Scholl Consulting Group, Inc.

Claim Processor

What is MHC?
  GUI CSIM add-on
  GUI Membership/Provider add-on
  Claim Processor
  UniBasic Programming
  HIPAA Compliance
  ODBC Setup
  Data Warehousing
  Java Eligibility Verification

ClaimAudit, a complete one-stop encounter processor for MHC.


ClaimAudit is a Visual Basic program that processes encounter batches for the MHC system. The complexity of the existing MHC claim and encounter adjudication system let my client to the step of rewriting the whole process in Visual Basic. Though these are encounters, my client was bound by the state to adjuducate and check those encounters for their validity. Here the steps, that the system performs:

  • Encounters arrive in batch files with a fixed length format. Usually they are deposited in an ftp server.
  • ClaimAudit takes these files and parses the information out.
  • Each Claim goes through a verification process, where data integrity and completeness are checked.
  • The member and the provider is checked against the MHC system, using the Universe API.
  • Encounters with errors are written to a seperate file and an entry into an error log is made, so that those encounters can be returned to the submitter.
  • The encounter information is then written to a Universe file in the same layout as the MASTER.CLAIM file.
  • Then the claim is audited according to most of the criteria a full medical claim would go through. The member's group and benefit package is analyzed to see if the member is eligible for the procedure, the provider information is checked to see if this procedure is within the provider's capacity and contract and the amount is checked to see of this is less or equal to the amount in the fee table.
  • If the claim passes all the audits and adjudications, it is written to MASTER.CLAIM and marked as adjudicated. If there is reason to suspend it, the claim is marked so and an entry is made into SUS.CLAIMS, so that a claim adjudicator can go back to it and manually adjudicate the claim.
  • The ClaimAudit program creates a detailed error and success report for each batch.

The processing time is reduced to a fraction of the time it took to before. All the import and verification routines are integrated instead of requiring manual intervention with each step.

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