Medical Claims Routing

Few payers today can operate on data exchanges between themselves and their providers alone. Larger administrators need to communicate and exchange data with multiple trading partners such as PPO networks, and other bill review and cost containment partners. Certain lines of business, such as Medicare supplemental insurance, also rely on having similar dedicated connections in place to submit and receive information. Managing these connections through a front-end gateway streamlines your workflows allowing you access to all of the trading partners you connect with, while only needing to manage one data stream between you and your gateway.
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Affiliations and Partnerships

Smart Data Solutions is connected with over 200 PPOs nationwide allowing for an easy up-front way to obtain your network discounts.

Medical Claims Routing

Claims Routing

Every business has their own unique networks and routing rules. Smart Data Solutions configures every routing workflow according to each of your needs. We are able to assign routes based on member, group, provider, or facility location information. Smart Data Solutions can handle primary networks, wrap routes, tertiary routes, and any carve out exceptions needed.

Medical Claims Routing

Clinical Editing and Bill Review

Smart Data Solutions connects to a number of clinical editing and bill review service providers. Prior to adjudication, Smart Data Solutions can exchange the claim data with your partners allowing them to apply additional discounts or edits. This data is then combined back into the final EDI stream to your adjudication system.

Medical Claims Routing

MedSup Cross Connect

For clients that offer Medicare supplemental plans, Smart Data Solutions can help manage the CMS connection for you. We are able to take your existing membership data and format it into the expected E01 format used by CMS / GHI. We coordinate and manage this ongoing E01 data exchange in parallel with the inbound 837 clam receipt from CMS. Additionally, if we’re performing paper conversion to EDI, we can receive the claims with EOB attachments and run a duplicate check on the ICN to identify any duplicates.

Medical Claims Routing

Claims Routing

Every business has their own unique networks and routing rules. Smart Data Solutions configures every routing workflow according to each of your needs. We are able to assign routes based on member, group, provider, or facility location information. Smart Data Solutions can handle primary networks, wrap routes, tertiary routes, and any carve out exceptions needed.

Medical Claims Routing

Clinical Editing and Bill Review

Smart Data Solutions connects to a number of clinical editing and bill review service providers. Prior to adjudication, Smart Data Solutions can exchange the claim data with your partners allowing them to apply additional discounts or edits. This data is then combined back into the final EDI stream to your adjudication system.

Medical Claims Routing

MedSup Cross Connect

For clients that offer Medicare supplemental plans, Smart Data Solutions can help manage the CMS connection for you. We are able to take your existing membership data and format it into the expected E01 format used by CMS / GHI. We coordinate and manage this ongoing E01 data exchange in parallel with the inbound 837 clam receipt from CMS. Additionally, if we’re performing paper conversion to EDI, we can receive the claims with EOB attachments and run a duplicate check on the ICN to identify any duplicates.

Controls and Reports with the Process

Whether you are connected with one network or dozens our dashboard display provides a summary and detailed information to provide as much transparency into the process as possible. Smart Data Solutions monitors each claim out with the networks, tracking it every step of the way to ensure full reconciliation. If a claim is out with a PPO for longer than expected, automated reconciliation alerts are sent out to highlight the aging claim and to speed its resolution.

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791,000+
transactions routed per month
442
repricing network connections
400+
Clients
500M
transactions annually

Frequently Asked Questions

What form types does SDS provide a claim workflow for?

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x

SDS provides support for the following transactions in our claim workflow:

  • 837P: Healthcare Claim Professional
  • 837I: Healthcare Claim Institutional
  • 837D: Healthcare Claim Dental
  • 835: Healthcare Claim Payment Advice
  • 270/271: Healthcare Eligibility Coverage or Benefit Inquiry
  • 276: Healthcare Claim Status Request
  • 277: Healthcare Claim Status Response
  • 277/275: Healthcare Claim Request for Additional Information
  • 834: Payroll Deducted and Other Group Premium Payment
  • Faxes
  • Electronic Attachments
  • Direct Data Entry (DDE)
  • Eligibility and Enrollment Forms
  • Spousal Coverage Verification Forms
  • Doctor’s Notes
  • Non-Standard Forms
  • Proprietary Forms
  • Practice Management System
  • PPO Routing and Direct Connections
  • EOB Forms

We’re looking to automate our manual workflows such as matching of member and provider, repricing of a claim, etc. Does SDS help with that?

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x

Yes. SDS will receive your member and provider files and run automated matching on every inbound claim. Claim data is compared against provider and member extracts in order to validate the data captured. This can also be expanded to ensure that the members are eligible for services based on their coverage periods and dates of service. Matching can also ensure that the provider listed is on file in your system. In both provider and member match cases, SDS can backfill any missing data and normalize information to match your expected formatting conventions to ensure the highest auto adjudication rates possible. If claims fail to pass member or provider checks, SDS can issue rejection letters back to providers alerting them of the discrepancy.

SDS also automates repricing of claims. Based on eligibility, we will route claims to primary networks and wrap networks until a repricing amount is applied.

Does Smart Data offer image archiving and retrieval?

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x

Yes, Smart Data offers SafeClaim image archiving. We’ll archive the paper claim image, raw EDI, matching information, routing information. SafeClaim integrates seamlessly with QuickClaim, our main dashboard for real-time tracking and reporting. SafeClaim includes the following features:

  • 24/7 Access
  • Ten Year Claim Access
  • Indefinite Image Storage for Contracts/etc
  • HTTPS Secure Web Access
  • No Limit on Number of Users
  • Notes (Ability to annotate claims)
  • Hitching (Allows subsequent related documents to be “attached” to a claim)
  • Ability to print or e-mail from system
  • Back-up in triplicate
    • HIPAA tracker capability (Reports on everyone who has viewed the document)

Does SDS provide services for Medicare Med-Sup Cross Connect?

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x

Payers of Medicare Supplemental Insurance often receive both paper and electronic versions of EOBs, which can result in overpayments, lost time and lost money. SDS prevents these expensive duplicates by automatically comparing the ICN of any EOB entering the system through the following process:

  1. SDS takes the electronic 837 off the provider’s claim management system and captures the data while documenting the ICN
  2. If any additional paper or electronic claims are received SDS compares the ICN with previously received ICNs
  3. If any duplicates are found the duplicate is deleted and reported back to the client

The benefits of Smart Data’s Med-Sup Cross Connect solution include:

  • Lower processing cost
  • Immediate duplicate checking
  • Elimination of duplicate payments

Does SDS perform PPO Routing?

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x

SDS PPO Routing provides direct connections to many PPOs. SDS performs PPO Routing supported by our claim archiving and reporting engines. Clients have the ability to track claims at all times including routing history.

Does SDS perform Mandatory Insurer Reporting (MIR)?

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x

Smart Data Solutions does provide Mandatory Insurer Reporting (MIR) support. Smart Data can assist a client with group health plans in the following ways:

  • Ability to manage your initial and quarterly eligibility submissions to COBC
  • Reformat your file of insured’s so it is accepted by COBC
  • Provide a web interface to change the insured information where needed
  • Handle and process rejects to COBC with SP disposition coded by providing you an interface for corrections
  • Track and crosswalk all DCN, adjudication numbers, and HICN numbers
  • Provide real-time reporting and alerting to always keep you updated
  • Manage active covered individuals and the TINS they are affiliated with
  • Send the proprietary file to COBC
  • Manage the social security number gathering that is required
  • Manage the MSP number returned from CMS with ’01’ disposition code
  • Handle new data field needs
  • Manage communication and alerts from COBC
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CLIENT TESTIMONY

Debbie Ziegler

“SDS performs all of our front-end services. This includes clearinghouse, scanning, imaging, OCR and mailroom. SDS also facilitates and performs ...”
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CLIENT TESTIMONY

Brian Janssen

“Smart Data operates as the EDI clearinghouse, paper claims and enrollment intake, and 834 enrollment hub for our commercial products. The development ...”
View Story
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CLIENT TESTIMONY

Matthew Estes

“SDS does EDI file translation mapping, eligibility checking, and routing to/from our business partners. SDS handles a lot of the heavy lifting for us ...”
View Story

CLIENT TESTIMONY

Debbie Ziegler

Executive Director of Operations
“SDS performs all of our front-end services. This includes clearinghouse, scanning, imaging, OCR and mailroom. SDS also facilitates and performs automated routing to PPOs and networks, thereby ensuring that we expediently maximize client discounts. SDS also does pre-adjudication edits, such as member and provider matching. Finally, SDS provides custom IT services such as file format conversion and transfer for our Amerihealth and BCI partnership claims. SDS has a comprehensive service suite thereby allowing “one-stop shopping’ for all our front-end services. This is both cost-effective and much easier to manage. In addition, their IT aptitude allows us to fill in the gaps for one-off type projects. The process runs smoothly without much intervention. When we do have an issue they are quick to respond with a solution.”
“SDS performs all of our front-end services. This includes clearinghouse, scanning, imaging, OCR and mailroom. SDS also facilitates and performs automated routing to PPOs and networks, thereby ensuring that we expediently maximize client discounts. SDS also does pre-adjudication edits, such as member and provider matching. Finally, SDS provides custom IT services such as file format conversion and transfer for our Amerihealth and BCI partnership claims. SDS has a comprehensive service suite thereby allowing “one-stop shopping’ for all our front-end services. This is both cost-effective and much easier to manage. In addition, their IT aptitude allows us to fill in the gaps for one-off type projects. The process runs smoothly without much intervention. When we do have an issue they are quick to respond with a solution.”
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CLIENT TESTIMONY

Brian Janssen

VP, System Solutions
“Smart Data operates as the EDI clearinghouse, paper claims and enrollment intake, and 834 enrollment hub for our commercial products. The development and execution of these solutions is always done partnered with the business leaders to ensure meaningful improvements are achieved. Because of that, Smart Data is considered a valuable partner by business leaders. When we start a Smart Data initiative, as a corporate leader I do not have to worry about whether the outcome will be successful.”
“Smart Data operates as the EDI clearinghouse, paper claims and enrollment intake, and 834 enrollment hub for our commercial products. The development and execution of these solutions is always done partnered with the business leaders to ensure meaningful improvements are achieved. Because of that, Smart Data is considered a valuable partner by business leaders. When we start a Smart Data initiative, as a corporate leader I do not have to worry about whether the outcome will be successful.”
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CLIENT TESTIMONY

Matthew Estes

Chief Information Officer
“SDS does EDI file translation mapping, eligibility checking, and routing to/from our business partners. SDS handles a lot of the heavy lifting for us and allows us to focus on what we do best. No matter how complex the setup and routing, SDS has always been able to make it work for us.”
“SDS does EDI file translation mapping, eligibility checking, and routing to/from our business partners. SDS handles a lot of the heavy lifting for us and allows us to focus on what we do best. No matter how complex the setup and routing, SDS has always been able to make it work for us.”
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