Source: http://www.odjfs.state.oh.us/tutorials/mits-external-training/t2d014_intro_claims_edits_audits_html_ois_ada/intro_claims_edits_audits_ada/index.html
When claims are submitted, an application has been created for them. The application control (Control C1) will review the claim application for its appropriateness, completeness and accuracy. The objective of this control is to avoid system disruption by performing upfront validation and editing to ensure the integrity of data before it is entered into the system’s files and databases. This control will check for presence, format, consistency, and reasonableness of data, as well as allowable values. When invalid data is entered into the system, the application will be rejected and providers are required to change their input data. If the control does not detect any errors, the system will accept the claim which will then be reviewed by an employee of Nyguard.
Controls C2, C3, C4, and C5 are access control. Since each claim is reviewed by Nyguard’s employees to validate provider, recipient and reference information, these controls ensure that the system provides two-factor authentication that authenticate responsible employees based on a unique identifier and a confidential password for each employee. The system makes sure that non-authorized employees are not allowed to access any sensitive customers’ information and/or data without first being authorized by the system’s security mechanism.
The data on the claims continue to be validated against a series of rules, edits, and audits. All these processes are also conducted by authorized employees. Edits and audits processes ensure that claims are processed in accordance with state policies. All claims in process are checked if the service being billed has any policy restrictions based on other claims in history. Data of a claim in process are compared with paid claims history data to determine the appropriateness of the service (Control C6). After auditing, claims are submitted to be reviewed and approved by management-level personnel to determine claim disposition (Control C7).
After claim disposition is decided, if the status is paid, output control (Control C8) ensures that claims scheduled for payment are actually paid. All claims have to be saved to main database. Control C9 and C10 ensure that data are backed up periodically, generally weekly full backups with daily incremental backups. All backup data are stored offsite in a secured data center. All suspended claims have to go through the whole process again for revalidation. Nyguard’s claim process system is protected by firewalls that create appropriate security zone for network and information assets.
Claims are monitored as they are processed through the systems with real time tracking of the system’s performance. Paper claims that are received in the mail room are reviewed by authorized employees. All paper claims have to be approved by a supervisor before uploading into the system to ensure segregation of duties. They are tracked to ensure timely processing.