Claims Management
The end-to-end claims management cycle is digitized from members’ eligibility checking to service provision, case management, claims adjudication and payment settlement. We ensure better cost containment measures and unparalleled patient's experience.
A. Utilization Management
An Accelerated and Well-Monitored Process
- Our online application, CareGate, deployed at healthcare providers’ facilities, allowing them to instantly verify members' eligibility and submit claims.
- Most outpatient coverage decisions are automated through a robust business, policy-related, and medical rules engine.
- Fast turnaround time for non-automated authorization requests handled by GlobeMed.
Constantly Evolving Cost Containment Measures
- Real-time detection of medical, pharmaceutical, and coding discrepancies, misuse, or potential areas of abuse through our advanced expert system.
- Concurrent reviews to ensure the most appropriate treatment is administered while maintaining cost efficiency.
- Case management aimed at controlling the cost of specific cases while ensuring the proper level of care for insured members.
Enhanced Patient Experience
- SMS notifications to inform patients about the coverage decisions.
- Automatic safety checks and alerts based on patients’ medical conditions.
- Minimized patient waiting time at healthcare facilities.
- State-of-the-art mobile application, GlobeMed FIT, allowing insured members to manage their insurance online, anytime, anywhere.
B. Claims Adjudication:
- Accommodates a wide range of claims submission procedures, including real-time submissions, digital uploads, or offline manual reception when needed.
- Automatic price adjustment based on provider contractual agreements.
- Adjudication of claims based on policy rules and validation of medical necessity through the medical rules engine.
- Medical audits conducted by specialized medical officers to review flagged claims.
- Quality assurance processes ensuring data consistency and integrity by detecting potential errors before claim closure.
C. Third Party Accounting:
- Timely settlement capabilities with highly flexible reporting options accessible to payers, facilitating the payment and reconciliation cycle.
- Streamlined,web-enabled monthly reconciliation with providers, allowing them to review adjusted claims and confirm balances.
