HIPAA Code Sets

DataCodes has teamed up with Eldorado to provide users with HIPAA mandated codesets. DataCodes is the only code supplier to provide ICD-9 updates which plug directly into your HEALTHpac® claims system without the need for an update program and CDT dental updates containing type of service information used by the HEALTHpac® tooth charting system. Additionally, our CPT and HCPCS updates use standard upload programs already found in the claims system. You can find more information and order the updates for the current year on our website at www.datacodes.net.

Emdeon Corporation provides services that help physicians, consumers, providers and health plans navigate the complexity of the healthcare system. Our products and services streamline administrative and clinical processes, promote efficiency and reduce costs by facilitating information exchange, communication and electronic transactions between healthcare participants. Emdeon Envoy is the leading provider of electronic data interchange services for healthcare providers and commercial health plans and is Eldorado’s preferred vendor in this area.

Data Entry, Fulfillment and Repricing

JMS provides "Simple Solutions for Complex Problems" to the Health Care Payor Industry. Our solutions begin with receiving EDI and Paper Caims, Converting Paper to EDI, Claim Validation & Correction of Eligibility and Provider Data, Network Routing, Re-pricing of Medical and Dental Claims through EDI and Web Systems, Web Claim Viewer Systems, and Remote Adjudication Services. To find our more visit us at www.jmsassoc.com or call us at (248) 489-8888.

PPO Provider File Clean Up

Bases Loaded, Inc. is a service bureau company that converts PPO (Preferred Provider Organizations) provider, facility, and fee schedule data into our client's specifications.

Bases Loaded, Inc. has a patent pending calculation to detect duplicate provider information. This calculation will eliminate the duplicate providers prior to the data ever getting to your claims adjudication system.

AMPS is a cost containment and reduction services company for the entire healthcare payer community. AMPS provides medical bill review (MBR), fee negotiation, and claims repricing services on behalf of payers using a cadre of physician specialists and a proprietary network of over 61,000 medical providers, and robust HIPAA compliant technology.

AMPS has developed unique technologies that allow them to quickly and seamlessly review the details of medical bills and supporting clinical records. They protect their clients' interests by leveling the playing field of knowledge on medical service delivery.

AMPS mission is to assure that their clients are receiving "A dollar's worth of healthcare for every dollar spent."

U&C Fee Schedules & Claims Edits

MDR/PHCS
Employers, group health insurers, managed care organizations and many other specialty service companies are relying on ways to manage their reimbursement risk - and establish equitable fees - while controlling administrative costs.The Medical UCR Module provides UCR guidelines for more than 95 percent of all current CPTTM-4 codes for surgery, evaluation and management, medicine, radiology and laboratory procedures.

Claims Edit System (CES)
Claims Edit System is an automated, clinically derived editing and repricing tool that automatically reviews claims for coding accuracy and appropriateness prior to a claim being paid. CES is seamlessly interfaced into the Eldorado system allowing payers to turn on and off the edits by client and type of edit. Edits can be set to automatically be changed by the system or be pended for further review.

U&C Fee Schedules

Ensuring that the right service is administered at the right cost is a cornerstone of proper healthcare coverage. Captiva’s UCR offerings make certain that insurance companies, employer groups and other healthcare organizations or administrators have direct access to the fee information necessary to operate in today’s diverse and widespread healthcare environment. Captiva’s UCR databases were developed over several years by a team of fee experts and mathematicians. As a result, users can now acquire cost effective fee management solutions that are exceptionally credible and defensible.

Currently available UCR databases include: Medical, Dental, Anesthesia, HCFA’s Common Procedure Coding system (HCPCS) and Outpatient Facility. Additionally, more than 60 data and fee products are available for integration or reference purposes.

Fraud and Abuse Screening

HealthCare Insight (HCI) provides overpayment services to Third Party Administrators and other payor organizations that adjudicate healthcare claims. HCI’s services identify fraud, abuse, and overpayments of healthcare claims. Therefore, the fraud and abuse services significantly reduce annual claims expenditures. HCI’s unique service approach utilizes proprietary software and databases and we couple that with a seasoned clinical staff of expert analysts who provide clients with additional insight into challenging reimbursement decisions. HCI’s services seamlessly integrate into all claims adjudication operations with minimal disturbance to their existing processes. The end result is that the client pays less for the same medical services and identifies medical providers that are not accurately billing for the services performed. HCI is a HIPAA Business Associate.

SOCRATES, INC. is the only healthcare claims recovery firm that provides outsourcing services and software programs to health payors so that they achieve recovery rates that exceed industry norms with unparalleled case management from the Eldorado claims processing platform. The MY SOCRATES© software was developed by legal, claims recovery and programming experts. We have 15 years of health payor industry knowledge.

With over 15 years of experience, SOCRATES, INC. serves the healthcare payor industry and has a diverse customer portfolio, including health plans, third party administrators (TPAs), self-funded welfare benefit plans, Medicaid and Medicare products and governmental plans. Providers such as WellPoint®, Definity Health, Inc., John Deere Health, UnitedHealthcare®, Meritain Health, f/k/a North American Health Plans, along with a variety of BlueCross BlueShield licensed plans, have benefited from SOCRATES, INC’s outsourcing services and software. Socrates can be reached at 1.800.653.3144 or www.socratesinc.com.

PHX delivers advanced cost management solutions for health plans. The company combines claim processing automation with professional services to deliver a centralized approach to cost management, increasing savings in both the near and long term while dramatically reducing errors and turnaround time. The firm's solutions are used by a number of the industry's leading insurance companies, Health Maintenance Organizations (HMOs), and Third Party Administrators (TPAs). Services included in the PHX offering include bill review and audit, secondary network re-pricing/claims negotiations, claims editing, fraud and abuse detection, and health benefits trend analysis and reporting. All services are handled in-house for maximum privacy and legal and regulatory compliance. PHX also supplies full technology implementation, training and support for quick, seamless integration into any organization. Visit www.phx-online.com. for more information. PHX is the leader in cost management.

In today's dynamically changing health care landscape, the greatest challenges facing plan administrators are containing claim costs and managing profitability. Subrogation and other recovery vehicles are important tools to control the cost of your benefit plans. The Phia Group specializes in controlling costs by retrieving collectible claim dollars. We estimate that over 2% of annual claims paid are recoverable through an effective subrogation and reimbursement program. This represents substantial money that can be returned to your benefit plans.

Our technology allows us to discover more cases with recovery potential while our experienced attorneys ensure that your recoveries are maximized in every case. This results in more money returning to your plans.

Real-time Windows Based Ad-hoc Reports

Actuate Corporation is the leading provider of Information Delivery solutions for Global 2000 companies and packaged application software vendors. Actuate provides the leading platform for retrieving business information from corporate databases and delivering interactive Web pages and Excel spreadsheets to customers, partners and employees. Actuate content is seamlessly integrated into corporate Web sites and packaged applications and can be printed and used to exchange data with other applications.

ABF is the founder of Healthpayers USA, healthcare's first nationwide payer postage CO-OP. Healthpayers USA was developed to eliminate millions of dollars of excess postage for ABF clients. Founded in 1998, Advanced Business Fulfillment (ABF) has become the largest and fastest-growing outsource vendor for healthcare-specific claims communications. Based in St. Louis, Missouri, ABF has grown at an average of 9 new health administrators per month for the past three years. ABF currently services over 300 healthcare insurance companies, managed care organizations (MCOs), health maintenance organizations (HMOs), dental plans, self-insured companies, and third party administrators (TPAs) with covered lives ranging from 10,000 to 3 million.

PPO Network

MultiPlan - With more than 30 years of experience, MultiPlan knows provider networks. We understand how to bring providers and payors together for mutual benefit. And we know that to deliver value to both payors and providers - and by extension to members - primary and complementary networks can't be the same product with different labels. That's why we've structured a suite of solutions that clearly delineates between primary PPO, complementary network, and out-of-network services. The solutions can work either alone or in combination, using MultiPlan as a single gateway to a multifaceted claims cost management solution. All solutions are HIPAA compliant and leverage The MultiPlan Network®-the nation's leading independent network with 4,500 acute-care hospitals, 84,000 ancillary facilities, and 400,000 individual healthcare practitioners.