Insurance Eligibility & Authorization Verification Report

INSURANCE ELIGIBILITY &
AUTHORIZATION VERIFICATION
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Phone: (646) 661-7853 | E-mail: ronnie.hastings@sunknowledge.com

Private & Confidential 2Phone: (646) 661-7853 | E-mail: ronnie.hastings@sunknowledge.com
SUN KNOWLEDGE OVERVIEW
Key Facts Awards, Affiliations & Certifications
 ‘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
Office at
41 Madison Avenue, 25th Floor,
New York, NY 10010

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 – Physicians, Hospitals, DME, P&O, Home Health Care and Pharmacies
Payers – Commercial Plans, MA Plans, Medicaid HMOs, MAPD/PDPs, IPAs, MSOs, TPAs, PBMs and RBMs

SUMMARY OF SERVICES
PRACTICE
MANAGEMENT
Scheduling
Eligibility &
Authorization
Verification
Prior Authorization
Customer Care
BILLING &
COLLECTIONS
Coding
Charge Posting
Claims Submission
Payment Posting
Denial Management
Accounts Receivable
PAYER SERVICES
Claims
Adjudication
Credentialing
Utilization
Management
Customer Care
TELEMEDICINE
Telemedicine
Remote Patient
Monitoring

ELIGIBILITY &
AUTHORIZATION
VERIFICATION

ELIGIBILITY VERIFICATION – HIGHLIGHTS
 Full range of verification services
 Fast 24-hour turnaround time
 Above 99.9% accuracy
 Detailed documentation
 100% HIPAA compliance
 Experience with national and private carriers
We have the experience, training and resources to complete quick
verification checks, a feature that Urgent Care Centers love us for.
In some cases, such services can even be rendered
in real-time (with the help of rapid database access
through appropriate lookup software applications)

AUTHORIZATION VERIFICATION – HIGHLIGHTS
 Diligent follow-up till resolution and closure
 Uniform importance given to every account irrespective of size, age or claim value
 Fast completion of authorization process
 Periodic follow-ups to maintain authorization validity
Years of experience in working at
claims adjudication for major
insurance companies in the US
have given us a unique
understanding of the
authorization process, allowing
us to complete the process faster
than others!

ELIGIBILITY VERIFICATION – SERVICE FEATURES
Eligibility check covers the following:
 Policy active for date of service
 DME coverage
 Copay / Coinsurance / OOP
 Rx & Dx entry (with appropriate timeframe)
 Provider status (INN / OON)
 CSI check
 Authorization requirement
 Obtaining authorization
 Patient responsibility

SAMPLE REPORTS
0
20
40
60
80
100
120
140
4/6/2015 4/7/2015 4/8/2015 4/9/2015 4/10/2015
96
83
94
98
96
29
11
6
31
32
125
94
100
129
128
41
32
26
30
28
ELIGIBILITY VERIFICATION
Number of New Patient Patient Brought Forward
Primary Checked Secondary Checked (if applicable)
0
5
10
15
20
25
30
35
40
45
50
4/6/2015 4/7/2015 4/8/2015 4/9/2015 4/10/2015
45
25
38
44
46
20
15
26
22 21
25
10
12
22
25
AUTHORIZATION VERIFICATION
Auth Required Auth Obtained Auth Pending

BENEFITS OVERVIEW
 360o operations support in medical benefit coverage
 Quick authorization process
 Detailed documentation
 100% HIPAA-HITECH compliance
 Experience in working with both Payers and Providers
 Highly accurate eligibility data maintenance (in sync with CMS)
 Excellent references from more than 7 years of successful operation

PRIOR AUTHORIZATION

PRIOR AUTHORIZATION – A CONSUMMATE SOLUTION
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.

PRIOR AUTHORIZATION – SERVICE PORTFOLIO
 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

BILLING & CODING

SERVICE HIGHLIGHTS
 FREE Billing Software
 FREE EMR
 FREE Setup, upgrades and support
 Up to 97% Collection Rate
 Claims Submission within 48 hours max.
 Error-free Patient Entry
 Over 99.9% Coding Accuracy
 Real-time Audits
 Methodical and Proactive AR Follow-up
 100% HIPAA Compliance
 Custom Reporting

MEDICAL BILLING CYCLE
Encounter
(SOAP)
notes
review
Superbill
generation
and code
review
Claims edit
checking
and
correction
EDI claims
submissio
n through
clearing
house
Rejection
management
ERA/EOB posting
and
reconciliation
Automatic
secondary
payer billing
Denial
Management
AR
Follow-up

BILLING CYCLE – DETAILS
 Order entry based on the Rx received from the Physician
• Patient demographics & insurance entry
• Provider information entry
• Product code, Rx & Dx entry
• If necessary, a telemedicine consultation can be completed to obtain a Rx to expedite the order entry process
 Eligibility verification and authorization requirement enquiry
 Patient’s appointment with Practitioner for Practitioner to assign codes
 Collection of detailed Rx from ordering Physician’s office
 Collection of documents required by Payer for authorization approval, e.g. Diabetic Verification Form, initial
evaluation, medical notes to support K level, PPR Form
 Calculation of service estimates (Patient and Payer responsibility)
 Determination that payer criteria are met before delivery of device (if criteria are not met,
the Patient needs to be contacted & informed of the additional financial liabilities)
 Generation of delivery ticket (based on which delivery is made to the Patient)
 Creation of claim after receipt of confirmation of delivery
 Submission of EDI/paper claim to Payers
 Cash Posting
 Rejection & Denial Management
 A/R follow-up

CODING SERVICES – OVERVIEW
Service Offerings
Medical Coding
• Place of Service Based Coding – Inpatient, Outpatient Coding
• Provider Specialty Based Coding– E/M, Cardiology, Orthopedics, Physical Medicine etc.
GoTelecare handles medical coding - promptly, perfectly and professionally –
using Kareo® or other billing systems as preferred by the client.
• Review medical notes and clinical documents
• Assign ICD-10 codes for the diagnosis identified by the physician and Procedure codes (CPT/ ICD 10 PCS)
• Assign modifiers as applicable
• Code review and quality assurance
• Communication with Physician’s office for additional medical documentation and clarification
Key Tasks

PRACTICE MANAGEMENT AND BILLING SYSTEM
GoTelecare billing executives have experience in working on several industry standard
practice management and billing software systems such as:
We can provide medical billing & coding services using customer’s billing system
or can set up customer’s practice in a billing system managed by us.
 Kareo  SOS
 Emdeon / Capario One  Meditech
 Brightree  Alpha Collector
 Fastrack  OPIE
 CPR+ HME  Futura
 DME Works  PrimeRx
 Team DME

OTHER PRACTICE
MANAGEMENT SERVICES

PAYMENT/DENIAL POSTING PROCESS
Payment posting is crucial to the billing process. Due to the sensitivity of this process,
accurate and efficient payment posting process is indispensable.
Our billers are known to be highly efficient and analytical in the payment posting process.
Payment Entry Process
Select Patient Account
Select EncounterSelect Encounter
If not found
Refer Client SpecifiesDenial
Denial Code
Hold Transfer BalanceTransfer BalanceWrite-off
Post Payment
Payment

DENIAL MANAGEMENT
Auth Related
14%
Coding Error
5%
OON Issue
8%
COB Issues
10%
Patient info
missing
6%
Exceeds
Timely Filing
8%
Duplicate Claim
5%
Service Not
Covered
6%
Primary
Paid Max
7%
Pre-Existing
Condition
5%
Others
26%
Distribution of Denied Claims

HIPAA COMPLIANCE
& BENEFITS SUMMARY

HIPAA COMPLIANCE SUMMARY
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

SOCIAL MEDIA MARKETING

EVEN MORE BENEFITS
ACTIVE BRANDING & VIGOROUS LEAD GENERATION THROUGH SOCIAL MEDIA MARKETING
3.4
Million
Healthcare
Providers
Tap into our massive, and ever-growing, database
of over 3 million healthcare providers from every
corner of the US, and discover your next client!
Active
Multi-
Channel
Marketing
Targeted, high quality lead generation through various
digital channels for B2B marketing such as Email
marketing, SEO (Search Engine Optimization), LinkedIn®
marketing, PPC (Pay Per Click) advertising, and more!

SUMMARY OF BENEFITS
 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 27001:2013 & HIPAA Compliance for End-user Data Privacy and Protection

TESTIMONIALS

CLIENTSPEAK
“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

CLIENTSPEAK
“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

CLIENTSPEAK
“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 Avenue, 25th Floor,
New York, NY 10010
For Additional Information, Please Contact…

Insurance Eligibility & Authorization Verification Report

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