Simplified Claims Transactions

Sources the cleanest route from provider billing to claim adjudication.

Hand Shake

What's Inside the Box

  • Single Source Clearinghouse
  • Mailroom & Scanning
  • PPO Network Administration
  • Claims Repricing
  • Negotiations

Payor Overhead Reduction

Typical repricing looks like.

  • 1. Claims come in from various sources
  • 2. Sort by group
  • 3. Scan paper claims
  • 4. Send to EDI vendor for conversion to HIPAA format
  • 5. Determine which network is primary & send claim for repricing
  • 6. Claim is repriced by network
  • 7. Claim sent back to TPA for processing
  • 8. Eligibility determined & verified; claim processed or denied
  • 9. Claim is not in primary network
  • 10. TPA sends to wrap network
  • 11. Eligible in wrap, repriced, sent to TPA for processing
  • 12. Not in wrap – claim returned to TPA
  • 13. TPA sends to supplemental network
  • 14. Supplemental reprices, returns to TPA for processing
  • 15. Not in supplemental network, claim returned to TPA
  • 16. TPA sends to outside firm for negotiation
  • 17. Claim is negotiated & repriced; returned to TPA for processing
  • 18. Claim is not negotiated, return to TPA for OON processing
  • 19. Is claim eligible? Do you need accident details, medical records, etc?
  • 20. Claims must be monitored - were all claims sent to networks returned?
  • 21. TPA maintains provider file, handles additions, changes, terminations
  • 22. TPA maintains fee schedules & must make any changes
  • 23. TPA maintains PPO contracts, makes changes, etc.
  • 24. TPA handles any disputes, customer service for providers
  • 25. TPA deals with potential loss of discounts if TAT exceeds 30 days

How claims could be handled

  • All claims are received by INETICO
  • All claims are delivered to the payer in 837 format for adjudication

Consolidated Clearinghouse Process

  • Provide

    Single source for electronic claims transactions

  • Convert

    Paper to EDI

  • Validate

    Provider and member data

  • Route

    To primary, wrap, supplemental networks or negotiate discounts

  • Monitor

    Location and status of claims
    Typical TAT 24-48 hours
    (3-5 days if negotiated)

  • Maintain

    PPO contracts

  • Handle

    All customer service & provider inquiries

  • 100%

    Of claims ready for adjudication


The INETICO Advantage

  • Automated workflow reduces pre-processing costs and improves auto adjudication
  • No fee for member matching -
    INETICO retains eligibility
  • No claim volume minimums
  • Simplified single-source claim routing to unlimited networks
  • Set-up within as little as 14 days
  • National payor ID# - picks up from all locations
  • No fee to view claims status
  • Average turn around time 24 to 48 hours

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