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Managed Care Services

24 Hour Claims Centre

NEXtCARE operates a 24-hour, 7 days a week claims centre that unlike other TPAs is staffed exclusively by doctors. This medical advantage allows enhanced communication with providers, facilitates faster and more accurate claims decisions, as well as providing a centralized point for any insured member's question or requirement ranging from medical referral to benefit and coverage queries.

Pre-certification, Concurrent & Retrospective Review

NEXtCARE’s centralized Claims Centre provides pre-certification and micro-management for each inpatient admission as well as for relevant outpatient & emergency cases. This ensures that patients are treated in the most medically appropriate and cost-effective manner.

Second opinion review is an additional service provided as part of NEXtCARE’s claims management approach. This service focuses on providing selected patient cases with free second opinions and other expert review(s) to ensure medical necessity and appropriateness of care.

Impartial Claims Decisions

NEXtCARE ensures that members are given balanced, fair decisions related to claims coverage and payment. Decisions are based on eligibility of the beneficiary and the terms and conditions of his or her policy on a direct billing or reimbursement basis.

Claims Processing

NEXtCARE has a data entry team specialized in  detailed capture of medical bills related to medical services rendered to beneficiaries covered under contracts that have been guaranteed by the Payer.

Payers receive a detailed claims report(s) per Contract Holder, per Healthcare Provider and per beneficiary which displays the claimed amount, the approved amount, the reason(s) for non-approval, non-approved amounts and the payment due dates.

NEXtCARE continuously monitors quality of data captured.

Confidentiality

With a claims centre staff which is staffed 100% by medical doctors, medical confidentiality is paramount to providing professional services. Confidentiality protocols, informed consent for medical release, fire-walled software, quality assurance procedures as well as highly professional staff ensure that patient privacy is safeguarded.

International Guidelines

International standards such as the World Health Organization’s International Classification of Diagnosis, the Current Procedure Terminology, HCPCS and other ancillary service nomenclatures and structures are just some of the standards used in NEXtCARE’s claims administration procedures and software. International clinical guidelines such as Milliman & Robertson, etc. are used widely as a base in NEXtCARE’s customized approach to claims management.




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