Systematic Workflows Designed to Streamline the Adjudication Process

Claims Adjudication Support

Recognizing that the accurate and timely processing and payment of claims is a critical customer satisfaction measure for TPAs and health plans alike, Vee Healthtek follows a systematic workflow to quickly prepare healthcare claims for payment.

Our Claims Processing and Adjudication Services Include:

Member/Coverage Eligibility Verification:

Our claim processers review the claim to verify if the service is eligible to be paid by the health plan. This process compares the member’s benefit information and the submitted claim to determine if the member has active coverage. We can complete eligibility verification within or outside a client’s system. If the member has active coverage, the claim is forwarded for processing. If the claim is ineligible, it is rejected and returned to the claim submitter with the reason for the denial.

Benefit Determination:

To establish the amount to be paid, claims are reviewed to determine the member’s co-pay and if the deductible has been reached.

Payment Amount Calculation:

Our team reviews the claim and calculates the allowed payment amount based on the provider’s in-network/out-of-network status.

Vee Healthtek has supported its clients in adjudicating over 60 million claims, delivering a 98% accuracy rate. We have substantial experience processing claims in a variety of systems, including medical, dental, vision, and prescription (drug) claims.

Large/High-Dollar Claims:

A dedicated, highly skilled team takes care of handling large/high-dollar claims. Typically, these claims require a complete review of itemized statements, clinical review reports, discharge reports, invoices raised by the equipment/implant suppliers, and any other details needed based on the nature of the treatment. We send requests for supporting documentation and complete the follow-ups with members/providers until the inform. Once the relevant information is received, the claim is processed in accordance with the client’s instructions.

Dental and Vision Claims:

Our team of dedicated experts is assigned to handle dental and vision plans.

Prescription Claims:

Prescription/drug claims are received from various PBM networks but are different from regular medical claims. The claims are reviewed to determine and differentiate the generic and non-generic drugs to determine payments based on the plan offering. Special attention is given to drugs, which are non-approved by FDA and plan exclusions.