top of page

Health Claims Processing System

SSI's Health Claims Processing System is designed to handle the needs of a health benefit's plan administrator. The system is designed with menus which allow the user to easily select the task he or she wishes to perform. The entry screen is a prompted, fill-in-the-blanks operation which guides the user through each transaction. The system is HIPAA compliant for both the privacy and data interchange requirements. The programs are menu-driven, with extensive operator prompting to keep operator training to a minimum.   The system supports a wide range of reports and additional reports can be generated through Access, Crystal Reports or any standard SQL based reporting function. If the client has an integrated imaging system, there will be easy links throughout the system to retrieve relevant documents, e.g., in the claims history function there would be a link to the actual claim form submitted to the Fund.

The programs provided in SSI's Health Claims Processing System perform the following functions:


This function stores and maintains the various benefit levels and descriptions of each particular Health Plan in the system. This gives the user total flexibility to handle multiple plans, and in the selection of various categories to complete a plan, such as:

Plan number - handles unlimited number of Plans
Multiple Start and End Dates
Type of benefit category

(i.e. Hospital, Medical, Surgical, DXL, Psychiatric, Dental, Prescription, Major Medical, Life and AD&D, Optical, Ambulance, Emergency treatment, etc.)

Ability to allow or restrict Basic benefits
Records Frequency or Dollar limitations
Automatic exclusion codes
Coinsurance % by category
Stop-Loss amount
Category deductible by Member, by Family and by Family limit
Carry-over deductible
Plan year maximums or Calendar year maximums
Lifetime maximums
Combined Basic/Major Medical maximums
Memo field


These functions store and maintain any basic tables used in the automatic calculation of benefit payments, including:

Procedure descriptions - long and abbreviated descriptions
Multiple Start and End Dates
Procedure restrictions - age, sex, place of service, etc.
Management Review code
Up to 5 fee schedule amounts per procedure
Allows % of charge - in full or up to specified amount
Ability to track number of days/visits
Memo field that is displayed within Claims Entry


This function maintains a file of user-defined codes and functions that include such information as:

Reject / Pend / Hold codes will print either a long description (printed on EOB), a short description (displayed within Claims History) or will, if selected, suppress printing any description
Diagnosis codes / descriptions with normal length of stay
Second Surgical Opinion flags those CPT codes requiring second opinions and associated penalties, if not obtained
Pre Payment Audit establishes by claims payor the Audit criteria for that individual payor, i.e. maximum dollar amount that payor can authorize, maximum amount of charge that payor can review, or if all COB claims must be Audited, or creation of a random Audit based on number of claims processed, etc
Letter Text enables the creation of system letters with associated follow up criteria, ability to print follow up letters with different signatures and, if desired, to include within the body of letter the actual claim procedures involved in that claim
Evaluation Class / Group Limit enables like Benefit Categories to be linked together towards common maximums, i.e. frequency or dollar either yearly or lifetime
Speciality codes with descriptions
Management Review codes with descriptions
PPO grouping codes with descriptions


This function maintains a file of all providers of care, including:

Provider Social Security Number/Tax ID number
Provider name, address, phone and fax number
Tracking of up to 5 Specialty codes
Fee schedule elected
Management Review code option
PPO category with Start and End dates
Combined check indicator
'Do Not Pay' indicator
Search ability by name, portion of name, zip, specialty, etc
Memo field


This function enables the user to enter non-electronic claims into the system for future payment. The system automatically compares service dates with eligibility dates and rejects services performed during periods when not eligible. Various other on-line editing is done during Claim Entry, such as on-line duplicate checking, management review requirement, benefit maximums and procedure compatibility with patient age and sex. Other editing is done during the claim evaluation process to improve examiner productivity on-line and allow for internal auditing and quality control. Electronic claims are adjudicated in a batch process, but then can be reviewed in the same manner as a manually processed claim. Information entered or displayed during the entry process is as follows:

Claim number
Date claim received
Member alpha/text search
Member name and address
Employer with dates of eligibility and termination
Member and spouse date of birth for COB (Birthday rule)
Spouse COB information - displaying types of coverage carried
Ability to select patient from list of dependents
Patient name, sex code, date of birth, dependent code, etc.
Diagnosis alpha/text search
Diagnosis (primary and secondary) code with description
Provider of Care alpha/text search

5. CLAIM ENTRY (Continued)

Allows up to 5 Providers of Care per claim
Patient account number associated with each provider of care
Displays each Provider's name, address, PPO affiliation, specialty codes, management review code with description, etc.
Procedure alpha/text search
Procedure code with description
Benefit category with description (text search available)
Assignment or non-assignment of payment to either a member, provider or alternate payee
Service dates - from and to
Provider's charge
Automatic adjudication of Basic and Major Medical dollars withholding Deductible, where applicable
Automatic determination of amounts in excess of reasonable and customary charges
Automatic COB calculation (other insurance company payment)
On-line duplicate checking
Second Surgical Opinion (SSO) reduction, if applicable
System generated letters with full follow up diary features
Pend problem claims for later determination
Modify, correct or change, up to check issuance, any claim
Adjust paid claims for additional payments
Place of Service indicator/edit
Number of days of hospital confinement or occurrences
Reason code for override of normal scheduled payment
Reason code for rejection
Reason code for pending

In addition, the Claim Entry function gives the user the ability to enter claims paid prior to automation (for history only), including appropriate accounting data, (i.e. check number, check date, amount of check).


This function produces a printed transaction log of all claims entered each day, showing:

Member name
Patient name
Provider of care
Provider's charge
Amount payable by plan
Number of procedures in claim
Examiner ID
Total number of claims entered
Total amount payable to members
Total amount payable to providers of care
Management review requirement code


This function produces a detailed report that enables quality control review prior to the printing of checks, EOBs, letters, rejections or pends. It further produces productivity totals that report the number of claims processed and the dollars that those claims represent. This Edit/Report can be printed for all operators or one selected operator. The claims detail and productivity can be printed either together or separately.

The detailed claim portion of the report displays the following:

SSN of member
Claim number
Member name
Member address
Diagnosis code & description
Patient name
Date of birth
Sex code
Dates of service - from & to
Procedure code & description
Benefit category code & description
Name of Provider of Care


Payee - provider or member
Requested amount
Excluded amount
Basic amount
COB amount
Major Medical amount
Deductible amount
Place of service code
Reject code 1
Reject code 2
Total payable amount

The productivity portion of the report displays the following:

Initials of operator
Total # of history claims
Total # of all claims
Total # of all procedures
Total # of paid procedures
Total # of pended procedures
Total # of rejected procedures
Total # of COB procedures
Total # of adjusted procedures
Total # of procedures with override

The dollar portion of the report displays the following:

Initials of operator
Total amount requested
Total amount excluded
Total amount COB
Total amount Basic
Total amount Major Medical
Total amount paid to Members
Total amount paid to Providers
Total amount paid to Other


This function produces a hard copy of all possible, or actual, duplicates that were identified by the system during the adjudication process. Additionally, procedures, members, or providers on Management Review that had claims processed on them, will appear on this report.


This function, which runs prior to check printing, provides the user with audit totals of claims to be paid. It shows the appropriate totals of checks to be issued and the total number of claims for audit comparison to daily claim logs and the actual check register. This also enables the user to transfer funds to the appropriate checking account, when necessary.


This function prints checks and detailed Explanations of Benefit to members and providers. This function gives the user flexibility to issue separate checks/EOBs, or a combined check to one provider for multiple members, with the appropriate audit trail supporting the check. The system also supports "positive pay" reporting to the Fund's bank to protect the Fund from fraud.

Various information is printed, including:

Member name, address and Social Security Number
Patient name and relationship
Provider of care name, address and patient account #
Procedures performed by category
Dates procedures performed
Amount charged
Amount payable by plan
Amount charged to deductible
Amount in excess of reasonable and customary charge
Employer or shop name and number
Other insurance company payment data


This function is used to display or print the claim history of a member or his or her dependents. Claim History can be displayed in either Summary or Detail. In addition Claim History can be selected by the following criteria or group of criteria.

Claim History Selection criteria:

By Claim Number
By Patient
By Family
By Date of Service or range of Dates
By Diagnosis or range of Diagnoses
By Provider of Care
By Benefit Category

Claim History Summary will display:

Claim Number
Dates of Service
Patient name
Relationship to member
Amount of Total Requested
Amount of Total Paid
Status (Pended, Processed, Paid, Held, Letter, etc.)
Date this status occurred
Providers of Care

By entering a line number appearing to the left of each claim within Summary Claim History the screen will display the full Detail of that claim.

Claim History Detail will display:

Patient name
Provider of Care name
Provider of Care Tax ID number
Status date
Entry date
Time of entry
Initials of Payor
Primary Diagnosis
Secondary Diagnosis
Procedure codes with description
Benefit Category with description
Date of Service (from and to)
Fee Requested Amount
Excluded Amount
Basic Amount
COB Amount
Deductible Amount
Major Medical Amount
Place of Service
# of Days/Visits
Assignee of Benefits
Reject code 1 with description
Reject code 2 with description
Display of memo entered during Claims Entry
Letter sent and associated dates of follow up
Check number
Check date
Check amount
Summary of deductibles (individual and family)
Benefit credit amount
Summary totals by category showing year to date and lifetime
Benefits accumulated year-to-date and lifetime


This function prints a register of checks, showing:

Check date
Member's Social Security Number
Check number
Check amount
Claim number
Total amount of all claims paid


This function permits the entry of information about a manually written check, or to void an already issued check under strict security controls. It is possible to invoke an automatic reissue of payment for the claim or claims paid with the voided check.


This function produces management reports, including reports containing information concerning:

Benefit utilization by:

Dollars charged versus paid
Number of claims
Number of procedures grouped by Benefit Category
Number of spouses
Number of dependents
Number of members
Total number of patients
Fee schedule selected

Utilization by employer
Utilization by procedure
Utilization by provider


Provider profile showing by provider:

Procedure performed
Date procedure performed
Member on whom procedure was performed
Dollars charged versus paid

Pended claims by reason code and aging

Reports can be produced and selected for any period of time and by user-defined categories.


This function is used to delete from the system an unpaid claim that was entered in error.


This function is used to produce reports on the claims paid for each provider on file. This function also produces printed 1099 tax forms. When the 1099MISC forms are created, an extract is created at the same time to be prepared for the electronic submission of the necessary data to the IRS. SSI is an authorized combined filer for the IRS.

bottom of page