How does PAS work?
First, an insurance Carrier must precisely define its business rules (plan limitations, prior authorization requirements, eligibility parameters, etc.). Additions, terminations and other changes will be made via system updates, as necessary. PAS can be used with (or instead of) a Carrier's existing in-house claims processing application. If PAS is used in conjunction with a Carrier's software, daily batch files containing eligibility status and information related to claims "paid" (authorized) by the online system (PAS), will be exchanged to ensure that both applications are kept in sync.
AIS encourages all application developers in the healthcare industry (including those who develop pharmacy applications), to integrate PAS’ claims processing formats into their applications. Should a Provider elect not to use a product from the growing list of third party applications into which PAS has been integrated, AIS' own Provider application can be installed. All relevant databases will be setup on the Provider’s computer, and AIS will coordinate and facilitate all training. The application is intuitive and user-friendly, thus training usually takes hours instead of days, even for those who have limited familiarity with a computer. Our application is known as EPOS (External Point of Service), and it should never be regarded as a compromise to the average Practice Management application. More can be learned about EPOS from our PowerPoint presentation on this site. The basic requirements for EPOS include a computer with 64MB RAM, 6GB Hard Drive, a magnetic strip reader (provided by AIS), and receipt printer. A network version of EPOS is available for larger Provider sites such as hospitals.
Authorization numbers are assigned to "paid” claims and are then associated with the return transaction, thereby contributing to the audit trail. Of equal importance are the coherent explanations associated with rejected claims. Whenever a claim is rejected, PAS notifies the Provider as to the exact reason why the Carrier will not pay a particular claim. Common reasons for rejection include; patients not having sufficient funds to cover the services being rendered; a particular procedure or drug not being covered by the subscriber’s plan; and the Provider not being authorized by the Carrier to render the service (or dispense the drug) being claimed for.
The following databases of codes are recommended (but not mandatory) in setting up plans and submitting claims from EPOS:
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ICD 9/10 & CPT for medical, dental, optical, etc. diagnoses and procedures
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ADA & ICD 9/10 for dental procedures
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Drug Codes for pharmacy claims
The aforementioned databases are provided with EPOS, which also includes extensive prescriber and drug databases, wherever relevant. Note that the most complex plans can be structured by using these databases, and that a single plan can include multiple provider types, all with a guarantee that electronic adjudication will take place in under 3 seconds!
Where PAS is being used as the sole claims processing engine (and optionally where it is not), IPOS, a derivative of EPOS, is used in-house by the Carrier to submit paper claims. Since PAS was designed with a parameter driven infrastructure and an intuitive Graphical User Interface (GUI), training (both for Carriers and for Providers) is neither burdensome nor time consuming.
Enhanced Communications
Enhanced communication between Carriers and Providers, as well as between Providers themselves, is a major hallmark of PAS. The Provider Access System employs a country-wide Internet Protocol/Virtual Private Network (IP//VPN) extranet that facilitates e-mail and other convenient (and cost-effective) methods of communication. PAS can be set up on an inter- or intra-regional scale, thus providing tremendous opportunities for a Carrier's expansion, opportunities which do not require the duplication of administrative overheads.
Click here for more information about how PAS benefits Carriers, Providers, Subscribers, Epidemiologists and the Public Sector.