Page 25 - C.Journal 4th edition

Claims Journal 4th Edition Claims Journal 4th Edition

Claims channel Claims channel

Level 2 Technical Audit process
Technical Updates Inception date: March 2017

Objectives:
• To increase production with high percentage of quality.
Improvements-New process • To revalidate Technical shortfalls if valid or not.

Level 2 Recon process- Weekly quality checking • To highlight issues to providers to decrease or eliminate repetitive technical errors.

Scope:
Inception date: Nov 2016 • Top 20 providers
• Dental and Optical Batches
Objectives: • Statements with high SF % and zero approved
To re-validate difference in computation reasons, claims not received and Invalid memberships.
To Identify typo errors in the batch headers and double check the figures. • Issues to be double checked:

• Invalid service codes
How it is done: • Late submission of claims
A team leader is assigned per week to do the revalidation of every batch done by recon team. • No PA claims
• Tooth number not attached
• Duplicate services
Sample Monitoring Sheet • Invalid benefit type/ head
• Attached BME card is not valid
• Rejected referral batches

How it is done:
Top 20 providers, dental and optical batches, statements with high SF % and zero approved will
be re-assigned again for technical audit to tech quality team.

Provided by :

Reginald King Sorra

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