Our copyrighted proprietary software is
available for licensing to those organizations whose claim systems reside on IBM's AS/400, iSeries and IBM i platform. Existing interfaces are available for
MC400®, iBenefits® and powerMHS®.
For those IBM based claim systems which we do not currently
interface to, we will modify our Overpayment System to interface to your host system at no cost to you.
Pilot Information Systems also offers a Web
Service interface directly to our server for those organizations that require a real-time call from their EDI and/or online claim processing programs. Using this interface entails setting up a REST
connection through Secure Socket Layers (SSL) utilizing JSON for the data interchange.
Software as a Service (SaaS)
Using this method, claim shops can FTP their
claims to our server where it will be picked up, processed and sent back within in a matter of minutes.
Written to perform
Mining for overpayments can be a very intense job, especially when sifting through millions of claims. Our system was written with this in mind and includes routines that lighten the load on the host system. As a result, we have seen high end units process several million claims an hour.
Our unique user interface,
coupled with the platforms Open Query File facility, allows you to select on any field contained in your claim files using a variety of selection criteria including single values, ranges, wildcards,
"contains" as well as exclusion clauses. This feature permits you to quickly audit specific groups, plans, members or just about anything else your claim files
Among the unique features of OaRS is its ability to let the user customize the examination of their claims. The most popular customization feature is the user’s ability to sequence the order in which the edits fire. Another popular customization feature is its flexibility in identifying duplicate claims. Most systems define duplicates as claims that have the same procedure, performed on the same patient on the same date by the same provider. Not with OaRS, because we leave the definition of duplicates entirely up to you. Our software allows you to define a duplicate by the use of nearly two dozen different selection criteria. For instance, in order for a claim to be considered a duplicate, must the billed charges be the same on all potential duplicate records or can they be within a certain variance of, say, 15% of each other?
Included in the system is a module that allows you to reprocess all of the duplicate claims that are discovered. This permits you to automatically reverse duplicates that have already been paid and gives you the ability to pend or deny claims that are waiting to be paid.
In Good Company
Our system is installed at many health plans, TPA's and self-insured plans around the country.
AS/400, iSeries and IBM i are trademarks of International Business Machines. MC400 and iBenefits are trademarks of ITEL, Inc. powerMHS is a trademark of DST Systems.