Advanced Claim Validation
Closed-Loop Experienced-Based Results
With Advanced Claim Validation (ACV), GTESS accomplishes through technology what takes many BPO organizations years to master, if ever – claim review based on deep industry knowledge and actual historical claims experience with individual providers, geographies, specialties and settings of care.
ACV is a technology that is placed between the image capture and exception processing functions of GTESS' ClaimPRECISETM platform. Its role is to assess the quality of incoming claims within the context of historical filing patterns across multiple dimensions. ACV then generates specific instructions for the GTESS Exception Processing technology to direct claim specialists to problem areas for correction.
When industry and customer-specific business rules are empowered with statistical filing patterns sampled from millions of actual claims, the results are impressive. Our business rules evaluate each new claim against history for a provider or geographic region across diagnosis, procedure, setting of care, price and other measures. This enables GTESS to "know" your providers and create customized instructions for each claim to quickly highlight issues for correction by our exception processing team.
ACV evaluates over 350 independent rules during a typical healthcare claim review. Rules specific to Professional, Institutional and Dental claims compare relationships among fields within the context of the claim and also with national reference sources for National Provider Identifier, controlled medical and dental terminology, U.S. Census and Postal data and many others. ClaimPRECISE uses 29 industry data sources in addition to the context of historical claims to establish "Clues" about the accuracy of the claim. The Clues are then assessed together to come up with "Decisions" that drive the creation of exception processing "Instructions" custom built for exception processing each individual claim.
About Advanced Claim Validation (ACV)
GTESS' unique ACV technology combines standard business rules with 29 different industry data sources and details of a client's past claim history to create customized instructions for each claim, identifying and flagging issues and potential resolutions for handling by GTESS data verification personnel. By automatically reviewing a client's past claim histories, Advanced Claim Validation is able to offer accurate correction suggestions to data verification teams, ensuring that each claim is handled as quickly and efficiently as possible, while customizing the issue review process for each client.