Recognizing that the accurate and timely processing and payment of claims is a critical customer satisfaction measure for TPAs and health plans alike, PBI follows a systematic workflow to quickly prepare healthcare claims for payment. PBI has professionally handled medical claims processing outsourcing tasks. With proven technical management capabilities, we are experts at gathering, analyzing, and reporting healthcare claims data. Our claims adjudication team can quickly identify and take action against inappropriate utilization of services and quality of service concerns. We assure you of HIPAA compliant security for your data.

We understand that the payers and TPAs have set their claims engines to auto-adjudicate claims received from providers. During auto-adjudication, the claims engine verifies member/patient eligibility and provider information on a claim using the client’s database. Any claims that do not match are exported to the manual adjudication queue. However, manual adjudication results in a fluctuation of quality, as manual adjudication can never be as efficient or accurate as the auto-adjudication process. We ensure to arrest this problem by matching member and provider information on claims against the client’s database before the claim is even loaded into the system.

• Loading the unique pointer into the claim file so it can be loaded into the engine
• Providing matches using the appropriate business rules
• Manually matching any claims that cannot be automatically matched
• Creating database records
• Adding providers’ specialty and category from the NPIDB to new provider records
• Capturing the client’s database’s unique IDs and adding them to the claims’ EDI files
• Instant identification of appropriate eligibility so that provider records can move on to the next step of the auto-adjudication process

You can count on us for all or any of the below services at all times. We guarantee high quality out put at optimal cost within realistic deadlines.