Healthplan Claims Reviews & Audits

Glenridge experience with payer and provider clients enables us to understand and appreciate the complexities and operational requirements for billing and claims processing.   We have many years experience working with provider and payer billing and claims adjudication systems,  provider databases, credentialing systems and data mining / management report writing.  

Our extensive experience as developers and managers of physician and hospital A/R systems, as well as payer system experience, has given us valuable insight into the challenges and opportunities to efficiently and accurately adjudicate claims per contracted rates and terms.

Over the years, our payer clients have called on Glenridge to assist in various aspects of claims analysis and adjudication including:

• Claims analysis, including review and correction of overpayments, outliers, provider-specific settlements, and product-specific reimbursement issues.
• Root cause analysis of claims adjudication errors and inefficiencies
• Claims audits
• Contract audits
• Recovery projects
• Adjudication system updates, including data mapping and updates to codes, crosswalks and fee schedules.
• Provider file and credentialing database reconciliations with claims systems