Claims Processing
The Claims Department is one of the operational arms of the organization and is solely responsible for processing all reimbursement claims and encounter visits submitted by providers. Claims are received from all providers who render services to Health Care Plus, Child Health Plus, and Family Health Plus members.

Processing claims includes logging in the claim; verifying eligibility of the member, provider and service; utilizing applicable contract and medical policy; pricing the services claimed; entering the data into the claims database; and adjudicating the payment or capturing the encounter data. The department handles both written and telephone correspondence and is responsible for any modification to the original adjudication of the claim. The department is headed by a director and staffed by 2 supervisors and various levels of claims processors who are familiar with medical coding and medical terminology and trained in various policies necessary to adjudicate claims and encounter visits.

In addition to paying claims, the department captures vital information for the organization each time it adjudicates a claim and enters the data. This data is an important source of information for the utilization, medical, and financial management components.