Running head: TERM PROJECT PROPOSAL 1
Term Project Proposal - Current
BMIS 510 - B01
Liberty University
TERM PROJECT PROPOSAL 2
Abstract
After an appointment, a doctor or clinic sends a bill to a third party administrator (TPA)
to process and pay the submitted medical claim. The TPA gathers and reviews all relevant
information as paper copies including the patient appointment sheet, intake forms, and the proper
services documentation. The data is manually entered into the internal claims system, to be
reviewed against the patient's healthcare policy, pricing regulations, and to determine coverage of
services. Once coverage is determined, the TPA generates and prints paper checks, remittance
advices (RA), and explanation of benefits (EOB) for covered services, mailing the paper
documents to the appropriate party based on payment assignment.
TERM PROJECT PROPOSAL 3
Current Process
Stakeholders
Physician/Clinic
Patient
Customer Service Representative (CSR)
Claims Examiner
Claims Audit
Benefit Claims Analyst (BCA)
Claims Payable Specialist
Distinct Business Activities
Submitting medical claim for payment
Membership benefits managed
Medical claim and appropriate documentation reviewed
Medical claim data entered
Patient eligibility and benefit level determined
Pricing claim edits applied
Proprietary claim edits applied
Claim adjudication completed
Claims payment process completed
RA, EOB, and payment printed
Payment and remittances mailed
AS-IS Business Process
At the beginning of each week, the physician and/ or clinic prints and mails manual claim
forms for all patient visits from the prior week.
At the beginning of each month, the BCA reviews all received paper forms with
membership and benefit updates for each TPA managed health plan. They manually
update new and terminated members and/or change in member benefit levels in the
claims system. If a member is termed, a manual letter is generated and mailed to the
member. Once all updates have been completed, a manual email is generated and sent to
the Claims Examiners and Claims Audit team to notify them that all changes have been
completed.
TERM PROJECT PROPOSAL 4
At the end of each month the BCAs review the monthly updates related to health plan
pricing and provider contracts. They manually update all changes to the contracted
pricing rates in the claims system. Once all updates have been completed, a manual email
is generated and sent to the Claims Examiners and Claims Audit team to notify them that
all changes have been completed.
At the beginning of each day, CSRs open all newly received paper claim forms, sorting
and grouping by health plan. The CSR determines if all needed documentation has been
received to complete processing of the medical claim. If all documentation is not received
the original paperwork is returned to the doctor and/or clinic with a letter requesting
any/all missing data.
A status form is attached to each received claim form. The sorted and prepped claim
forms are hand delivered by CSR to the specific Claims Team that processes claims for
the specific health plan.
The Claims Examiner follows a Monday through Friday schedule to determine which
health plan claims are to be processed. Depending on the day of the week, they enter each
claim into the claim system in a first-in-first-out queuing system.
oThe Claims Examiner manually generates the claim number in the claims system
based on a preset criterion and writes the claim number on the status form.
oTo process and price the claim, the Claims Examiner locates the corresponding
member in the claims system and determines eligibility and benefit level. They
then pull the corresponding health plan document from the filing cabinet.
If the member is found to not be eligible a denial code is added and the
claim is adjudicated in the claims system. The status form is marked,
TERM PROJECT PROPOSAL 5
indicating the claim is denied, then signed and dated by the Claims
Examiner. The claim documents are hand delivered to the Claims Payable
Specialist.
oThe Claims Examiner manually applies insurer proprietary and general pricing
claim edits using a pricing Excel spreadsheet and the corresponding health plan
documentation.
oThe status form is marked, indicating the claim is processed, then signed and
dated by the Claims Examiner.
If the claim paid total is over $2000 the status form is marked as pending
in the claims system and the claims documents are hand delivered to the
Claims Auditors.
If the claims are less than $2000 the claim is marked as adjudicated in the
claim system and the claims documents are hand delivered to the Claims
Payable Specialist.
The Claims Auditors review any claims with a payment total over $2000 to ensure they
are valid requests and the pricing has been entered correctly.
oThe Claims Auditor pulls the corresponding health plan document from the filing
cabinet. They manually review the processed claim with the health plan
documentation to determine correct policies, procedures, compliance regulations,
and schedule of benefits have been followed.
If an error is identified, an error form is filled out and attached to the
original claim form. The error and claim forms are hand delivered to the
Claims Examiner for reprocessing.
TERM PROJECT PROPOSAL 6
If no errors are found, the status form is marked as audit complete and the
claims documents are hand delivered to the Claims Payable Specialist.
oThe Claims Auditors manually enter audit data into the database to document and
develop reports based on the audit findings.
The Claims Payable Specialist follows a Monday through Friday schedule to determine
which health plan claims are to be processed. Depending on the day of the week, they
compile claims for payment in a first-in-first-out queuing system.
oThe Claims Payable Specialist initiates the claims payment process in the claims
system.
oUsing a calculator, the Claims Payable Specialist validates the total payments
being issued indicated by the claims system equal the total of the corresponding
claim forms. The payment cycle is completed and the check register printed.
If an error is identified, the claim causing the error is removed from the
payment cycle, the status form is marked with the error and the claim is
hand delivered to the Claims Examiner to review and reprocess.
oThe payment totals and check numbers are manually documented in the
corresponding Excel spreadsheet and the printed check registers are filed.
oThe status form is marked, indicating paid, manually adding the corresponding
check number and paid date, signed by the Claims Payable Specialist. The claim
forms and all documentation are then filed.
oThe Claims Payable Specialist prints the individual checks, RA’s, and EOB’s and
they are manually stuffed in envelopes. The check and RA envelopes are mailed
TERM PROJECT PROPOSAL 7
to the provider, and the EOB’s are mailed to the member/patient, both via US
Postal services.
