and procedures of claim administration simplify and standardize healthcare information, reduce cost, enhance service at point of care and create convenience for members (policy holders / patients) when seeking healthcare services. This service will enable our clients to focus on strategic activities of their organization, relieving them from infrastructure cost and back office management, reduce provider billing aging, reduce data entry cost, improves data accuracy and accelerate claim payment to the providers and/or policy holder.

Our experienced claim professionals utilize AdCPS (AdMedika Claims Processing Systems) technology. This state-of-the-art, on-line, real-time system provides instant claim and eligibility information and able to process even the most complex transactions efficiently. We strive to process claims with 100% accuracy and with the fastest time possible. When speed, accuracy and cost are critical, our solution alleviates the pressure.

AdMedika Claim Management Services are able to accommodate both Indemnity & Managed Care healthcare scheme. And with our flexible processing system, we are able to customize our service to handle Hybrid healthcare scheme which is a fusion between Indemnity & Managed Care

Claim Management Key Features

Our unique approach and efficient methods is what distinguished AdMedika from other Third Party Administrators in Indonesia.
Learn more what makes AdMedika Claim Management Service only provide the best solution from start to end.

   Provider Relation

We always maintain a close relationship with all of our partners including the healthcare providers. The healthcare provider's is the front-line of the healthcare activities. Full and constant support is needed to ensure efficiency of the entire administration process.

Each of our healthcare provider's networks is equipped with EDC terminal and connected to the AdMedika Claims Processing Systems (AdCPS). Our provider relations helpdesk will advice and assists with policy and procedure interpretation, training needs, development and implementation of training programs regarding AdMedika's system services and EDC maintenance and support.

Our goal is to bring as much quality healthcare providers (hospitals and clinics) as possible to be in our provider network whilst maintains accurate and current provider databases relating to provider facilities, specialties, practice limitation and physician information. This will help our insurance partners to expand their healthcare providers network and for our members to choose the best provider based on their needs.

   Membership Administration

Entrusted with millions of members / policy holders, AdMedika’s membership administration service is proven to be the most efficient and benefits all our partners and members. The membership administration, including member enrollment is done electronically utilizing the latest technology and method.

  • Health benefit plan setting according to each insurance policies.
  • ASO (Administrative Service Only) settings to maintain insurance limitation with report and alert.
  • Customizable setting of benefits covering hospitalization and surgical (inpatient), GP and Specialist (outpatient), Maternity including prenatal treatment, dental, optical, etc.
  • Collection and maintenance of member’s record including its benefit schemes, policy extension and exclusions.
  • Daily update of member’s record pertaining to addition, deletion, endorsements, renewal, lapsed policy. This will be done online and real-time to minimize abuse and excess.

Each of the policy holders including its family members will be given a personalized healthcard with unique 16 digits identification number (ISO-standards) magnetically encoded. Each health insurance company will have its own personalized design.

   System and Network
With the Front-end Healthcard Network Technology that leverages on the existing Banking Credit Card Infrastructure and our state-of-the-art back-end AdCPS (AdMedika Claims Processing Systems) technology, we are able to electronically automate the administrative process of eligibility verification, data capture, admission authorization and claims processing at the point of care in real-time mode.
   Real Support

We understand the importance of communication in this business and there is no “office hour” for one to seek healthcare treatment. That's why our in-house Call Centre and Customer Care staff is working in 3 shifts, 24 hrs a day and 7 days a week, all year long to handle all queries or complaints regarding Benefit Coverage (plan/limit), Procedure (inpatient / outpatient) and Providers Referral.

We handle customer service with a team approach. Team members are cross-trained, so they can assist other team members and taking pride in providing the best service to our partners and members.

   Case Monitoring

Hospitalization or treatment phase is the most significant and critical phase in the whole healthcare process. We understand that in this phase the patient will expect the best care and all the attention they can get.

The Medical Team - which is supported by expert medical advisers- continues to monitor and assess the patient's condition, progress and quality of care throughout the period of admission. Our doctors will closely discuss with the treating doctors and provide recommendations and advice as to how the patient's condition is being treated, what further action might be required and its necessity with the objective of giving the most effective treatment.

A thorough case management will ensure cost containment by minimizing excess of hospitalization claims caused by exhaustive benefit limit, policy exclusion and non-medically necessary treatment.

   Online Web Monitoring

Keeping our partners in track on their information regarding the claim processing is an important part of our commitment of giving fast and quality services to them. Our online web systems are accessible by the insurance companies and policy holders (members) through unique and secure username and password provided by AdMedika. Information on Members Enquiry, Claims Enquiry, Claims maintenance, claims adjustment), Online real-time reporting and online alert can be accessed anytime, anywhere.

Claim Management Benefits

For Insurance & Corporations
per month
  • The vast increasing needs for health insurance and its variety of benefit plans has made health insurance companies or self-insured companies administrative works become more complex than ever. AdMedika provides services pertaining to healthcare claims administration management for members of health insurance and employees of self-insured companies.
  • 24/7 Call Center & Case Monitoring
  • Largest healthcare network providers.
  • First hand information on risk exposure.
  • Minimizing claim excess
  • Minimizing fraud & abuses.
  • Increasing corporate image and adding value to its services.
  • Standardization of health care services for policy holders.
  • Making administration process easier, thus increasing employees productivity.
  • Minimizing labor cost
  • Online and real-time web reporting and claim status
For Healthcare Providers
per month
  • No more data contra-distinctions, excess claims quarrel and time consuming claims verification and administration between healthcare providers and payers. Our comprehensive Healthcard Network and back-end AdCPS technology cover both the outpatient and inpatient.
  • 24/7 Call Center & Case Monitoring
  • Increasing corporate image and adding value to its services
  • Broadening hospital clientele
  • Standardization of health care services for policy holders
  • Easier to monitor billings and/or account receivable management
  • Acceleration of service process (patient and billing administration)
  • Online and real-time verification, minimizing ineligible claims.
  • Simplify administration process, thus increase the employees productivity
For Members / Policy Holders
per month
  • The members / policy holders are the center of healthcare providers' activities. Giving fast and first class quality services insured consumer loyalty and increases corporate image. Each member will be given electronic ID cards needed to validate their identity at the time of admission. The member can enjoy cashless hospitalization, easy and hassle-free claims administration process.
  • 24/7 call center service with medical advisory
  • Quality choices of healthcare providers, nationwide
  • Received the best quality treatment and/or health insurance
  • Cashless treatment
  • Online, real time verification with information on benefit, plan and limit.
  • Information on policy term and condition, exclusion, limitation of benefit and administrative process
  • SMS notification updates
  • AdMedika Valuecard Program

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.


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.


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


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.

Claim Management Service Type

Full Service / ASO
Partial Service
Technology Only
Member Data administration
Realtime Eligibility
EDC Network
Claim Verification
Online Monitoring Web Access
24/7 Contact Center
24/7 Case Monitoring
Customer Care
Admin Payment (Optional)
SMS Notification
AdMedika Valuecard

Finding The Best Solution

AdMedika Claim Management Service has a wide range of types, schemes and service level that would provide the best solution for every type of healthcare insurance. The services are flexible and can be tailor made to fit your specific requirements.
Here are a quick guide on how to find your best Claim Management solution.

  • Type
    Choose the Claim Management Service Type that suits your requirements. Full Service / ASO, Partial Service or Technology.
  • Scheme
    Choose the Healthcare Scheme that fits you best. Indemnity, Managed Care or Hybrid.
  • Level
    Choose your Claim Management Service Level that suits your requirements like dedicated contact center team or dedicated claim team
  • Add & Customize
    You can add On-Top services to your AdClaim suchs as AdClaim Plus, AdClaim CoB, I-Assist or AdBrief. AdMedika Claim Management can be tailor made to best fit your requirements.

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