CLAIMS

Claims and Encounters

AMM provides the supervision, technical expertise, policies, and systems necessary to efficiently and accurately pay claims for eligible IPA patients. Claims adjudication software and procedures assure that only valid claims are paid and that contracted fee schedules determine reimbursement. AMM accepts claims in HCFA 1500 and UB92 format on paper or in HIPAA compatible electronic files (837I & 837P). AMM processes fee-for-service claims and capitated encounters on the same timetable, which assures that statistical analysis of monthly data includes all services performed. Electronic claims and encounters are routinely processed within 10 business days of receipt depending on the payment schedule of the IPA.

AMM provides to all client IPAs a pre-check run reporting of all claims and encounters queued for "payment". This report is sorted by provider and allows each IPA full discretion and review authority over claim payment or denial. Check runs are generated weekly in accordance with CMS, DHS, DOC and DMHC guidelines. Checks are matched to EOBs and check register for IPA review and signature. Check runs are imported into AMM bookkeeping software for reconciliation against monthly bank statements. Dispersements for accounts payable in addition to medical services can also be processed for client signature.

Each month an IBNR (Incurred But Not Received) report is generated which calculates the liability of approved referral authorizations for which no claims have been received. Other paid claims reports sorted by PCP, Specialist, Specialty, Health Plan and other custom programming are generated monthly and reconciled to the P&L and Balance Sheet. Claims processing timeliness and denial accuracy reports for Health Plan review are submitted on behalf of the IPA on a monthly basis. AMM also submits monthly encounter data to all Health Plans electronically.