Coalition America, Inc.

Coalition America, Inc. (CAI), a leading out-of-network medical claim repricing and PPO network management company based in Atlanta, Georgia, has achieved significant growth in medical claims submitted by clients using electronic data interchange (EDI), the electronic submission of medical claims. "A little over two years ago we introduced the most capable, real-time Internet repricing solution in the market," says Scott Smith, President of CAI. "Clients can simply log into our website and reprice their medical claims within seconds. Within a year 90% of our clients were accessing savings on in-network and out-of-network claims via the Internet. Today, we have seen a significant swing toward EDI transmission of medical claims. We have grown the percentage of EDI claims from 24% in January 2002 to 48% in January of 2003. We anticipate that by the end of 2003 over 60% of the claims we receive will be in some form of EDI", said Smith. CAI can receive and transmit via a HIPAA compliant 837 EDI format as well as translate proprietary formats on behalf of its clients to meet HIPAA compliancy.

The clear value of EDI for healthcare payors is the ability to automatically transmit and receive a significant volume of medical claims to preferred provider organizations (PPOs) and other medical claim repricers, eliminate the need to enter the same information twice, and provide an opportunity to achieve compliance with the federal government’s mandates of the Health Insurance Portability and Accountability Act (HIPAA). Additionally, through EDI, clients can eliminate thresholds on repricing out-of-network medical claims since use of internal resources is significantly reduced.

Coalition America has taken this concept even further with the introduction of EDIPlus!, a revolutionary solution for eliminating mail room and data entry costs for payors. EDIPlus! uses scanning and optical character recognition (OCR) and clearinghouse services to convert paper claims to EDI transactions, eliminating the need for paper handling and data entry. Once paper claims are scanned, they are combined with other medical claims submitted electronically by providers through a clearinghouse. Both types of medical claims are then forwarded to CAI for repricing.

According to Smith, CAI will then return the repriced medical claim back to the clearinghouse or OCR vendor for formatting into whatever layout the payor needs. The payor then accepts the repriced electronic medical claim into its adjudication system for processing. Both payors and providers will see several benefits with EDIPlus!

EDIPlus! complies with HIPAA regulations that require medical claims to be transmitted in a standard 837 file format. Further, there are no expensive adjudication system upgrades or file translator black boxes needed to achieve compliance.
Administrative costs associated with receiving, repricing, negotiating and processing medical claims are reduced through the elimination of paper claims.
Claims payment turnaround is improved and the system reduces or eliminates the number of medical claims pended for repricing.
EDIPlus! users can achieve greater savings on out-of-network claims through access to multiple supplemental networks and negotiation services offered by CAI.

"We have subjected our clearinghouse and scanning/OCR vendors to extensive review," said Smith. "They have state-of-the-art technology and the highest quality standards for fail-safe claim accuracy, HIPAA compliance, performance guarantees and world-class service levels. CAI monitors performance between these vendors and our clients to ensure a high level of service, performance and satisfaction."

For more information about EDIPlus!, contact Coalition America, Inc., 4151 Ashford-Dunwoody Road, Suite 615, Atlanta, GA 30319, 404/459.7201 or sales@coalitionamerica.com.

About Coalition America

Coalition America, Inc. (CAI) is a leader in healthcare cost-containment and preferred provider organization (PPO) network management services. Cost-containment is achieved by repricing out-of-network bills using supplemental PPO networks and by direct provider negotiations. The range of services offered by CAI includes cost containment, primary PPO network integration and management, electronic data interchange (EDI), Internet repricing and data-entry options for group health and workers compensation plans on all bills. For more information on Coalition America, please visit www.coalitionamerica.com.

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