Claims Administration Services

Spectrum Administrators provides the claims administration services of a team of quality focused claims analysts, led by a deep field of benefit plan experts. They are supported by a highly skilled customer service team and a process-oriented production staff, all linked by a state-of-the-art computer system. With a commitment to customizing programs to meet individual employer needs, Spectrum Administrators offers the following claims administration services:

• Indemnity, PPO and Point-of-Service plans
• Consumer-driven Health Plans
• Claims Adjudication by dedicated Benefit Analysts
• Data Management
• Claims Processing
• Eligibility Maintenance
• Student Status Verification
• Coordination of Benefits
• ID Card Design and Issuance
• Referral Processing
• Claim Repricing
• Verification of Treatment and Expenses
• Disbursement and EOB Issuance
• Protection of Subrogation Rights
• Management of banking and funds transfer
• Reinsurance Filings/Coordination of Services
• PPO Coordination
• COBRA and HIPAA Administration
• Flexible Spending Arrangements/Related Section125 plans
• Rx, Vision and Dental Plans
• Superior Member Service

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Benefit Plan Design and Consulting

With experience managing a broad range of benefit plans, and through the interface of our medical management, claims programming and customer service teams, Spectrum Administrators is uniquely positioned to offer our clients guidance in developing benefits plans most suitable to their employees and their budgetary requirements.

• Development of new plans or refinement of existing plans, encouraging members to seek the care best combining controlled cost with quality of care;
• Plan document and SPD development;
• Negotiated fee arrangements; and,
• Historical review of claim experience to best design utilization review and pre-certification requirements.

Spectrum Administrators’ reinsurance/stop loss experts stand ready to develop stop loss coverage recommendations, seek premium quotes, procure and bind coverage with carriers rated A or better. Our carrier relationships ensure highly competitive rates with respected, qualified insurers who not only respond timely if and when reimbursements are due, but supplement our services with transplant networks, case managers and other specialty offerings.

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Information Systems and Data Management

The complexities of our ever transitioning health benefit marketplace, along with the inherent need to provide employers self-funding their employee benefits with the tools to contain cost, place technological demands on program administrators. To meet these demands, Spectrum Administrators utilizes the Resource Information Management Systems (RIMS) QicClaim/2 software. QicClaim/2 is a comprehensive, versatile, state of the art system designed for rapid, accurate and cost-effective claims processing.

QicClaim/2 is parameter driven, so client benefit plan specifications are built into the system. Claims are paid by following parameters set for diagnosis, procedure, place of service, benefits, coinsurance, pre-existing conditions, age limits, waiting periods, deductibles, out-of-pocket amounts, accumulation limits, etc. The flexibility of our technology and the manner in which we have built our coding logic permits our plan builders to create limitless plan provisions. Thus, Spectrum Administrators does not force our client plans to fit a pre-established mold; instead, individual plans are just that….individual.

The system can handle hundreds of separate plans with a multitude of variations. Benefit plans can be administered according to preferred provider or point-of-service arrangements or based on accepted procedure codes such as CPT-4, ICD-9 and HIAA. All reasonable and customary schedules, CRVS schedules, PPO factors and fee schedules are contained within the system. Because the plan abstracts are maintained and regulated in-house, with no outside hard programming, benefit plan changes can be made promptly, usually within a few days.

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Loss Trending and Analysis

Maintenance of loss data is essentially purposeless without the ability to access, evaluate and learn from it. Our ability to offer information back to our clients in the form of data trending and loss analysis to support program recommendations is critical.

To enhance our reporting capabilities, Spectrum Administrators employs a state-of-the-art data-warehousing product, customized to our specifications, along with powerful data-mining tools. This warehousing product and related tools broaden our ability to drill-down into loss experience and considerably expands the reporting capabilities of our core systems. As a result, our ability to help our clients get their arms around their loss experience is virtually limitless.

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Quality Assurance

The variation of plans we manage and, simply, our dedication to providing the highest level of quality benefit programming, requires a systematic, focused, quality assurance program based on established protocols and benchmarks. Our training and quality assurance functions interface directly, single-source, online resource and reference materials are reviewed and updated regularly, and staff members are engaged and encouraged to participate in the establishment and refinement of best practices.

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