WHAT IS YOUR TPA DOING FOR YOU?
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CHECKLIST
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IHS
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YOUR TPA
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Claims Administration
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*Audit Procedures
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C 100% audit on claims over a set dollar amount, determined by auditing department
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xYes oNo
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oYes oNo
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C Random audits performed on all claims adjudicators
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xYes oNo
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oYes oNo
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*Claim Processing Standards
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C Statistical Accuracy 98 .0%
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xYes oNo
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oYes oNo
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C Financial Accuracy 99.3%
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xYes oNo
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oYes oNo
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C Processing Accuracy 98.0%
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xYes oNo
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oYes oNo
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C 3-4 day claim turnaround time
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xYes oNo
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oYes oNo
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*Online Capabilities and Services
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C Online Claim Reporting
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xYes oNo
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oYes oNo
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C Online Claim Status & Inquiries
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xYes oNo
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oYes oNo
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*Claims System Editing Prompts
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C Duplicate Claim Alerts
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xYes oNo
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oYes oNo
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C Full Time Student Status
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xYes oNo
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oYes oNo
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C Coordination of Benefits
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xYes oNo
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oYes oNo
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C COBRA Payment Coordination
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xYes oNo
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oYes oNo
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*Medical Claim Review Department
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C Multiple Surgeries
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xYes oNo
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oYes oNo
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C Assistant Surgeons
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xYes oNo
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oYes oNo
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C Bundling/Unbundling
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xYes oNo
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oYes oNo
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C Over-utilization of services
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xYes oNo
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oYes oNo
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*Customer Service
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C Prompt and Efficient Service
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xYes oNo
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oYes oNo
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C Hold time less then 2 minutes
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xYes oNo
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oYes oNo
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C Direct contact with claim adjudicator
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xYes oNo
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oYes oNo
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C Courtesy Call to Plan Sponsor for claim payments that exceed a pre-determined dollar limit
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xYes oNo
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oYes oNo
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Managed Care (NHS)
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*Utilization Review
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C URAC Accredited National Organization
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xYes oNo
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oYes oNo
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C Online Capabilities (Real-Time in DEW's database)
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xYes oNo
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oYes oNo
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*Large Case Management
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C Trigger Diagnosis
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xYes oNo
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oYes oNo
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C On-Site Physicians and Registered Nurses
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xYes oNo
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oYes oNo
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C Intervention Programs
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xYes oNo
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oYes oNo
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Banking Arrangements
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*Funding Account
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C Option of the Plan Sponsor to maintain their own claims account, or to have the TPA maintain an account on their behalf
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xYes oNo
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oYes oNo
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C ACH Transfer Capabilities
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xYes oNo
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oYes oNo
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C Weekly Check Register Sent to Plan Sponsor via email
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xYes oNo
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oYes oNo
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Eligibility Maintenance
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*Enrollments/Changes/Terminations
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C Received, Processed and filed daily
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xYes oNo
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oYes oNo
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C Online Capabilities for Plan Sponsor
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xYes oNo
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oYes oNo
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Compliance
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*Plan Documents
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C Prepared by Plan Document Department, consisting of Paralegals and ERISA Attorney
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xYes oNo
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oYes oNo
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*COBRA/HIPAA Administration
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xYes oNo
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oYes oNo
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*DOL Final Claim Regulations
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xYes oNo
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oYes oNo
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*Federal Standards for Electronic Transactions (EDI) See Compliance Checklist
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xYes oNo
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oYes oNo
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