Our software was originally built and is maintained as one, fully integrated system. From enrollment to adjudication and billing, there's complete system interoperability. Our software captures hundreds of data points — all relative benefits data including claims images, plan parameters, eligibility, etc.


Our system is “Rules Based” and “Eligibility Driven”.

 

The financial and accounting features form the foundation of the Lifebridge administration system, facilitating the administrative and billing functions as well as claims adjudication and claims payment functions. Each plan design begins with the specific accounting detail and financial data including premiums and rates, as they pertain to the group, division and/or specific class of employee.

 

Plan designs are then layered over the accounting parameters in exquisite detail to facilitate the system’s auto-adjudication function. Auto adjudication eliminates human intervention in more than 90% of claims, which enhances the accuracy and efficiency of the adjudication of claims. 

 

Individual employee data, including their dependents information, optional coverage elements, class and/or division are then input into the system.  


Once established and tested; claims are then ready to be processed.

 

Pay-direct card services are available for prescription drugs and dental services. Claims are adjudicated electronically, as per the plan design and paid at the point of service.

 

For all other covered services claims must be submitted to Lifebridge Health Management’s claims department for reimbursement.

 

Lifebridge’s expert claims examiners process the claims in batches and enter claims data into the system for adjudication. All pertinent rules are applied to each claim resulting in over 90% of all claims being auto-adjudicated, and released for payment.

 

Claims are flagged and supervisor intervention is required for multiple scenarios, including for example:

  • Claims submitted from our "Questionable provider" list
  • Potential duplicate claims
  • Potential treatment of the same teeth
  • Potentially fraudulent claims
  • Random spot checks as determined by the plan supervisor

Once the supervisor has reviewed the claim, it is then released for payment or declined, as appropriate. Full explanations are provided to support each claim payment or declination.


Claims Adjudication