Email info@claimsbridge.com  Phone (410) 349-3222

ClaimsBridge Solutions

ClaimsBridge DirectSM

Our ClaimsBridge® High Performance Networks are custom provider network solutions for self-insured employers, it takes the empowerment of independent healthcare groups to new levels with the end-to-end infrastructure and experience needed to operate their own High Performance Networks. Results include more control over coverage, more quality of care and lower group healthcare costs.

The ClaimsBridge High Performance Networks are the ONLY custom network resource powered by ClaimsBridge Technology which connects providers, payers, TPAs and other entities involved in all aspects of healthcare claims management. Efficient design, intuitive operation, flexible solutions, reduced redundancy and scalability for future growth are all hallmarks of the ClaimsBridge Technology suite of services.

ClaimsBridge Direct builds High performance Networks with Medicare based direct provider agreements for:

ClaimsBridge Direct
  • Self-Insured Employers

  • Third Party Administrators (TPAs)

  • Accountable Care Organizations (ACOs)

  • Health Insurance Brokerages

  • Benefits Administrators

  • ANY organization interested in gaining more control over group healthcare costs, coverage and quality through the development and management of their OWN provider network.

ClaimsBridge Direct Services can help you.

Q: What sets ClaimsBridge apart from other builders of High Performance Networks?

A: Quite simply, technology and depth of experience.

Q: How can ClaimsBridge help my company reduce healthcare costs?

A: At organizations with 200 or more employees, approximately 85% of covered workers are enrolled in partially or completely self-funded plans. Employers self-fund to cut costs, hopefully without sacrificing plan service quality. ClaimsBridge helps self-funded employers custom-build and operate their own health provider networks. Building your own network is a practical way to gain even more control over healthcare costs and quality of coverage. ClaimsBridge replaces the “one size fits all” leased network model with a cost effective custom network created around the specific needs of your business and employees. ClaimsBridge’s High Performance Network model provides unmatched flexibility to deliver the most efficient, cost effective coverage attainable.

Q: What is a High Performance Network?

A: There are four structural differentiators from the more costly leased network model. With a High Performance Network:

  1. Providers are selected based on your own group’s specific needs.

  2. Better discounts are contracted from fewer preferred providers.

  3. Direct provider contracts are based on Medicare methodology.

  4. High Performance Network health plan designs benefit your Group, members and providers… without layers of cost for leased network administration, insurance company access fees and other low-value overhead.

BENEFITS

  • Simple, competitive provider agreements using nationally indexed data

  • Claim stability through competitive provider reimbursements

  • Stop Loss premium discounts

  • NCCI and Medicare claim editing

  • Lower member out of pocket expenses

FEATURES

  • Replace the "pre-designed" network with a cost-effective custom network

  • Elimination of high cost providers

  • Leverage plan design and steerage to reduce member liability

  • Simplicity of provider contracts

ClaimsBridge ConnectSM

ClaimsBridge Connect – our claims processing infrastructure line of business – securely connects healthcare providers, PPOs, TPAs and payers over the internet so they can provide rapid, accurate, and cost effective solutions, with reduced redundancy and scalability for future growth.

The ClaimsBridge Connect technologies, efficient design, intuitive operation and flexible solutions are hallmarks of its suite of services which include:

  • EDI Transaction Management

  • Repricing

  • Claims Conversion Services

  • Data Validation & Scrubbing

  • Routing Services

  • Web Portal Solutions

  • Contract Management

  • Claim Status & Tracking

ClaimsBridge Connect

Clients simply choose which ClaimsBridge Connect services best meet their needs at any given time.

EDI
  • ClaimsBridge maintains two-way EDI connections to major clearinghouse services in addition to supporting direct connections to our clients and providers

  • ClaimsBridge supports 5010 as well as proprietary claim formats for HCFAs, UBs and Dental claims. Most common HIPAA transaction sets are 837s, 835s, and 277s

  • ClaimsBridge uses intelligent, rules-based processing applying the business rules for each specific client

  • Each claim is processed individually, not in batches, and advances at its own pace

  • ClaimsBridge uses industry standard FTP, Secure FTP and PGP protocols to protect data

Paper to EDI

ClaimsBridge users have several choices for how to convert paper to EDI format

  • Mailroom services can be implemented to handle high-volume paper claim volumes – open, sort, forward and store – allowing 100% paper based organizations to transition to EDI smoothly and benefit from its use immediately

  • Conversion to EDI – both OCR and KFI techniques are supported. Accuracy can be enhanced by using our custom-built scrubbers

  • Scanning can be performed on your site or in our mailroom facility

  • ALL EDI claim data as well as associated images are fully indexed and accessible through the ClaimsBridge Web Portal

Scrubbing
  • The objective of the ClaimsBridge scrubbing services is to maximize our client’s auto-adjudication or auto-pre-pricing rates

  • Data Validation – to provide the most accurate editing and validation ClaimsBridge uses industry standard code sets and HIPAA specifications to validate claim format and content. Using artificial intelligence techniques ClaimsBridge is able to automate the validation processes

  • Client provider and eligibility data can be used to match incoming claims The matching algorithms follow each client’s specific business rules

  • The fully customizable ClaimsBridge export module is capable of adjusting claim markings to fit your particular needs

Repricing
  • ClaimsBridge can automate much of the repricing process using business rules and pricing structures applicable to each ClaimsBridge client

  • Repricing rules can be as complex as needed, based on one or more of the following: CPT/HCPCS, Revenue Codes, DRG Codes, Primary Diagnosis Codes, Anesthesia, Fixed Dollar amount or Percent of Charges, Reprice claim segments with different schedules, calculation rules hierarchy

  • Claims which can not be priced by the primary network can be automatically diverted to wrap networks for processing before the claim is returned to the client.

Routing
  • Point to Point Routing – Clearinghouse, PPO, Provider to Payer or PPO for further processing

  • Wrap Routing – Rules based structure that seamlessly adds wrap networks in the claims flow built on rules defined by the client

  • Affiliation Routing – ClaimsBridge Router solves the complex claims flow between an affiliation of networks/PPOs joining each entity together by using customizable business rules utilizing data such as eligibility, provider location, etc.

Web Portal
  • The ClaimsBridge Web Portal is a powerful interface that helps clients view data while speeding up problem resolution and simplifies customer support

  • This secure, easy to use website means that ClaimsBridge clients can always access their data and never need to worry about installing the latest update of software

  • All Client data is stored securely in the ClaimsBridge Data Warehouse

  • In addition to supporting powerful lookup and reporting capabilities, the Web Portal can be used to:

    • View data integrated from various sources

    • Check eligibility and plan participation

    • Update/correct provider data

    • Generate directories of providers

    • Maintain fee schedules

    • Upload scanned batches for paper to EDI processing

    • View online ClaimsBridge user guides

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