Claim Adjudication for Health Plans

Netmark Business Services’ claim adjudication services for health plans comprises benefit configuration, testing, claim adjudication and audit ensuring regulatory compliance and adherence to plan guidelines.

Netmark Claim Adjudication for Health Plans

Do you need to catch up on processing and determining the validity of your health insurance claims? Or do you have a high number of claims that have been pended? Netmark Business Services offers expert assistance with experienced examiners, adjusters, provider reconsideration specialists, and appeal adjudicators for health plans, health systems, and TPAs. Why put the stress of handling claims on your internal claim staff when you can have an entire claims team working alongside them? By outsourcing to a team specializing in claims processing, you’ll experience fewer errors in the examination process, greater efficiency in the number of claims processed, less expensive and more flexibility in adjusting to your business needs.

This extensive experience and knowledge enable us to efficiently and effectively process claims, ensuring prompt and accurate handling. We at Netmark are dedicated to providing the best service possible to our clients, while constantly updating to keep up with the latest industry developments.

Netmark’s team of experts can offer professional audit services for processed and pending claims to improve efficiency and productivity. These services include reviewing and analyzing claims data, identifying errors or discrepancies, and providing improvement recommendations.

Netmark’s expert examiners can provide specialized audit services for both processed and pending claims to improve efficiency and increase overall throughput.

Our primary objective is to serve as the go-to claims examining office for health plans and TPAs. We understand the importance of maintaining a long-term relationship with our clients and strive to be a trusted partner for health plans and TPAs we work with.

We also offer “Clutch” services for clients who need to clear backlogs within a short timeframe. Our team has over 15 years of experience working with various health insurance companies and Fortune 500 self-insured plans, which allows us to analyze our client’s needs and provide customized solutions to keep them competitive in the industry.

Our expertise includes claims adjudication, member benefits, and a deep understanding of CMS regulations and other health plan needs. We are committed to providing our clients with the support they need to succeed, and we look forward to building a lasting partnership with claims directors.

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Frequently Asked Questions

Claim adjudication for health plans is the process of determining coverage, examining claims, and reviewing them against plan benefit guidelines and regulatory requirements. This process is undertaken by a claim adjudicator/examiner, who reviews each claim and determines whether it will be paid, pended, rejected, or denied.

Claim adjudication status is the current state of a claim that has been processed by an insurance company or third-party administrator. The status indicates whether the claim is pending, denied, approved, or under review.

The right claim adjudication services for a health plan will depend on the requirements and needs of the plan. If the health plan is under a time crunch, then an adjudication service with immediate resource availability would be important or if the criteria is familiarity with a specific adjudication platform like QNXT or FACETS, or HealthEdge then that will determine the choice. It is important to ensure that the services are in compliance with the applicable laws and regulations and that they include efficient claim processing and audit capabilities. Netmark Business Services provides comprehensive health plan adjudication services that meet all of these criteria.

There are several types of adjudication services from commercial, SNIP, Medicare in health plans, and adjudication or examination for TPAs