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Claim Administration
Along with the administrative expertise of our staff, GISC utilizes a
unique, custom designed claims system. High levels of automation insure
speed, accuracy and consistency in adjudicating even the most complex
benefit plans. The following are some of the features and functions of
our system:
- Online, real-time processing
- Quick turnaround based on up-to-the-minute information
- Extensive edits to insure data integrity Automatic eligibility
determination
- Automatic and date sensitive pricing files and fee schedules
- Automatic adjustment of coordination of benefits (COB).
- Online, real-time plan design including individual and family
benefit accumulation and maximums
- Daily and monthly reports on claims
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Claim Adjudication
The GISC claim system allows for both benefit and eligibility checks
along with benefit determination. The edits built into our system allow
us to:
- Detect reasonable & customary abuse
- Detect Fraud
- Detect Physician overcharges
- Detect and avoid duplicate payments
- Identify services inconsistent with diagnoses
- Establish claimant status for COBRA, COB, retirees, students,
etc. to comply with customers specific exclusions and overrides.
- Verify eligibility, benefit plan,waiting periods, pre-existing
condition provisions and timely filing limitations
- Interpret claimant, service and provider data to determine service
eligibility
- Provide a variety of reports to help the customer analyze their
plan using service provider and ICD-9 code data.
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