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The GWI-Claims System is the premier
product for automated, rapid, and cost effective
administration of medical claims. The automated
adjudication component of claims administration
results in a claim being received via Electronic
Data Interchange (EDI), and processed (paid,
denied, pended or rejected) based on set of
specified benefits and contractual rules with
a built-in repricer.
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EDI–Payer – This module identifies all EDI trading partner information within 3 subsystems: EDI Trading Partner Information, Depository Financial Institutions and Payer Information. |
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Benefits – Includes Insurance Products, Plan Riders, Benefit Plan Maintenance, Benefit Plan Inquiry, Benefit Plan Copy, Benefit Payment, Benefit Options Update, Broker Management, Group Maintenance, Group Benefit Plan and Group Inquiry subsystems. |
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Provider This module provides four major subsystems: Provider Contracts, Provider Information, Provider Performance Index and the Facility Group subsystem. |
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Membership – Consists of eight subsystems: Member Inquiry, Enrollment, Member Correction, Subscriber Address Correction, Family/Member Status Change, Eligibility Subscriber Update, Eligibility Delete, Family Delete and Multiple Coverage. |
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Claims – This module consists of three subsystems: Claims Entry Subsystem (Manual, OCR, EDI), Claims Correction and Claims Inquiry.
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Authorization A comprehensive subsystem allowing authorization, pending or denial of services. The system coordinates referral requests with the member’s benefits, professional providers’ contracts and facilities contracts. With this information, the system creates an IBNR for the referral request, and accomplishes notification by email, fax and/or letter to members, and providers. |
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Rebundler – Automates rules for provider reimbursement based on a CPT coded rule base. |
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Code Maintenance – Contains eleven subsystems: Code Search, ICD9 Code Maintenance, CPT Code Maintenance, Internal Code Maintenance (with 85 query and maintenance regulated coding files), Provider Contract Classification, Professional Benefit Categories, Facility Benefit Categories, Conflict Benefit Categories, Preexisting Condition System and GL coding system. |
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Billing/Reinsurance – Three billing subsystems, consisting of Premium Rate, Invoice and Inquiry Systems serving TPA functions, and three Reinsurance subsystems consisting of Product Coverage, Reinsurance Setup and Risk Member Inquiry. |
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Payment – Consisting of five subsystems: Make Payment, Payment Inquiry, Payment Information, EOB/EOP Notification and Form 1099. |
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Notebook – Consists of three subsystems: Insurance Company Information, Contacts Information and Home Company Information. |
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Data Exchange – UNIX Data Loader, Parameters and Reports Distribution subsystem. |
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Call Center – Call tracking, new case and history. |
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