Cutting Edge Technology
As an industry leader, TML IEBP provides its Membership with the sophistication of cutting edge technology to maximize accuracy in claims adjudication and claim cost management services. TML IEBP and the United Medical Resource Alliance (UMR) use a fully integrated, state-of-the-art Trizetto (RIMS) claim adjudication system. The platform is an IBM 6000 with 4 GB of RAM and 500 GB of storage. The version is 3.30.30. We use Trizetto QicLink software with online "real time" processing, CBX processing, Auto Audit for non-network claims, Electronic Acquisition and Adjudication capabilities, and two years of online detailed claim history.

Claim Processing
Besides the Trizetto (RIMS) QicLink software, UMR has a front-end "claim scrubbing" system called ValiData that verifies eligibility, providers and networks. It also checks for non-network claims and automatically sends them via electronic data interchange (EDI) to our national network for potential discounts. ValiData also screens up front for potential accident diagnoses. UMR has the ability to build specific business rules and modifications into this system down to the client level.

The result is extremely clean claim data going into our claim-paying system, for faster, more accurate processing. ValiData also performs repricing for networks allowing access to their fee schedules. Also, the onsite OnBase system scans claims and all related correspondence for storing as electronic images in our RIMS system.

The OnBase system scans pended claim letters, EOBs, appeals and other claim-specific correspondence, matches it with the existing claim, and routes the scan to the appropriate Examiner. Scanned claims also go through an optical character recognition (OCR) and correction process. This claim data is sent to an EDI file that is run through ValiData. The combination of claim document scanning and ValiData lets us reduce the average time required to process claims in our system to just 48 hours or two business days. Our processing setup also improves the overall quality of claim data going in and out of our systems.

TML IEBP backs up the claim adjudication information into an Application Service Provider (ASP) Milliman Datawarehouse, which assists in the provision of accurate claim reporting and analysis of utilization trends.