R2006-137 AUTHORIZING AGREEMENT - Laserfiche WebLink

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� The Honorable Paul Osborne � City of Decatur August 30, 2006 Page 7 � Administrative Procedures Review The claims audit begins with a review focused on procedures used for all claims rather than specifics of any individual claim to ensure proper claim control measures are in place for ef�cient administration of the Plan. Our analysis will include administrative procedures that have a potential impact on claims processing and financial reporting as well as administrative processes that could affect member satisfaction, including: ❑ Administrative Staff - division of duties; experience and training; quality assurance programs; ❑ Mail Handling System - mail receipt, sorting, distribution; claims record storage and retrieval; ❑ Enrollment and Eligibility - member and dependent verification; receipt of employer eligibility data; timeliness of system record updates and procedures used for retroactive terminations; interface with claims processing system; 7 Provider/Participant Communications - customer service access and response; benefit statements clarity; denial and appeal process; information requests and follow-up procedures; refund recovery; ] Detection and Investigation Procedures for Other Coverages - i.e., coordination of benefits, workers' compensation,third party liability; J Processing Guidelines - claims adjudication; request for additional information; referral for medical review and/or hospital audits; calculation of multiple surgical procedures; � Fee Schedules and Provider File Maintenance - usual, customary and I reasonable (UCR) allowances; participating provider discounts; provider record i updates; and I ❑ Claims Processing System - duplicate payment edits; detection of fraudulent or I unbundled charges; plan design changes; automated tracking of accumulators; system security. • Individual Claims Audit Individual claims audits can be structured to review specific types of claims or produce a sample of all benefit determinations. If desired, the sample can be selected in a manner that provides statistical validity in the audit findings. Regardless of inethodology, each sampled claim will be reviewed by the Segal auditors as if they were making the initial benefit determination, tracking each claim from receipt in the office through each step of processing. Sample payments are reviewed to determine if: J Claims were paid in strict accordance with Plan provisions and documentation is on file for claims paid and verified when necessary. J Established administrative procedures were appropriate, within industry guidelines, and followed during adjudication.