CLIENT SERVICES

Active Employees

Professional Benefits Services was founded for the purpose of providing claims adjudication for self-funded clients. That was many years ago. Since then, we have not only expanded our services, but continually enhanced and perfected our skills and quality controls. Along with our professional capabilities, we have invested in advancing technology so that today 60% of all medical claims are received through EDI. PBS projects this number of electronically entered claims to be at 98% in early 2005. What this means to the client is faster and more accurate claims processing time. By receiving re-priced claims electronically from PPO networks, we can significantly improve claim payment efficiency. Our claims system also has the ability to automatically detect separate charges for services which should be bundled to reduce costs for the client. The PBS claims adjudication system also checks to confirm PPO Network discounting. If no discounts apply based on the primary network, the system will automatically search all national networks to find any discounts which may be applied to the service.

Quality Audits are performed on all client accounts on a monthly schedule. Metrics for success include claims turnover, integrity of plan design, financial accuracy, and a host of others. (See Table 1) Current PBS claims turnover standards are set at 6-8 days, but with the efficiencies we are experiencing through EDI, we expect to set a new metric at 5-7 days in 2005. Many accounts are turning claims adjudication at 3-4 days currently.

Actual claim payment release is controlled by the client upon receipt of claim check registers from PBS.

On-line Access to employee accounts is now available to employers. For those clients who wish to accept it, access to individual accounts will become available to employees by mid 2005. Employers may look up claims and payment status. This on-line capability does not substitute the hands on, personal service of PBS Customer Service Analysts, but for those HR professionals who cherish flexibility and real time access, our system provides that option.

Another welcome feature for client HR staff is our on-line enrollment and eligibility maintenance. Enrollment criteria and form design can be customized by the client.

• Explanation of Benefits
• Claim Status Inquiry
• On-Line Enrollment

Employee Enrollment Process

PBS is prepared to initiate and complete the entire enrollment process for the client. We can provide enrollment forms, conduct employee meetings, and provide PBS staff to assist employees or retirees in completing enrollment forms. PBS can present a full benefit review at the meeting and include consumer guidance on cost containment, or simply provide health plan benefit communication materials for the employer to present. PBS will do as many or as few meetings as the client would like. All of this, to the extent the client chooses, is provided for one setup fee.* But, that’s not all! There are no extra charges for ID Cards, plan documents (SPD), or personalized check setup.

(* There is a travel charge for PBS staff to provide meetings in multiple locations within one state, as well as travel between states.)