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Every business has its 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.
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.
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.
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.
SDS provides support for the following transactions in our claim workflow:
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.
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:
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:
The benefits of Smart Data’s Med-Sup Cross Connect solution include:
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.
Smart Data Solutions does provide Mandatory Insurer Reporting (MIR) support. Smart Data can assist a client with group health plans in the following ways:
Our tools, solutions, and continued research into new AI and machine learning processes help payers nationwide reduce costs, achieve greater process efficiency, and reduce turnaround times.
