Claim Processing

Lifetrenz is a new generation Healthcare IT System, in which the RCM module maintains separate workflow queues and the stages of a case within each workflow queue. The queues maintained are primarily for ePrescription Management, Insurance Eligibility Check, Insurance Prior-Authorization, Bill Finalization, Claims Processing (including handling Remittance Advice, Rejections & Resubmissions) and Accounts Receivable. Lifetrenz RCM is integrated to the DHPO and HAAD insurance gateways.

Lifetrenz RCM has a very useful function called the “Talk to Doc” functionality. This is a very effective and important ‘Messaging’ capability for the insurance team and doctors to communicate contextually on cases, and track communication and close cases fast. This helps the doctor to make corrections to a patient's case sheet, or send back an appropriate communication back to the initiating team. All back and forth communication is tracked and is available in the System, ensuring accountability and timely action and reducing delays in processing and submission of the case.

ePrescription Management

Doctors have a provision to contextually submit an ePrescription electronically at the end of a consult, directly from their consulting screen. Doctor can also capture observations for diagnosis or medication prescriptions which will get included as part of the eRx xml submitted. Further, from within the consult screen, the doctor has a provision to cancel an ePrescription already submitted or re-submit a new ePrescription electronically.

However, if the Doctor did not submit the ePrescription, it will queue up in the RCM module to submit the pending ePrescription. In the RCM, the ePrescriptions are maintained status wise in separate buckets, as — Open, Approved, Submission Errors, Cancelled, and All Cases.

Eligibility Check

Front Desk, Nurses and Doctors should have a provision to contextually check eligibility details of a patient's insurance, while managing the patient. They should be able to view previous captured eligibility information as well as submit eligibility details electronically to DHPO to check patient's eligibility, ensuring that all important roles which interface with customers can take informed decisions. In the Lifetrenz System, for insurance users in the RCM, under eligibility module, all cases where eligibility check has not been done will queue up for them to validate and verify the insurance details submitted by the patient.
Separate bucket are provided in the RCM to list cases based on status of the work queue for eligibility check. The various statuses to be maintained are 'New and Open', 'In Process', 'Eligible', 'Not Eligible', 'Errors' and 'All Cases'.

Prior Authorization Request

Once the doctor marks a consult as 'Ready to Bill', if the case is for an insurance patient, it will queue up in the 'Authorization Request bucket'.
However, for cashless insurance health check up, at the end of the sales team's activity of closing a sale for health check-up, they can manually raise a request for 'Authorization'. The Authorization Request Queues are again separated by the status of the case. The status based bucket in the authorization module are: Open, In Process, Fully Approved, Partially Approved, Denial, Errors, Order Extension, Expiry Extension, Cancellations, Pre-Approved and All Cases.

Post Authorization Follow-up Queue

In OP setting, once the authorization is received for a case, such cases land in the ‘Follow- Up Queue’. This helps to proactively call the customer and inform him/ her of the Authorization status and fix an appointment so that they can come back to the clinic and get the activity conducted, before the claim can be submitted.

Bill Finalization (OP DNFB)

On the day of the OP patient visit, the front desk is only generating receipts for payments collected for self-pay services or patient payable component of the cashless-insurance patients. They are not generating or finalizing the bill itself at the front desk. Though the bill finalization process is fairly simple and straightforward for self-pay cases, for the insurance cases there could be several stages and validations to be done before the bill is finalised and before submitting for claim. OP DNFB cases also have multiple statuses and are segregated into separate buckets to ensure smooth workflows, as each case would require different action based on the status. The different status/buckets maintained for OP DNFB cases in Lifetrenz are - ‘Open Bills‘, ‘Need Split or Clean‘, ‘Ready to Finalize‘ and ‘Finalized Bills‘.

Need to Split bills

For an insurance patient, if there were activities in the case that were not authorized by the receiver but conducted (as patient was willing to pay for services at self-pay rates), or the case was conducted after the authorization expired, then such activities need to be split as a separate case of self-pay bill. This ensures that there are no such items which are included in the insurance bill or claim, and that they can be recovered from the patient as a separate bill at self-pay rates.

Need for Clean

For an insurance patient, if there are activities in the case that were ordered, however they were not conducted despite having received authorization (since the patient declined to do it, or the patient didn't come back after the authorization was received), then such items need to be removed from the activity list for the case, so that they are not billed and are not part of the claim activities submitted.

Claims Processing

All cases in the Claims Process are also segregated based on statuses into separate buckets, to ensure that separate work queues based on statuses are maintained. Some actions to finalize the bill are also duplicated in the Pending Claims status (As bill needs to be finalized before claim is submitted). The status/buckets maintained in the Lifetrenz System for claims are ‘Mandatory Results’, ‘Open‘, ‘Need Split or Clean‘, ‘Ready to Claim’, ‘In Process‘, ‘Complete Remittance’, ‘Partial Remittance’, ‘Denials’, ‘Errors’, ‘Historical Remittance Advice’ & ‘All Cases’.