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What is Complete Claims?

Claims adjudication services encompass a variety of sectors such as medical, dental, vision, and prescription claims, along with both short and long-term disability cases. These services can be accessed on-site with a license or through a hosted application model (ASP). Powered by Microsoft technology, the system employs an SQLServer database and a Windows front end for optimal performance. Our customer service team is highly esteemed, comprised of healthcare claims experts with at least 12 years of experience in the industry. Every support request is documented, allowing clients to track their status online. The system includes a plan copy and modification feature that enables quick implementation of changes. Auto-adjudication is facilitated through benefit codes built on business rules that take into account over 25 variables related to both claims and claimants, all processed by the adjudication engine. Submissions can be made in various formats, including scanned images, EDI, or traditional paper submissions. The system adheres to HIPAA EDI 5010 transaction sets, guaranteeing secure and efficient processing. Furthermore, re-pricing fees and UCR schedules can be entered into the system ahead of their effective dates, while the date-driven logic ensures re-pricing is executed based on the service date, enhancing the overall workflow of claims processing. This comprehensive solution not only streamlines claims management but also significantly improves client satisfaction and operational efficiency.

What is Adjudicator?

Adjudicator functions as an innovative platform designed for the administration of plans and the evaluation of prescription claims, catering to a diverse range of entities, including pharmacy benefit managers, hospitals, health systems, managed care organizations, and retail pharmacies. This platform boasts customizable plan configurations and benefit structures, supports multi-tenant environments, and facilitates the oversight of pharmaceutical networks, drug formularies, and maximum allowable cost (MAC) pricing. Users gain access to a member portal that provides real-time information on benefit statuses and the ability to track pending claims, along with options for secure document uploads and timely alerts. Moreover, a prior authorization dashboard offers insights into claims data while fostering secure communication among various stakeholders. An integrated API framework allows for efficient data exchange with both internal systems and external partners, ensuring smooth interoperability. By equipping organizations with these robust tools, Adjudicator enables effective management of pharmacy benefits and prescription claims, significantly improving operational efficiency and the quality of service provided to members. Ultimately, the comprehensive features of Adjudicator allow stakeholders to remain agile in response to the dynamic landscape of healthcare and pharmacy management, ensuring they are well-prepared for future challenges.

Media

Media

Integrations Supported

Additional information not provided

Integrations Supported

Additional information not provided

API Availability

API Availability

Has API

Pricing Information

Pricing not provided

Pricing Information

Pricing not provided

Supported Platforms

SaaS

Supported Platforms

SaaS

Customer Service / Support

Standard Support
Web-Based Support

Customer Service / Support

Standard Support
24 Hour Support

Training Options

Not specified

Training Options

Documentation Hub
Webinars
Online Training
On-Site Training

Company Facts

Organization Name

Complete Health Systems

Company Website

completehealthsys.com/claims/

Company Facts

Organization Name

Cervey

Date Founded

1978

Company Location

United States

Company Website

cervey.com

Categories and Features

Claims Processing

Not specified

Health Insurance

Not specified

Categories and Features

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