Claims Adjudication: Healthcare Claims Management Solutions

Partner with Envolve for Claims Adjudication

Claims are arguably the single most important data gathering aspect of any healthcare operation. Envolve recognizes encounter data is critical to risk adjustment and program integrity and provides both accurate and complete original healthcare claims management, including encounters submissions, as well as supplemental diagnosis data. 

Envolve, through its family of companies, provides both accurate and complete original encounters submissions, as well as supplemental diagnosis data in HIPAA compliant paper and EMR formats or various proprietary submission formats as required.

Our claims processing system's audit trails retain snapshots of all transactions for current and historic activity. We compare financial data (from paid claims) with corresponding encounter submissions to ensure encounter data is a complete representation of the services provided.

When there is a potential recognized risk or delay in providing timely, accurate, and complete encounter data to our clients, our healthcare claims management services identify the root issue, conduct analysis, and resolve the issue in accordance with applicable standards.

Our claims adjudication process is the same for both network and non-network providers and traditional and non-traditional providers. Our healthcare claims management process performs six primary steps of claims adjudication that a claim must pass in logical succession to reach a “finalized” (paid or denied) status. 

With our technical management capabilities, we gather, analyze, and report data to identify and take action against inappropriate utilization of services and quality of service concerns. This proactive approach to fraud, waste, and abuse, including the Coordination of Benefits savings, cost avoidance and recovery activities resulted in over $1.2 billion in savings in 2016 through all of Envolve’s affiliated health plans. Experience has shown that the best approach to cost avoidance is to minimize the need to recover costs in the first place. 

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