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Staff Systems

Claims Processing

All forms are scanned, checked for image quality, and transferred using a Virtual Private Network (VPN) or a secure dedicated network to the appropriate production facility. Using STAFFSYS proprietary Data Capture Solution (DCS) all the zones (fields) are electronically identified. Data in each identified zone is recognized using OCR/ICR technology. These field values are checked against a list of validation rules. Fields that do not meet the validation criteria are routed for field correction. Next, a form level validation is performed which includes cross field validation. Any form that fails this validation is manually reviewed for corrective action. The image output format can be TIFF, PNG, JPEG, GIF or any other image format. The data output format can be flat file, CSV, ASCII, EBCDIC, Binary DB specific format, XML, HIPAA 837, NSF or any other customer specified format. Claims Adjudication After the data is uploaded into the customer adjudication system, the claims are auto adjudicated. The claims can be rejected, paid, or pended. STAFFSYS adjudicators will log into the customer system and review all pended claims. Based on the business rules of the customer, the claims are adjudicated. This may result in payment to the providers / members and generation of Explanation of Benefits (EOB), or a request for further documentation from the providers / members.

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