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Administration

Our Team Management Approach
Claims Processing: Medical, Dental, Vision and Disability
Plan Administration
ClinicaLogic Claim Editing
Healthcare Information and Reporting
Flexible Spending Accounts
HIPAA
COBRA
NYHCRA
Cost-Containment
Short-Term Disability
Subrogation
Reinsurance Management
Data Management and Reporting

Our Team Management Approach
Account Management Team - Fiserv Health creates an Account Management team for each customer account, and this team’s first goal is to ensure that all product and service components are fully integrated to provide efficient administration. The team is then dedicated to the ongoing service of client accounts, including response to questions from designated vendors and providers, and resolution of related issues in the most appropriate manner.

Plan Implementation – The Account Managers and Implementation Coordinator will work with all internal departments and external vendors to gather necessary customer information to actively manage the implementation process. Using sophisticated project management tools and a stringent QA process, Fiserv Health’s goal is to deliver a seamless implementation and provide a new benefit plan in the shortest possible time.

Report Requests – Fiserv Health’s special reporting unit, Report Central, will prepare regular reports and will handle special requests. Contact your account manager to assist you with any report requests.

Claims Processing: Medical, Dental, Vision and Disability
Claims for medical, dental, vision and disability income programs are processed on an automated basis.

Fiserv Health adjudicates both dental and medical claims using state-of-the-art imaging and EDI processes in conjunction with our processing engine, Trizetto’s ClaimFacts/ software. ClaimFacts is a highly stable, reliable transaction processing engine that allows Fiserv Health to attain auto-adjudication rates as high as 90%.

With system availability greater than 99.99%, Fiserv Health stores benefits directly in the system, tracks claim data and automatically adjudicates claims on-line in real time. The system produces EOBs, checks and report output. In addition to the claim database, Fiserv Health maintains a separate Oracle relational database with five (5) years of data for analysis and reporting.

Fiserv Health’s automated process checks for duplicate submissions using a matrix of dates of services, types of services, procedure codes, dollar amounts, and provider data.

Components of the system include files for each covered individual, a full plan description, files of all providers, and files of reasonable and customary cost data. The database maintains full historical information on claims processed by claimant and includes various other associated information.

Plan Administration

Plan Document Preparation – Fiserv Health has a dedicated staff that, in conjunction with the Account Manager and Benefit Plan Analysis Department, will prepare the Master Plan Document and Amendments which serves as the Summary Plan Description.

I.D. Cards - I.D. cards are provided upon completion of initial enrollment.

Forms - Forms may be customized and Fiserv Health offers consultation services to produce forms that are straightforward and easy to use. Claim and eligibility forms can be made available electronically.

Customer service - For non-online members, a toll-free telephone number for employees and providers is available for inquiries on the status of claims, eligibility, and benefit plan information. Members may also contact customer service directly using our secure messaging feature.

Claim Records - Complete claim payment records are maintained.

System Security – Built-in system security offers savings to the employer due to the reduction of errors in several areas, including claim adjudication, eligibility and provider maintenance. This system also provides the maximum protection against claims fraud.

Audit/Quality Review – Fiserv Health’s corporate audit department conducts a comprehensive auditing program to ensure quality and accuracy of claims processing, from claim input through claim payment. Customer claims are randomly reviewed by the audit department for accuracy relating to the input of the claim, dollar and financial accuracy, and benefit determination. Additionally, all claims over a certain dollar amount are automatically audited prior to their release for payment.

Billing - We have the ability to separate costs and bill by locations or groups, divisions or product offering, as well as consolidate payments for other services.

Fund Administration - Claim drafts are issued on the client’s own bank account. Fiserv Health will provide a check register and a monthly reconciliation report of issued drafts, voids, and refunds.

Data Reports - Fiserv Health provides an extensive array of reports from which to choose. These reporting options include benefit modeling, and normative reporting, and basic information for daily management of benefit plans including electronic check registers and eligibility reports. We also provide an extensive reporting package which can be used to manage cost trends, identify opportunities to attain efficiencies and control benefit costs.

Printing - The production of checks, Explanation of Benefit forms, statistical reports, and correspondence is automated and completed in a secure facility to protect sensitive information.

ClinicaLogic Claim Editing
A key system feature is ClinicaLogic, a logic-editing program fully integrated with the claims processing system. ClinicaLogic is a comprehensive, knowledge-based sub-system of the Trizetto ClaimFacts adjudication software, which reviews and analyzes all procedures to ensure that a medical claim is paid correctly. The system examines how accurately surgical, laboratory, radiological and other medical procedures are coded, based on accepted medical standards, and detects and corrects any coding errors that would result in overpayment. This helps to ensure that reimbursements are made only for appropriate procedures that are correctly billed.

ClinicaLogic always prompts examiners when a clinical edit of the system takes action on a claim, and they are provided with the medical guidelines on which the edit is based. Certain clinical edits provide advice on the handling of claims payment issues. For example, examiners may be advised that an operative report is required and that a physician should review it in order to settle the claim. This on-line prompt system is intended to provide the examiner with guidance to ensure processing results that are consistent with accepted medical guidelines.

Healthcare Information and Reporting
Fiserv Health supports client objectives by making use of its sophisticated management reporting capabilities. Fiserv Health’s Analytic Information Management (AIM) service has enhanced its analytic and reporting capabilities through the development of utilities in its SAS-based reporting system.

These utilities allow Fiserv Health to extract, manipulate, analyze and present meaningful information. Meaningful reporting requires that information be presented in both an understandable and useful form, so the standard reports maximize the display of a client’s relevant data and convey information the client requires to facilitate plan management.

Fiserv Health’s reports are divided into 12 functional report groups, each encompassing several individual reports. Individual reports are further segmented by multiple presentations of the data to facilitate analysis. Report categories are as follows:

Executive Summary Statistics
Case Management Reports
Reports by Diagnosis
Reports by Type of Service
Coverage Type Reports
Network Reports
Demographic Reports
Provider Reports
Reports by Procedure
Paid Claim Lag Reports
Carve-Out Reports
Graphic Reports

Also available are client-specific custom designed reports:
Enhanced Reports
Ad hoc Reports
Prototype reports

Flexible Spending Accounts
A Flexible Spending Account (FSA) can enable an employer to reduce their payroll taxes and allow an employee to pay for certain benefits with tax-free dollars. The effects of plan changes that can shift more costs to employees can also be minimized. Fiserv Health also offers a flexible spending debit card that reduces paperwork and allows payment at the time of service with the swipe of a card.

Fiserv Health manages FSA administration while maintaining strict observance of IRS Section 125 regulations. We administer Health Care Reimbursement Accounts and Dependent Care Reimbursement Accounts, which may be purchased individually or as a package. Maximum employee contributions are established by the employer, subject to Federal limitations.

HIPAA
The Health Insurance Portability and Accountability Act (HIPAA) is a federal law enacted to improve the availability and continuity of health insurance coverage. It limits exclusions for pre-existing medical conditions, permits certain individuals to enroll for group health care when their other health coverage is lost or they have new dependents and prohibits discrimination in group enrollment based on health status. Fiserv Health assists clients in meeting HIPAA requirements.

On August 21, 1996, the United States Congress enacted new legislation entitled Health Insurance Portability and Accountability Act (HIPAA). Various portions of this legislation have already become effective dealing with new Cobra requirements, nondiscrimination requirements and claims payment requirements.

The Administrative Simplification section of the legislation has drawn the greatest attention. The basic rationale behind HIPAA Administrative Simplification is to force the health care industry to adopt a single set of standards and codes for the electronic submission and payment of claims - EDI Standards - and thereby reduce the administrative costs associated with submitting, processing and paying of health care claims. Once claims processing is reduced primarily to an electronic format, then there is an increased need to ensure that access to such data will be limited so as to protect the privacy of the patients - Privacy Standards. Finally, in order to ensure that such privacy would be maintained - Security Standards must be developed for the computer systems transmitting and storing such information.

Fiserv Health offers a turnkey HIPAA Privacy and Security Compliance Solution to take a substantial portion of the burden of HIPAA compliance off our customers.

For customers of the Fiserv Health TPAs who enroll in this solution, The Fiserv Heath TPAs will assume the responsibility for providing HIPAA privacy and security compliance for your company's Health Plan by assuming the privacy and security compliance requirements otherwise imposed on the Health Plan as the "Covered Entity". This will remove this compliance obligation from the Employer/Plan Sponsor. In order to assume this HIPAA compliance obligation, the Fiserv Health TPA will take on the entire responsibility for the Health Plan's compliance obligations.

Contact your Fiserv Health representative for more information.

COBRA
Fiserv Health’s regulatory knowledge, administrative expertise, and state-of-the-art technology can alleviate the burden of COBRA administration. We will notify eligible enrollees and/or bill for premiums while maintaining strict adherence to COBRA guidelines.

NYHCRA
The New York Health Care Reform Act of 1996 (NYHCRA) became effective January 1, 1997, and imposes surcharges and assessments on a variety of medical services provided by New York medical facilities. As a self-funded business, employers are subject to this law if they have employees receiving care or treatment in the State of New York. Employers may “elect” to have Fiserv Health remit the surcharge and assessments directly to the State of New York on their behalf. For “non-electing” employers, the surcharge is paid to the Provider, who in turn remits the surcharge to the State of New York.

Fiserv Health Cost-Containment
In assessing the appropriateness of services, Fiserv Health’s ClinicaLogic software applies its database of extensive clinical rules for appropriateness of the procedure against variables that include, for example:

• Gender
• Use of assistant surgeon (where applicable)
• Anesthesia service and time (where applicable)
• Procedures that should be included in global procedure codes
• Laboratory testing
• Outdated procedures

Specific system edits include, but are not limited to, identification of:

• Bilateral procedures coded as multiple unilateral procedures
• Procedures billed twice but usually found once in a provider/patient relationship
• Code unbundling
• Subordinate procedures that can be done in the same surgical session and should be billed at a reduced charge
• Procedures that should not be billed separately because they are integral to the primary procedure
• Procedures not normally performed on the same patient more than once
• Separately-billed follow-up care

Short-Term Disability
Accident and sickness claims are reviewed for appropriateness, and weekly income replacement checks are issued to covered persons who cannot work.

Subrogation
Fiserv Health maintains a relationship with a major subrogation firm to provide claims negotiations and maximum recovery efforts from responsible third-party insurance companies and other payors. These recovery professionals include experienced attorneys, property and casualty experts, registered nurses, and paralegals.

Reinsurance Management
Reinsurance Through Fiserv Health’s Own Underwriter
Fiserv, Fiserv Health’s parent company, owns the BP, Inc., MGU. (www.bpire.net) BP, Inc. currently has underwriting authority with Combined Insurance Company of America, the issuing carrier. Since 1919, Combined Insurance Company of America has been bringing quality supplemental accident, disability, health and life insurance to individuals and families across the United States and 11 other countries. Combined is the largest consumer insurance underwriting company of Aon Corporation, the world's premier insurance brokerage, consulting services and consumer insurance underwriting organization. Negotiations are underway to add several new carriers to the BP, Inc. portfolio, including those with non-lasering options. All carriers represented by BP, Inc. will have an A.M. Best rating of “A” or better. Traditional reinsurance coordination issues are eliminated when using BP, Inc. and competitive rates can be made available to our customers through this relationship. For more information, visit the Combined Insurance Company of America Website at: www.combined.com.

Other Reinsurance Relationships
Fiserv Health maintains strategic relationships with the highest rated stop loss carriers throughout the country. Due to our national presence, employers have access to virtually any stop loss carrier and multiple types of coverage while benefiting from the most competitive rates.

Stop Loss Solutions – Fiserv Health has access to a wide variety of stop loss products and services that include individual and aggregate coverage, an aggregating specific product, premium risk sharing arrangements, and a terminal liability option. We also have access to Managing General Underwriters (MGUs) who represent carriers that provide specific products and solutions to meet unique customer needs.

Vendor Integration – We can bill, collect, and remit monthly premium payments directly to the carrier eliminating the need to process multiple invoices and payments.

Monthly Review – Fiserv Health will review paid claims by individual to monitor the progress of claims reaching or surpassing 50% of the Individual Specific Deductible. When necessary, we will notify the carrier of the specific details of the claimant and together, Fiserv Health and the carrier, will closely follow the claim. The aggregate claims, if applicable, will also be tracked to ensure awareness of any approaching aggregate claims.

Renewal Review – Fiserv Health will evaluate the stop loss pricing at renewal and ensure a fair and competitive market value for the services offered.

Data Management and Reporting
In addition to plan design and administration, we provide the documentation and plan performance reports that employers need to manage benefits more effectively. These tools help monitor basic utilization and can be useful in identifying new options for greater savings.