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Claims Management (Access Management Software)

For years, managed care companies have used automated systems that can simplistically assess, track and triage consumers entering or re-entering their systems of care. Practice Management Technologies has forged ahead and developed a very straightforward and easy to use system that is now available for behavioral health organizations of all sizes and budgets.

PMTech's Claims Management Module is specifically designed for Managed Care Organizations, Specialty Networks, and Behavioral Health Service Providers who want to monitor client service provision and dollars spend on treatment. Integrated with the Client Tracking and Billing Module, our Claims Management Module will track member eligibility, create and track authorizations, and process claims.

Member eligibility data can be manually entered into the system or complete client databases can be uploaded from the service provider organization.

Client service authorizations can be entered manually or created using the Client Level of Care (LOC) Determination Wizard. Authorizations can be created based upon units of service or specific dollar amounts. Effective dates for authorizations can also be created as required.

Each service provider can establish the services they provide in 6 levels of care based on dimensions of assessments. In no way is our system prescriptive, it lends structure to a system that has been utilized and proven to be effective. The Gate-Keeper merely presents areas of assessment and then guides the caseworker to the level of care where the service provider decides which services and amount of service will be authorized. There may be several services the consumer, professional and/or the authorizing caseworker can gain agreement based on the consumer's needs and desires.

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This system will authorize and track episodes of care and maintain an ongoing history of access. This information is interfaced with our Client Tracking and Billing application where it populates the "Authorizations" so that the services can be tracked as they are utilized.

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The Claims Management Module can report on a variety of items including Client Provider Authorizations; Claims accepted, paid, or rejected, and claims transactions.

Report filters allow you to customize each report so you are getting exactly the information you desire. Filters include Agency, staff, procedure code, status code, and date. In addition, reports can be generated for all claims, accepted but not yet paid claims, paid claims, and rejected claims.

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The Claims Management Module makes claims processing a snap by allowing you to import the 837 from provider organizations to validate and adjudicate claims against existing authorizations. Each claim is reviewed with a recommendation to be paid, rejected, or the claim is flagged as needing individual review. Once claims have been processed, those approved are sent to your accounting software's AP system for processing and payment.

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An electronic 835 is created to send back to the provider.

Provider Agency and Staff Credentialing is completed through the Client Tracking and Billing module. Agencies and staff can be credentialed by activity code or service.

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The system allows you to setup each provider organization as a separate entity. This allows you the ability to enter contract requirements, service codes, fee schedules, and credentialing by provider organization.

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