Medication, Health Insurance, Dental Insurance, Surgery #49

It is quite easy to create a new processing batch for an individual.

One has only to search for a given individual. This search can be achieved through various criteria search such as social security number, date of birth, surname, name and other method of search.

Furthermore the search can be done using only a portion of the information required.

Hereby for example, we can search for a name or part of a name and the selecting list will produce only the file corresponding to the search criteria’s.

Once the file has been identified, we will then have full access to the individual’s file.

In accordance with traditional working method when managing an insurance batch, it might be frequent to find claims from other individual in the same family in the said batch.

It is then possible for the operator to check complementary search icon that will provide with all the additional information needed to properly identify the specific individual associated with a given insured.

When the annotation icon is highlighted, it indicates that one or more annotations are included in the employee’s file. It is recommended to view the file before processing any claim. A priority annotation can automatically pop up whenever opening the individual file.

You can access the accumulator very easily.

Depending on the configuration criteria of the claim plan; it will be possible to access the various accumulators. For each accumulator, the system will automatically cumulate the amounts following approved of individual adjudication.

To process a claim, one has only to select the type of item which should be processed and then identify the invoicing date.

In our current example, now we will have to select a specific DIN as we are dealing with drug payment.

You have the full access to a list of these various drugs, whether by name or by DIN number.

We can take note that over 11708 available DIN through Allegroupe system.

And the only additional thing to add is the amount of the purchasing price for the corresponding item. 

Then, ask the system to proceed with the adjudication.

We invite you to explore the various blocks of information. You will notice that we kept the DIN number, the drug’s name and the various appropriate statistical codes.

In another section, we will find the approved amount, the applicable deductible, the co-insurance percentage and the amount the system will pay.

In another section will find all the information related to the contract coverage metric level. This will enable you to view cumulative deductible, individually or by group, the maximum coverage and co-insurance. Most important, in the event a customer has a health spending account, a health account option will allow the use, from said account, of additional amounts which are not covered by the current insurance benefit.

It is also possible that other items might be claimed by the same insured. Consequently, these items can be added to the current batch and we can resume our activity by simply using the OK+ button.

One will note how easy it is to move from one type of claim to another. From drug, we now move to extended health related services.

Each service cumulates inside a batch and the system process each claim independently.

Instead of the DIN number and the extended health services, it will be possible to select the category of service that was used.

We can now add the amount and ask the system to process.

Once again, depending on the contract’s specific terms, the system will display the deductible, the co-insurance percentage and the amount to be paid.

At any given time, the operator may choose to add a new item to the batch or to terminate and close it. To do so, just select the button OK or OK+. It is also possible for the operator to use functional key allowing him to work directly from his keyboard without having to use a mouse.

This will create a highly productive environment as you will be able to add new activity or choose within a list of services.

When a claim cannot be authorized, a red comment will be displayed stating such service is not cover and the reason why.

The same procedure goes for dental cares.

For dental service, we will use the number provided by the Quebec Professional Office or of each province. A list of equivalents is available to manage inside the system allowing for the creation of equivalences between various provinces using the one from Quebec as point of reference.

Each individual act is coded according to the industry codification hierarchy.

To this day, 738 acts have been catalogued within Allegroupe. This will permit the operator to proceed with his search based on various criteria so to find the service provided to the principal insured. 

All dental acts were identified according to the value of each service.

The adjudication of a claim will be based on the eligible amount from which the deductible is extracted when applicable. Once more, the co-insurance percentage applies. 

Complimentary information areas, such as contract coverage metrics and applicable limits will enable the operator to better understand the process been registered or adjudicated by the system.

We may continue to process the insured’s batch by adding new items.

As one can see, many elements can be added and each one can be processed individually based on the business rules selected by the analyst. 

Once the last item has been added to the batch, the system will display a summary of the overall requested activities.

Various blocks of information are now available for the operator to quickly review the most important information.

A summary section is displayed on the top right side of your desktop so to view the number of processed items, requested amount, eligible amount and the authorized payment.

At the bottom of the screen, one can see the complementary information in relation to each batch items.