Accident and Health

Long-running or multiple service line item Accident and Health claims can be easily managed using the STEP Claims and Settlement portal. STEP manages the entire claims life cycle of long-running claims for disability and Long Term Care products managing all aspects of the claims processes:

  • Management of Qualifiers of Activities of Daily Living (ADLs) and Cognitive ImpairmentManaging HIPAA 90-Day Certification Requirement
  • Advance Searches by Insured, Policy, Product and Agent
  • ICD9/10, Provider, Workflow, Business Rule Engine Features
  • Provides for Requirement and Proof of Loss Tracking
  • Diagnosis Management
  • Applies Claim Rules to all Policy Benefits, Provisions and Limitations
  • Management Control of Claim Assignment and Reassignment
  • Audit Select by Examiner, Product Line, Age and Amount at Risk

In addition, STEP offers a unique Plan of Care Management (POC) template, which provides easy set up of the allowed benefits, based on the product configuration. The POC templates are incorporated with the product provisions and claims rules that are configured as part of the product configuration. The POC templates and their versions are set up as part of the product and activity is monitored during the claims process. The business process records and tracks POC and all Policy Benefits are managed around the POC. The versioning of POC templates allows for Multiple Versions of the Plan of Care for the same product plan. All claims are compared to the Approved Plan of Care with Policy Benefits and claims are adjudicated at the service line based on allowable benefits.
The entire claims adjudication process is managed by the STEP Claims Calculator, which:

  • Calculates Claim Payments in accordance with the Plan of Care
  • Tracks remaining Benefit Balances and the Pool of Money
  • Generates an Explanation of Benefits (EOB) at the Service Line Level
  • Adjudicates Non-Sequential Claim Payments
  • Considers inflation increase in Maximum Benefit Limits
  • Performs rule-based Policy Benefit calculations
  • Determines Indemnity and Reimbursement – prorated and non-prorated payments
  • Conducts daily, hourly or per visit Benefit calculations

The claims process integration with the Policy Administration Level manages and synchronizes the claims status with the policy administration system. The integrated claims functions within STEP policy administration portal manages:
Request for medical information on claims via the Policy Administration System

  • Changes to claim status via the Policyholder Service System
  • Manages Return of Premium payments
  • Maintains 1099 information
  • Generates accounting to the policy accounting system

Control claim leakage

Claims Leakage GraphicNational statistics identify claim leakage in excess of 15% annually. STEP Solutions Claim System virtually eliminates claim management inefficiencies that contribute to claim leakage. STEP’s elimination of claim leakage alone delivers speedy and substantial ROI savings.

STEP Solutions utilizes a unique, all-inclusive strategy to gather important data that becomes the basis for precise claim amount calculations. STEP utilizes data from multiple sources:

  • Policy Administration System
  • Plan of Care
  • Service Lines
  • Product Definitions and Claim Rules