IBM PureSystems Centre

Extending the value of IBM PureSystems


Gregory L Seelenbinder & Associates
Provided by:Gregory L Seelenbinder & Associates
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Version:Release 18.0 2/10/15
Health Claims Payment Software for large employers, TPAs and Insurance companies. Handles Claims, Group, Trust and Flex Administration with ICD-10 coding. Optimized for PureFlex™ systems and Smartcloud™ computing.
  • - Business Value

    Pattern Overview

    Interactive Claims Adjudication Processing system with on-line help and inquiry capabilities. Provides fully adjudicated on-line claims payment for medical, dental, vision, WDI and fee claims and generates 1099s, W-2s, HIPAA certificates and other required government reporting including new HIPAA regulations for EDI compliance. Can perform up to 500 different on-line edits during adjudication, checks eligibility and selects the proper class of benefits.

    Uses CPT-4 and ICD-10-CM codes, performs UCR calculation based of CRVS, HIAA, Ingenix, MEDATA or any user-defined schedules, evaluates up to 50 different benefit equations with up to 45 different variables and automatically posts comments. Includes a complete Provider Pricing module, 2 clinical editors and automatic mail assignment.

    Calculations include individual and family deductibles and out of pocket with totals history update, benefit and year amounts and benefit and date amounts with stop payment beyond the maximum if required. Handles lifetime maximum and 12 month maximum amounts with stop payment and stop loss and high deductible amount with stop payment.

    Deals with amounts allowed per visit with stop payment at visit limitation and 28 types of COB including true coordination with or without benefit credit, non-duplication and carve out. Accommodates laser check printing, e-mail routing, agent commissions, imaging, EDI and outsourcing of checks.

    Business Case

    With the ability to set up 26 different claim systems on one iSeries™, you can sell your services as a TPA or a backroom processing company letting smaller companies pay their claims on your system, while you handle file backups etc.

    Business Problem

    Businesses are looking for ways to reduce staff and increase the throughput of claims payment. CAPS/2020 provides for those goals through it's auto adjudication capabilities.

    Businesses are looking for accurate claims payment which CAPS/2020 affords through on-line clinical editors. Businesses are looking for alternative sources of income, which CAPS/2020 brings to the table through it's many business partner alliances.

  • -Technical Details

    Up to 400 different on-line automatic edits are performed. User can also define client-specific edits in addition to the standard edits.

    Automatically checks for primary care and referral physicians, if relevant.

    Uses CPT-4, ICD-10, Place of Service, Type of Service, and location codes to point to proper benefits.

    Unbundles and Rebundles charges based upon Ingenix's Claims Edit System.

    Checks claim against clinical editor databases and will automatically deny, pend or process the claim accordingly.

    Calculates contracted provider pricing for PPOs, HMOs, and other negotiated arrangements.

    Evaluates up to 90 different user-defined benefit equations with up to 45 different variables.

  • - More Information

    Provider Information

    Name: Greg Seelenbinder


    Phone: 614-833-6952

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