ValiData

Problem

HCH Administration in Peoria, Illinois is a third-party administrator (TPA) with a problem that’s common to their industry – the quality of the EDI and data from paper claims. Inconsistent data inputs — from claims “mailboxing” for the provider to eligibility issues and data conflicts — dramatically slow down the auto adjudication process. And eat up considerable time and human resources. HCH needed a better system – and OnCourse provided it.

Solution

OnCourse provided ValiData, a front end data scrubbing solution. Set up as an ASP, all claims (EDI and data from paper claims) are funneled to the same front end preprocessing software. Robust provider and eligibility matching logic is used to perform automatic selection. CPT, ICD9 and modifiers are all validated using both the standard codes and any unique codes the client has developed. An unlimited number of custom rules known as “quirks” are consistently applied to all claims. The last step is for the operator to make corrections on claims that could not be resolved automatically. This process is designed to quickly and accurately make the final decision, eliminating the tedious process of clearing mailboxes. The data is then output to QicLink for adjudication.

Outcomes

• Provider matches at a significantly higher rate
• Eligibility matches at a significantly higher rate
• Database clean up tools implemented
• Custom claims rules are developed and implemented

Process Overview

• EDI and Data captured from paper claims are directed to the same FTP
• Claims are imported into the ValiData Software
• Automatic tasks are performed
• Manual tasks are completed in a far more efficient process
• Data is output to QicLink for adjudication

Advantages

• Productivity increases from 100 claims per hour to 300
• Significantly fewer claims are “mailboxed”
• Productivity is greatly improved
• Custom rules, “Quirks”, are universally applied to all claims
• No additional hardware is required to support the software
• Training is minimal