Prior authorization services by sun knowledge

1. Prior Authorization

2. SUN KNOWLEDGE OVERVIEW
Key Facts Awards, Affiliations & Certifications
2Sun Knowledge © 2015-16 Private & Confidential
 ‘Onshore /Offshore’ KPO & BPO Services
 Serving US healthcare industry since 2007
 Robust & scalable infrastructure
 State-of-the-art technology and systems
 Highly skilled and trained staff with good
communication skills and in-depth knowledge of process
 Structured training, feedback and coaching
 HIPAA-HITECH compliant
 State-of-the-art office inbuilt with all redundancies –
power, infrastructure and others
 ISO 27001:2013 and ISO 9001:2008 certified
 CMMi-SVC implementation in progress under KPMG
guidance
 Member of NASSCOM, the Governing Industry body for
IT/ITES in India
 Awarded ‘Best Emerging BPO Company of the year 2010’
by The Economic Times, India
 Recognized as one of the foremost 'Emerging companies in
Eastern India' by NASSCOM in 2011
 Awarded Asia-wide “Healthcare BPO Provider of the Year”
at the Asia BPO Excellence Awards ceremony hosted by
Asia BPO Summit on 14th February 2013 in Mumbai, India
 Awarded the prestigious “Outsourcing Service Provider of
the Year” award in the Asian Outsourcing Excellence
Awards ceremony hosted by CMO Asia on 1st August 2013
in Singapore
 Awarded “Highest New Job Creator (IT/ITES)” by STPI
(Software Technology Parks of India) on 3rd December 2015
41 Madison Avenue, 25th Floor, New York, NY 10010, USA

3. SUN KNOWLEDGE SERVICE PORTFOLIO
 Provider Support
 Member Support
 Member Retention Program
 Clinical Help Desk
Contact Center
 Utilization Management
 Medication Therapy Management
 Hospital Re-admission Management
 Therapeutic Interchange
 Formulary Management
Clinical Services
 Medical Coding & Billing
 Claims Administration
 Enrollment Processing & Member
Fulfillment
 Credentialing
 Premium billing and collections
Administrative Services
Analytics
 Telemedicine Services
 Remote Patient Monitoring
 Application Development & Support
 Technical Support
 Technical Documentation
IT Services
 Claims /Drug Utilization
Analysis
 PDE Analysis
 RAF Analysis
 Payment Reconciliation
We provide services to
Providers – Physician/Hospital/DME/P&O/Home Health Care, Commercial Plans, MA Plans, Medicaid
HMOs, MAPD/PDPs, IPAs, MSOs, TPAs, PBMs and RBMs
3Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA

4. PRIOR AUTHORIZATION
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41 Madison Avenue, 25th Floor, New York, NY 10010, USA

5. PRIOR AUTHORIZATION – INTRODUCTION
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“It’s a nuisance, time-consuming
and often not in the patient’s
best interest!”
– George G. Ellis, Jr., MD
Internal medicine physician &
Medical Economics editorial advisor
41 Madison Avenue, 25th Floor, New York, NY 10010, USA

6. PRIOR AUTHORIZATION – A CONSUMMATE SOLUTION
6Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Sun Knowledge provides a comprehensive array of prior authorization services for a
wide range of healthcare areas such as:
 Hospitals
 Nursing Homes
 DME
 Orthotics & Prosthetics
 Physicians’ Offices
 Radiology/Imaging Services
 Dermatology Practices, and many more!
Our services are designed to take the pain out of prior authorization and
free you from the need to engage your resources or spend precious time in
tedious prior authorization tasks.

7. PRIOR AUTHORIZATION – SERVICE PORTFOLIO
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 Full range service, comprising Authorization Request Follow-up Approval
 100% HIPAA-HITECH Compliance
 Low prices with no hidden cost
 Highly streamlined, fast and accurate service
• DME
• Hospitalization
• Outpatient Surgery requiring general anesthesia
• Skilled Nursing
• Organ, Bone Marrow, Stem Cell Transplants and other similar procedures
• Inpatient rehabilitation – Treatment for alcohol or drug abuse
• Other conditions
We cater to
41 Madison Avenue, 25th Floor, New York, NY 10010, USA

8. NO AUTHORIZATION
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 Certain procedures require prior authorization
 Submitting a request does not guarantee approval
 If an authorization was not previously requested, a retro-authorization may be requested for
services already provided
 The same guidelines as for requesting an authorization prior to service are followed
 Dates specific for retro-authorizations are used
 Once the authorization is approved, the bill is resubmitted
41 Madison Avenue, 25th Floor, New York, NY 10010, USA

9. AUTHORIZATION EOB CODES
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 EOB code 529 – Case is denied
 EOB code 530 – No authorization on file
 EOB Code 531 – Authorization for claimant, not for provider
 EOB Code 532 – Authorization for claimant and provider, not for dates of service
 EOB Code 533 – Authorization for claimant, provider, and dates of service; not for procedure
41 Madison Avenue, 25th Floor, New York, NY 10010, USA

10. FULL SERVICE PORTFOLIO
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41 Madison Avenue, 25th Floor, New York, NY 10010, USA

11. SERVICE PORTFOLIO
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PRACTICE
MANAGEMENT
Order Entry
Eligibility &
Authorization
Verification
Prior
Authorization
BILLING &
COLLECTIONS
Billing & Coding
Claims
Submission
Accounts
Receivable
PAYER SERVICES
Claims
Adjudication
Credentialing
Utilization
Management
TELEMEDICINE
Telemedicine
Remote Patient
Monitoring
41 Madison Avenue, 25th Floor, New York, NY 10010, USA

12. HIPAA COMPLIANCE
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41 Madison Avenue, 25th Floor, New York, NY 10010, USA

13. HIPAA COMPLIANCE SUMMARY
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SL. COMPLIANCE ASPECT HIGHLIGHTS
1 Physical Access Authorized access only | Bio-metric access | Proximity card system | Photo ID cards | Access log review
2 General Security 24 hour security personnel | Logging of visitor details | Physical register retained for 10 years
3 Monitoring CCTV monitoring (with recording) of production area | Daily review of recording
4 Vendor Access
Signing confidentiality agreement before accessing sensitive areas | Accompanied by security personnel/employee during
all times
5 Mobile Phones All employees (except managers) are required to deposit mobile phones in the locker box before entering facility
6 Personal Baggage No backpacks or other bags allowed | All baggage to be deposited in locker box before entering facility
7
Network &
Application Usage
Unique user IDs created using Microsoft Active Directory | Access to storage devices, shared drives, USB/mass
storage devices, printers – controlled by Domain Group Policy | No wireless access points
8 Firewall
Unified Threat Management System | Internet traffic regulation using multiple filters | Network Address Translation (NAT) |
Intrusion Prevention Systems (IPS) | Port-mapping for traffic between Virtual LANs | Default setting to deny all traffic
9
VPN (Virtual
Private Network)
Site-to-site IPSec VPN tunnels | Authorized access via client-to-site VPN connections | Access authorization
controlled by Active Directory's authentication service
10
Redundancy
Management
Fully redundant network stack | Two ISP links configured in active-active mode | Power backup supplied by 130 KVA UPS
and 750 KVA generator | 22 KVA UPS backup for server and network systems
11
Virus & Malware
Protection
Central anti-malware system | Automatic updates | Extra protection by gateway firewall |
Centralized OS patch management system (using Microsoft's WSUS server)
12 Other Measures Fire extinguishers at key areas | Half-yearly fire drills
41 Madison Avenue, 25th Floor, New York, NY 10010, USA

14. SUMMARY OF BENEFITS
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 Very Little Risk
• Proven track record in providing healthcare BPO/KPO services
• Experienced in providing services to both payers and providers
• Experienced working with various software platforms
• Quick and efficient resource for special projects requiring technical and process expertise
 Significant Upside Potential
• Great understanding of the Healthcare Industry. Operation scale-up with a short notice
• Extremely competitive rates, greater productivity, improved quality, increased member and provider
satisfaction
 Proven Process Performance
• Low denial rate  reduced collection time  increase in revenue collection
• Billing & Coding Accuracy > 99.9%; TAT: 24 – 48 hours
• Adherence to CMS billing requirements
 Clear Communication and Quick Response Time at All Times
 ISO 27001:2005 & HIPAA Compliance for End-user Data Privacy and Protection
41 Madison Avenue, 25th Floor, New York, NY 10010, USA

15. TESTIMONIALS
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41 Madison Avenue, 25th Floor, New York, NY 10010, USA

16. CLIENTSPEAK
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“We have had the pleasure of working with the Sun Knowledge team
throughout the few months utilizing their services for patient data entry and
eligibility verification. They are a devoted and responsible team that is highly
experience in what they do. They are always concerned about the client’s
needs and are always there to help. I highly recommend the services offered
by Sun Knowledge.”
COO of a leading medical billing and credentialing company in New York
“Your team amazed me with the manual and the amount of info you provided
with that short training session.”
Practice Manager of a major Dermatology group in New York and New Jersey
41 Madison Avenue, 25th Floor, New York, NY 10010, USA

17. CLIENTSPEAK
17Sun Knowledge © 2015-16 Private & Confidential
“My firm has evaluated an outsourcing transaction with Sun Knowledge. They
provide superior service at a very attractive rate and have demonstrated to us their
commitment to this partnership. Their expertise across various process areas in the
PDP/MAPD domain and unique cost structure puts them in an incredible position to
work with plans throughout the healthcare industry.”
Chairman, President and CEO of a major New York based Health Plan
“Our company is very pleased with the administrative, and business analytical
solutions which Sun Knowledge delivers to our company from a quality & cost
perspective. They have been a true partner in bringing industry expertise, and
innovative solutions to the table. Their ability to grow with our evolving needs for
higher end services such as clinical services is a significant differentiator among
healthcare business process outsourcing firms.”
Executive Vice President of Operations of a leading MSO
41 Madison Avenue, 25th Floor, New York, NY 10010, USA

18. CLIENTSPEAK
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“I was always against the idea of outsourcing our back end claims processing
work but I was wrong. Sun Knowledge provided extraordinary deliverables
on a timely basis which led to cost cutting considerably for us.”
CEO of a leading MA-PD Plan
Ronnie Hastings
(646) 661-7853
Email: ronnie.hastings@sunknowledge.com
Sun Knowledge
41 Madison Ave., Suite 2511, 25th Floor
New York, NY 11001, USA
For Additional Information, Please Contact…
41 Madison Avenue, 25th Floor, New York, NY 10010, USA