EDGE Medical Services Private Network

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ACCURATELY VERIFY INSURANCE BENEFITS IN REAL-TIME Accurate verification of patient benefits is crucial element in determining the patient's out-of-pocket liability to the provider. Verifying benefits is easy and fast with EDGE's provider portal. Benefits from all insurance companies are delivered in a standard format. Benefits are available to be view in 3-5 seconds. This process frees office staff's time. No more waitingon the phone to h

Accurately verifiying insurance benefits is one of the most critical steps in claims management. Checking eligibility by phone is a time-consuming process because it is done one patient at a time. Verification of benefits with EDGE software delivers eligibility data to your desktop in a matter of seconds. “Real-time” eligibility means responses are returned within 30 seconds of the inquiry being sumbitted.

Eligibility responses are presented in a consistent, easy-to-read format. Eligibility information is displayed in a consistent format regardless of the payer.

Guides and prompts are displayed to ensure that different payer requirements are met when submitting eligibility requests. For example, “Does the payer require the patient’s date of birth, etc.?” This includes error checking with automatic resubmission.

Eligibility requests can be submitted in a batch mode to facilitate the processing of information for many patients. Some providers or offices prefer to run a batch eligibility for all patients that will receive health care services the following day.

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ADVANCED CLAIM SCRUBBING AND ON-LINE EDITING OF CLAIMS: Accurate verification of patient benefits is crucial element in determining the patient's out-of-pocket liability to the provider. Verifying benefits is easy and fast with EDGE's provider portal. Benefits from all insurance companies are delivered in a standard format. Benefits are available to be view in 3-5 seconds. This process frees office staff's time. No more waitingon the phone to have benefits cited or faxed

Our proprietary formula for scrubbing claims reduces rejections because we scrub each line of code at the beginning of the process. We check each claim for documented payer rules as well as “undocumented” rules that we have complied by analyzing data of thousands of payer rejections and denials.

This means no more delays from claims being repeatedly submitted and denied. Our unique process that includes predictive technology to correct claims before initial submission to the payer, means fewer delays to for the provider.

We compile payer rules in a comprehensive rules engine that is maintained and updated weekly — using payer bulletins, code releases, and by reverse engineering payer rejections and denials.

Rules are payer specific. Rules that apply only to Medicare are applied only to Medicare claims. Rules that apply only to a specific commercial payer are applied only to that payer.

Rule categories cover both professional and institutional claims:

•Gender and age restrictions verified, inclusion of required accompanying procedures, appropriate use of modifiers and proper place of service codes.

•CCI policy compliance and medical necessity using CPT/ICD9 crosswalk data and LCDs/NCDs

•Valid primary diagnoses verified, proper levels of specificity, and the inclusion of required accompanying diagnoses.

•All UB-04 specific codes — ICD9 procedure codes, DRGs, revenue codes, patient status, type of visit, condition, occurrence, treatment and value codes — are checked to see that they are correctly reported when required.

•Situational/conditional fields are verified to see if they are required.

•Professional claim examples — the reported diagnosis requires date of first symptom; referring provider required when referral number is reported; date last seen required for some specialty; etc.

•Institutional claim examples — the reported diagnosis requires an occurrence code; the reported revenue code requires a value code, a procedure code or covered days; date of service or patient status code required for this type of bill; etc.