Benefit Configuration
Benefit configuration is a critical process in managing healthcare benefits provided through various insurance plans. At SHAI, we ensure that all aspects of benefit configuration are meticulously handled to meet regulatory requirements and the needs of plan members. Our comprehensive approach includes:
- Defining and Managing Benefits: We define and manage healthcare benefits across employer-sponsored plans, government programs (e.g., Medicare, Medicaid), and private insurance, ensuring detailed specifications of coverage options, services, cost-sharing mechanisms, provider networks, and eligibility criteria.
- Regulatory Compliance and Rule Creation: Ensuring benefits meet regulatory requirements and creating rules for delivering and reimbursing various benefits like preventive care and prescription drugs.
- Industry Expertise and Regulatory Updates: SHAI brings a high level of understanding and experienced resources to address industry challenges, while keeping updated on the complex regulatory environment.
- Managing Fragmented Benefits and Data Integration: Handling fragmented benefits across payers and plans, and integrating data across multiple sources to ensure seamless benefit configuration.
- Customization and Member Experience: Focusing on customization to enhance member experience and meet specific needs.
- Cost Control and Sustainability: Emphasizing cost control and sustainability to manage expenses effectively.
- Ongoing Education and Adaptation: Providing continuous education on benefit changes and adapting to changes in healthcare delivery models, including resolving claims disputes.
Member Enrollment
Well-delivered and fast Member Enrollment Services enhance the patient experience and maximize retention.
- Application Processing
- Eligibility Verification
- Plan Selection
- Special Enrollment Period (SEP) Management
Member Support Services
24/7 omni-channel support insures access and satisfaction, demystifying the billing experience for members.
- Medical Billing & Inquiries
- Claims Resolution
- Coverage Clarification
- Pre-Authorization
- Dispute Resolution
Premium Billing and Payment Posting
Streamline revenue cycle management with accurate, technology-driven billing solutions that enhance efficiency and member satisfaction
- Timely payment posting eliminates revenue bottlenecks.
- Technology-driven process management simplifies complex billing systems.
- Efficient payment handling reduces delays and coverage issues.
- Member-centric solutions offer clear explanations and flexible payment options.
- Operational excellence ensures a seamless member experience.
Provider Credentialing
- Enhances provider credentialing efficiency
- Reduced turnaround times, up to 60%
- Ensured compliance, accelerated onboarding
- Optimized network availability and expanded access
Provider Data Management
- Accurate PDM through a blend of technology and expertise.
- Streamlined data collection, verification, and maintenance
- Benchmarked for accuracy and data integrity
- Measured by improved quality of care.
Provider Support Service
- Omni-channel, 24/7 accessible self-service portal
- Seamless and fast provider-insurer communication
- Claims, appeals, credentialing, authorizations, and eligibility support
- AI assisted live agents maximize support availability
Claims Adjudication
- Claims Adjudication Process: Claims adjudication is the process by which healthcare payers (such as insurance companies, health plans, or government programs like Medicare and Medicaid) review, process, and determine the amount to be paid for a claim submitted by a healthcare provider (e.g., physician, hospital, clinic).
- Verification of Claims: This process involves verifying the accuracy and completeness of the claim.
- Application of Policies and Benefits: Applying the appropriate policies and benefits to ensure payments align with the terms and conditions of the provider's contract with the payer.
- Payment Determination: Ensuring that payments are in line with the terms and conditions of the provider's contract with the payer.
- Proficiency in Professional and Institutional Claims: SHAI’s claims adjusters are proficient in handling both professional and institutional claims.
- Knowledge of Healthcare Terminology: They are knowledgeable in healthcare terminology used in both commercial and government programs.
- Expertise in Coding Systems: SHAI’s adjusters are skilled in various coding systems.
- Understanding Medical Necessity and Coverage Guidelines: They understand medical necessity and coverage guidelines.
- Claims Adjudication Process for Each Claim Type: They are familiar with the claims adjudication process for each claim type and pend queue.
- Payer-Specific Guidelines and Regulatory Compliance: SHAI’s adjusters are well-versed in payer-specific guidelines and regulatory and compliance requirements.
Prior Authorization
- Refines the PA Intake and Review process
- Confirms medical necessity, coverage, and compliance with clinical guidelines
- Deploys non-clinical staff for intake and triage
- Relies on clinical experts to conduct retrospective, prospective, and concurrent reviews
- Enables prompt care delivery and minimizes authorization-related denials
Case and Disease Management
- Provides Case Management and Disease Management services for individuals with complex or chronic conditions
- Advocate for patients and assist in navigating healthcare complexities
- Coordinate services to improve health outcomes while managing costs
Payment Integrity
SHAI leverages advanced technology and industry expertise to deliver seamless, compliant, and efficient payment integrity solutions.
- Accurate & Compliant Payments – Ensuring all transactions are legitimate, error-free, and aligned with regulations and industry standards.
- Error & Fraud Prevention – Identifying and addressing overpayments, underpayments, duplicate payments, and fraudulent transactions.
- Robust Verification & Monitoring – Implementing invoice matching, automated fraud detection, and compliance audits.
- Efficient Recovery Process – Detecting and reclaiming overpayments while maintaining vendor and client relationships.
- Continuous Improvement – Regular audits, KPI tracking, employee training, and process enhancements for optimal payment integrity.
