As an industry leader, TML Health provides its Membership with the
sophistication of cutting edge technology to maximize
accuracy in claims adjudication and claim cost management
services. TML Health and the United Medical Resource Alliance
(UMR) currently use the CPS claim adjudication system. The
CPS system includes interfaces with specialized systems for
eligibility and enrollment maintenance, plan building, claim
repricing, front-end document loading and HIPAA
compliance checking of EDI 837 claims, and Stop Loss
tracking and reporting. The adjudication component
includes the ability to auto adjudicate claims by submitted
batches each day.
At present 59% of submitted claims are auto adjudicated
resulting in a high degree of accuracy and a very short
turnaround time from receipt to final processing. The CPS
system interfaces to claim screening software for out of
network claims. Interfacing for screening of in network
claims is done via the repricing process with
UnitedHealthcare which utilizes the industry standard iCES
claim screening software.
TML Health utilizes medical management software from
Medecision which is fully functional, NCQA compliant
software for care management. The care management
software is integrated with the InterQual and Truven length
of stay software. Other software and tools used in medical
management include the Prochaska health behavior change
software and Optum Insight data analytics.
TML Health continues to face the pressures of mounting health
costs, lingering economic uncertainties and increasingly
complex reimbursement rules. TML Health will continue to stay
focused on managing the administrative costs of the plan.
The Health Information Technology Act assists TML Health in
managing administrative costs by beginning the conversion
from a paper process to electronic communication.
TML Health has developed and made available to all its groups an
on-line enrollment system with the value added benefit