Claims

The claims process at Prodigy is straightforward. The client’s TPA provides a fully documented claim file electronically to our claim department, who reviews and audits the file. Once the claim is reviewed and approved, Prodigy processes a reimbursement to the employer’s health plan. In situations where an employer needs to utilize a specific advance or monthly aggregate accommodation provision, we are quick to engage the claim team in the process to ensure the customer doesn’t experience delays in funding. These provisions may be critical for smaller groups and those with low specific deductibles that have limited funding available to pay claims.As a MGU we are acutely aware of the negative impact created when a claim reimbursement is delayed. In our experience, some brokers and TPAs have been unwilling to work with MGUs due to the potential delays created by internal claim processing.

How is Prodigy’s claim process different from others? We chose to outsource management of the claim department to Corporate Benefit Audits (CBA), which is a leading firm in the review and adjudication of large claims and aggregate claims for direct stop-loss insurers and marketing leading MGUs. In selecting CBA, our goal was to establish a relationship with a claim firm whose reputation was above reproach. This move also provides an independent review ensuring employers receive a fair and unbiased interpretation of their claims without unnecessary delays.The claim staffs at Prodigy and CBA are comprised of registered nurse and physician reviewers along with seasoned claim managers. Their shared expertise in reconciling an employer’s Plan Document to the medical stop-loss policy is unparalleled. The claim process also seeks to protect employers from inappropriate billing and delivery of care abuses, which are becoming more common under the Affordable Care Act.

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