Claim Payment Services
In an era when our contemporaries have reduced their margins by
automating their services, the management of EGP recognizes that the
true value provided by our organization is derived from the
contributions of professionals dedicated to servicing our clients.
Managed care provisions and the associated provider discounts cannot
effectively control health care costs without the necessary check
and balance system provided by a claim manager. Our claims
management system has been effective in curbing medical inflation,
which has enhanced our ability to provide premium and claim expense
Our Claims Department is committed to reducing claim
turnaround time, enhancing client service and ensuring payment
accuracy. Payment accuracy includes benefit plan provision
enforcement as well as medical necessity and usual, customary and
reasonable (UCR) determinations.
- Personal Service
Each claims adjustor is assigned a specific list of employer
groups. That means plan participants communicate with the same
individual when there are claim questions. Adjustors are
familiar with their assigned cases – including individual
medical and claim histories – which improves efficiency and
leads to active claim management and case management referral.
- Consistent, Efficient Claims Processing
Each claim received is processed by the same adjustor from start
to finish. Each adjustor is assigned maximum payment amounts,
and claims in excess of these amounts must be reviewed and
approved by the manager or supervisor. An internal random claim
audit procedure is also followed.
- Objective Determination of Medical Necessity
Medical necessity determinations are provided by an independent
medical consultant firm. Reasonable and customary levels are
provided by data from Medicode UCR tables or through the medical
- Thorough Review of In-patient Hospital Billings
All in-patient hospital billings, which meet specific criteria
including a minimum dollar amount, are audited by our medical
consultants. This audit consists of a review of the entire
medical file and a comparison to the itemized billings.
- Hold Harmless Protection
EGP provides access to Hold Harmless services as a protection
for plan participants against collection of charges which were
determined to be not medically necessary.
- Major Medical, Dental, Vision, Prescription and
- Detail claim financial performance reporting
- Coordination of benefits investigation and integration
- Third-Party subrogation identification and recovery
- Precertification, Utilization and Review, and Case
For the purpose of precertification, utilization and review,
medical claims auditing, and case management, Enterprise Group
Planning subcontracts with specialized providers.
The utilization management program takes a hands-on proactive
approach to managing health services. This approach involves
basing certification on medical necessity, being involved daily
in each case, and reviewing the quality and efficiency of care.
Communication with the patient, physician and hospital is
critical to ensuring the best possible care for the patient and
provides for a valuable resource to the family as a guide
through today's health care system.
Case management provides significant claim cost control through
the referral of specialty providers, recommendation of methods
of treatment, and the negotiation of fees. It also promotes your
organization by building significant goodwill with the family of
the patient who benefits from the advice, counsel and support of
a professional nurse during a period of personal stress.