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Medical Plan Administration
D. H. Evans Associates provides a full spectrum of Medical Plan Administration services to assist our clients to stay within their plan’s budgetary requirements wherever possible without sacrificing quality or availability of care.
Our claims administration system screens claims for various improprieties using a Claims Edit System that checks the appropriateness of the claim based on previous claims history and patient demographic information.
Our system is utilized by an experienced staff of Claims Adjudicators. Who do not simply enter data; they review and question the claims that they process, even those that are received electronically, to ensure that they are appropriate. We know that some claim billing errors are honest mistakes. We also know that there are inventive/fraudulent ways to code claims to garner a greater payment by a Plan and we have the capabilities to prevent such occurrences.
Our Claims Adjudicators also review claims for potential third party liability when there is an indication that an injury was the result of an accident. In addition, our Claims Department is continually confirming that network or negotiated discounts have been achieved whenever possible. These two functions are critical factors in containing a plan’s cost.
We are unique in that our Claims Department staff also handles all of the telephone inquires regarding benefits and claims from providers and participants alike. We feel that the most effective method of handling such inquiries is to have those who adjudicate the claims respond directly to the providers and/or participants involved.
Our Claims Adjudicators are dedicated to a plan, therefore reducing the possibility of errors based on unfamiliarity with specific plan provisions.