Integrated Services

Claims Adjudication
Claims for medical, dental, vision and disability income programs are processed on an automated basis.

Using QicClaim2 software program from Resource Information Management Systems, Inc. (RIMS), Benefit Plan Administrators provides many claim adjudication features not normally associated with the processing of claims. Our system maintains 24 months of on-line rolling claims history, along with tracking multiple benefit plans in multiple locations. The claims adjudication process includes a wide range of functions, including:

  • Electronic Claim Submission
    • Specific and Aggregate Reinsurance limits
  • On-line Eligibility and Coverage History
  • Automated Batch Adjudication
  • Automated Production of EOB forms
  • Automatic Claim Hold for Quality Reviews
  • Duplicate Payment Edits
  • Reasonable and Customary Edits
  • Automated Correspondence
  • IRS 1099 Reporting
  • Multiple PPO Contracts
  • Benefit Plan Design and Document Preparation
  • Check Payments Tied to Customer Funding Arrangements

Cost Containment
The following summarizes BPA’s cost containment features:

  • Eligibility dates prompt for pre-existing
  • Termination date can be input prior to the actual date
  • Benefits are pre-loaded
  • Duplicate Bills
  • Prompts for Pre-Admission Review, Second Surgical Opinion
  • Tracking frequency of examiner overrides of system edits
  • Claimant and Provider prompts
  • R&C updates semiannually for all CPT and ADA codes
  • History maintenance of deductibles, out-of-pocket and carryovers
  • Over-utilization (reports)
  • Claim dollar maximums
  • Semi-private prompts
  • Necessity of assistant surgeon
  • Custodial care charges
  • Diagnostic procedures
  • Pre-Existing Conditions

· Coordination of Benefits (COB) - Procedures include accessing the data gathered through enrollment and acquired through submission of each claim form where evidence indicates other health coverage. If there is evidence on the claim form that other coverage exists, the claims examiner inquires or “pends” the claim for additional information from the provider of service or from the covered participant.

Benefit Administration

Plan Document Preparation - BPA’s standard Plan Document is prepared by Corbel, a documents specialty company. Corbel is headquartered in Jacksonville, Florida, and deals solely with employee benefit related products and services.

I.D. Cards – Newly designed, double sided plastic I.D. cards are provided upon completion of initial enrollment.

Standard Forms - Standard claim and eligibility forms are provided.

Toll Free Number - A toll free telephone number for employees and providers is available for inquiries on the status of claims, eligibility, and benefit plan information.

Claim Evaluation - A complete evaluation of all claims is prepared based on the schedule of benefits outlined in the Plan Document.

System Security - Four levels of security are built into our benefits system. This security offers savings to the employer due to the reduction of errors in several areas, including claim adjudication, eligibility and provider maintenance. This system also provides the maximum protection against claims fraud.

Audit/Quality Review - 5% of all customer claims are reviewed by the audit department for accuracy relating to the input of the claim, dollar and financial accuracy, and benefit determination.

Billing - We have the ability to separate costs and bill by locations or groups, divisions or product offering, as well as consolidate payments for insurance products and other services.

Fund Administration - Claim drafts are issued on your own bank account. BPA will provide a check register and monthly reconciliation of issued drafts, voids and refunds.

Data Reports - BPA provides daily check registers and extensive monthly reports that provide management tools for analysis and control of benefit costs.

File Notes - Notes on-line provide for immediate review of specific details regarding any given claimant.

Printing - The production of checks, Explanation of Benefit forms, statistical reports, and correspondence.

On-Line Services - Claims, Eligibility, Express Requests, Schedule of Benefits and many reports are available on the home page of BPA through a secure log-on.

Financial Administration

Fund Consulting Services - Provide consulting service to establish an initial loss fund, an annual review of experience, and assist in the establishment of banking services to handle the flow of benefit payments.

Vendor Integration - Integrate the collection of fees for various vendors and pay vendors directly.

Check Printing - All checks are printed in our office on laser printers. (No pre-printed check stock required.)

Account Review - Provide the employer with an accounting of payments made, including sufficient detail to allow for audit and complete control of funds utilized.

IRS Reporting - Complete IRS 1099 reporting and provide data for the completion of IRS 5500 forms.

Subrogation Administration
BPA maintains a relationship with a subrogation firm to provide claims negotiations and maximum recovery efforts from responsible third-party insurance companies and other payors. These recovery professionals include experienced ERISA attorneys.

Claims Referral Process - BPA works with each customer to identify and maximize recovery efforts and manage all correspondence with employees and third-parties.

Claims Negotiation - Vendors negotiate and settle claims with insurance companies and other payors.

Subrogation Reporting - Reports document the recovery process on a monthly basis that include new case activity, active cases in process, and closed cases with recovery results. Reinsurance Management

Stop Loss Solutions - BPA has access to a wide variety of stop loss products and services that include individual and aggregate coverage, an aggregating specific product, premium risk sharing arrangements and a terminal liability option. We have access to multiple Managing General Underwriters (MGUs) who represent specific carriers that provide alternative products and solutions to meet unique customer needs.

Vendor Integration - We can bill, collect and remit monthly premium payments to your carrier. This will alleviate your having to process numerous invoices and payments.

Monthly Review - BPA will review paid claims by individual to monitor the progress of claims reaching or surpassing 50% of the Individual Specific Deductible. When necessary, we will notify the carrier of the specific details of the claimant and together, BPA and the carrier, will closely follow the claim. The aggregate claims, if applicable, will also be tracked to ensure awareness of any approaching aggregate claims.

Renewal Review - BPA will evaluate the stop loss pricing at renewal and ensure a fair and competitive market value for the services offered.

RIMS Management Reporting
BPA provides a wide variety of operational reports through our RIMS claim system. These statistical, management, and financial reports can be formatted, compiled, and classified based on your needs.

Standard Monthly Reports
We believe the majority of your reporting needs can be provided with our standard report formats. These include:

  • Coverage Analysis
  • Monthly Financial Transaction Register
  • Benefit Analysis
  • Claim Void Audit Register
  • Individual Specific Analysis
  • Fund Account Report
  • Paid Claims Analysis
  • Pending Claims Listing
  • Loss Ratio Reporting
  • Monthly Billing Statement

Optional Reports
BPA can provide additional reports upon request. These include:

  • Cause Code Analysis
  • Eligibility List
  • Claim Lag Study
  • Monthly Paid Claims Register
  • Claims Exceeded Analysis
  • Turnaround Time Report

Customized Reports
When a customized report is required, BPA has the capability of accommodating your needs. An additional fee might be involved.

  • Procedure Analysis
  • Average Length of Stay
  • Provider Payment (incl. 1099's and W2's)
  • Admissions per 100
  • Hospital Utilization Statistics
  • Co-payment Analysis
  • Benefit Utilization Analysis
  • Attending Physician Review
  • Weekend Admissions
  • Network Savings
  • Provider Comparison Analysis

Universal Claims Rules

BPA uses this RIMS “artificial intelligence” system to automate the claims processing function. A clean claim will flow thorough our system for adjudication and be processed without human intervention. This capability gives BPA increased quality control and efficiency.

Electronic Data Interchange (EDI)
BPA has the capability to receive physician and hospital claims electronically. Furthermore, we are automating the claims adjudication process so that a “clean” claim flows through our system and a check and EOB will be produced without staff involvement. This capability enhances efficiency and turn around time.

BPA COBRA PROCEDURES

1). Initial Cobra Rights & HIPAA Rights letter sent out when first enrolled. A separate copy is sent to both employee and spouse( if applicable ). This notice is sent proof of mail through the Post Office.

2) Responsibility of group to notify BPA within 30 days of qualifying event. When we receive the notice, the information is entered into Travis Cobra software and notices are sent within 14 days(mailed out proof of mail every Friday). This notice includes a letter stating their term date, amount of coverage they are eligible for, last date to enroll, certificate of coverage and payment procedure. It also includes an enrollment form, family member enrollment form and premium computation form. They also receive another COBRA & HIPAA rights letter.

3) Upon receipt of completed enrollment form and required premium payment, a confirmation letter and payment coupons are mailed to the Qualified Beneficiary’s home address within 7 days.

4) Upon receipt of a completed enrollment form without the premium payment, a reminder letter requesting payment and naming specific receipt deadline is sent out within 14 days.

5) Once a week BPA prints all Cobra letters. This will print out any new elections, terminations, non-payments or changes that were made. Software is date sensitive. These notices also include Social Security Administration, disability extensions, Medicare eligibility letters ( for 65th birthday only ).

6) For group rate changes, the participants need to be given at least a 30 day notice. These rates may increase only once within a 12 month period. Upon receipt of the increase, BPA will see that notices are sent out in a timely fashion.

7) BPA post payments daily ( as we receive them) in Cobra system and log book.

8) All elections are entered in log book and files are made for each individual that elects COBRA. Each group has a current file, a did not elect file, a log file and a correspondence file.

9) Cobra reports are sent out to the groups on a monthly basis. These reports include: Eligibility listing of all pending COBRA elections, all active COBRA participants, copies of log sheets showing all notices sent, and all premiums received for that month.

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