Fully automated, real-time processing system for complete, on-line adjudication of medical, dental, vision, prescription drug, disability and COBRA claims and encounters.  Comprehensive, yet highly flexible and easy-to-use system.  Sharing of information between subsystems minimizes data entry and human intervention. Provides the necessary components for fast, accurate, and cost-effective processing.

Fully automated, real-time benefit administration system, with support for eligibility, billing, collections, and commissions.  Addresses all aspects of health coverage remuneration for the administration of all types of health insurance.  Support for both group and individual.  Also accommodates life and AD&D coverage administration, and offers great flexibility in defining your life products.

Fully automated and comprehensive workers' compensation claims administration system that enables you to administer workers' compensation programs within established managed care guidelines.  Adjudication of workers' compensation and health claims within a wholly unified system.  Provides an extensive range of proactive cost containment strategies for effective managed care.

Fully automated, comprehensive, and integrated system for the management of Section 125, Flexible Benefit plans.  Offers complete administration of a full range of flexible benefit programs, from spending accounts to a full cafeteria plan.

Fully automated system for the administration of the Consolidated Omnibus Budget Act (COBRA).  Complete, onl-line administration of a wide range of individual and COBRA eligible health plans including medical, dental, vision, and prescription drugs.  From initial COBRA notification through coverage termination, FACTS COBRA performs the necessary functions to ensure COBRA compliance.  Allows for the efficiently and timely flow of pertinent data for your COBRA qualifiers and participants.

Laser printing module for print of check with an Explanation of Benefits (EOB).  Enables the print of this information along with the required logo, signature, and MICR encoding in only one pass through the FACTS MICR printer on blank security paper.  Simplifies and streamlines all aspects of the check/EOB printing, sorting, and filing process while greatly reducing your administrative and overhead costs.

Fully automated provider network processing module.  Provides you with a fully integrated database for providers (both practitioners and facilities). Contracts are driven by date-of-service, giving you the added capability of unlimited contract periods.  Unlimited number of PPOs per plan; unlimited number of providers per PPO; unlimited number of PPOs per provider. 

On-line, interactive claim editing and auditing module, which verifies claims for accurate procedure and diagnostic coding, utilizing the Ingenix™ statistical, multi-tiered claims editing database.  Allows you to identify excessive and inappropriate care quickly, for effective case management and cost containment.  Use of this system offers significant savings.

Fully automated and comprehensive pre-authorization, utilization review , utilization management, and physician referral system.  Offers a full range of case management capabilities to track patient activity, as well as containment strategies for effective managed care.  Industry database experience combined with the FACTS PRE-AUTH & REFERRALS system provides an effective tool for establishing goals for treatment and protocols, enabling you to evaluate the strategies which offer you the most cost-effective savings.

Fully automated provider capitation and sub-capitation module for use by doctors, hospitals, integrated delivery systems, and other types of Managed Care Organizations (MCOs).  Supplies providers with the functionality to effectively control and manage all of the major administration needs within a capitated environment.  Allows for multi-level capitation setup for multiple lines of business.  Supports multiple capitation agreements with providers accommodating variable rates by age, sex, region, and plan.

Fully automated system for the administration of a wide range of Point-Of-Service (POS) plans.  Supplies your FACTS database with a comprehensive database of provider credentials and relationships for effective network and employee election management.  Primary Care Physician (PCP) election at the member and dependent level; profiling and credentialing; and backup referral tracking at the plan, network, and provider levels.

Fully automated case management system.  Provides nurse managers and claims professionals with the necessary tools and information  for the management and review of hospital and medical services provided through the term of an illness or event.  Enables health care professionals to effectively monitor and manage all stages of patient care and treatment in a prospective, concurrent, and retrospective fashion.  Highly effective utilization management tool that allows the user to more critically ensure the maintenance of quality health care at the lowest cost.

Integrated, front-end system for Intelligent Optical Charater Recognition (IOCR).  Allows for on-line document imaging, scanning, storage, and retrieval.  Gives you the ability to process a greater volume of claim forms directly into the FACTS CLAIMS & ENCOUNTERS system quickly, accurately, and consistently.  Using OPTIFACTS, you can scan in the original claim form to disk and obtain a printed check instantly.

Electronic claim submission system for the high speed entry of claims and/or member data into the FACTS CLAIMS & ENCOUNTERS system, directly from a provider or claims clearinghouse.  Enables you to transmit hundreds of claims or member records within minutes, virtually eliminating all data entry requirements.  Significantly reduces the administrative overhead and costs normally associated with the claims entry process, by incorporating electronic claims processing technology

Fully automated claims pre-processing system which enables your clerical and non-technical staff to perform claim data entry tasks, easily and efficiently.  This pre-processing capability allows you to enter claim information and file it for processing and authorization at a later date, even if you do not have all of the general claim information.  Provides your organization with an effective mailroom data entry solution which helps you reduce administrative overhead and costs normally associated with the claims entry process.

Automated decision support system which provides for automatic coding of claims based on on-line analysis of claim parameters.  Utilizes master coding templates, defined by industry experts through the critical analysis of HCFA and UB92 elements to efficiently determine the appropriate benefit classifications through benefit codes.  Minimizes adjuster error in benefit code selection and standardizes claims processing throughout your organization.

Parameter driven, automatic adjudication module that adjudicates claims quickly, easily, and accurately, with minimal adjuster intervention.  Collects claims received via modem, tape, or diskette (using FACTS EDI), via optical imaging and IOCR (via OPTIFACTS), or via mailroom data entry (using FACTS PRE-PROCESSING) and creates a batch for automatic adjudication.

Electronic claim workflow management system for your adjusters.  Provides automatic routing of claims entered into the FACTS CLAIMS & ENCOUNTERS system via FACTS EDI, OPTIFACTS, or FACTS PRE-PROCESSING to adjuster work queues on a real-time basis.  Ensures your adjusters have the most current and accurate workload possible.  Provides your organization with a dynamic environment for enhancing claims throughput and turnaround time.

User-friendly, parameter driven and comprehensive ad-hoc report generator.  Extremely powerful, yet easy-to-use system for the production, maintenance, scheduling, and running of custom and standard reports.  Utilizes the information maintained by the user's FACTS database.  Flexible, custom reporting capabilities provide a wide range of options for specifying the data you want to include in a report, and the formatting parameters for report design.

First e-business platform designed specially for health care administrators using the FACTS system.  Facilitates the sharing of real-time information directly from your FACTS system to insureds, employees, and provider's web browsers through the Internet.  Eligibility, plan summary, and claim status information is available in a real-time fashion, 24 hours a day, seven days a week, 365 days a year.  Secured and protected access.  Leverages the power, connectivity, and efficiency of the Internet into your FACTS health claims management environment.  Includes EDI claims upload capability.

Interactive voice response system which gives employees, providers, and employee benefit administration representatives access to benefits eligibility and claim status information 24 hours a day, seven days a week, via touch-tone phone.  No human intervention required; calls are automatically answered by the system. Gives your customers access to information when they want it, in a timely and consistent manner.  Fax back capability also provided.