SERVICES OVERVIEW

Santa Fe Preferred Healthcare Claims Administration Services, Processing Solutions, and IT Services allow us to provide a portfolio of complete and integrated services. We continue to implement solutions to achieve the client’s specific business objectives. As one of a few outsourcing partners that understands the requirements of claims processing, Santa Fe Preferred Healthcare offers technology services for all aspects of Claims and Benefit Administration, including the following:

• Customer Service

• Claims Adjudication  / Subrogation Management

• Enrollment / Eligibility Management

• Provider Management

• Information Technology (IT)

• Reports

• HIPAA / ERISA Compliance

 

CUSTOMER SERVICE

Santa Fe Preferred Healthcare was founded on the principle of providing "second-to-none" customer service and value. The staff works diligently with our clients and their participants striving to make everyone feel comfortable. With unsurpassed response time, our clients are continually provided with service not often seen in today’s time. Well-trained representatives handle all aspects of customer service related to claims, including answering your questions and assisting with special requests. This means "first call" resolution on most inquiries.

 

Our Customer Service representatives are personally available to talk with you or your participants Monday through Friday, 8:00 a.m. to 4:30 p.m. CST. Our answering service allows for messages at all other times. Web Services available 24 hours a day at www.sfphtpa.com.

Santa Fe Preferred Healthcare is here for you, making your life easier by working harder.

CLAIMS ADJUDICATION / SUBROGATION MANAGEMENT

Santa Fe Preferred Healthcare has substantial experience in claims processing and understands the difficult process of claims payment and repricing. Just a glimpse of our adjudication process:

• Eligibility Validation

• Duplicate Claims Review

• Coding and Diagnostic Edits

• Benefit Determination

• Client Based Edits

Our claims system is proprietary and completely flexible, therefore, it does not dictate or limit your plan design.  Because our system has been developed internally, we can modify it to meet any client's needs.  Partner with Santa Fe Preferred Healthcare for your Claims Adjudication objectives and experience notable gains in quality and efficiency. 

Santa Fe Preferred Healthcare's data entry allows for a dramatic cut to our client's cost for hardware, software, staffing and training.  Accurate and efficient claims adjudication is ensured through our extensive knowledge of medical claim forms along with our IT expertise. 

Claim editing software validates each claim to flag errors prior to adjudication by using the knowledge base of customer specified and industry standard rules.  Claims are validated based on payer specific edits.  Santa Fe Preferred Healthcare ensures the highest quality and validity of the data. 

Santa Fe Preferred Healthcare tracking systems ensure that every document is accounted for at each step in the processing cycle.  With real-time status reporting via the internet, our clients get current information to better manage their business.  Extensive online reporting is offered to ensure that the client knows the inventory and accuracy of data at all times. 

Look to Santa Fe Preferred Healthcare for data-entry services.

With our Subrogation Service all payable claims are systematically evaluated for potential "third party" liability.  Once it has been determined that a "third party" liability may exist, the plan participant is contacted.  If there is in fact another responsible party, the case is opened and tracked to completion, with management reports generated to communicate our progress at any given time. 

ENROLLMENT AND ELIGIBILITY MANAGEMENT

Santa Fe Preferred Healthcare realizes the value of the fundamental principle of monitoring and auditing plan enrollment data to ensure only entitled individuals are receiving benefits under the health plan. The single most powerful cost containment management tool available to employer-plan sponsors today is effective eligibility administration.

All aspects of enrollment and eligibility for our clients is managed by the Santa Fe Preferred Healthcare Member Services Department. We maintain and update and/or modify eligibility databases as data is received.

Information necessary for proper administration is tracked through the eligibility system which is fully integrated with claim adjudication programs and fully historical. This means that claims are adjudicated in accordance with the specific plan, network and eligibility in effect at the time the service was obtained.

 

PROVIDER MANAGEMENT

Currently Santa Fe Preferred Healthcare has an expansive database that is maintained by the Provider Relations Department. Information to the provider base is updated and/or modified as new data is received. The Provider Relations department strives on providing the claims adjudicators correct and clear information in order to process a claim expediently and efficiently.

 

Santa Fe Preferred Healthcare understands that a client may already have a network of providers of their choice which can be updated to our database.  In addition, Santa Fe Preferred Healthcare provider relations will assist the client in negotiating new contracts.  The client will receive benefit of years of experience in provider relations negotiations from the Santa Fe Preferred Healthcare staff. 

 

INFORMATION TECHNOLOGY (IT)

Santa Fe Preferred Healthcare controls all of the development and operation of its proprietary software. We focus on our system’s flexibility and customization. Santa Fe Preferred Healthcare’s Information Technology department can accommodate clients with an infinite number of plan designs and network options.

 

 

 

REPORTS

Santa Fe Preferred Healthcare offers standard reporting at the client's desired frequency available at no additional costs. The types of reports available are check registers, utilizations, transaction registers, and management summaries. Clients may receive the reports via email or they may access the reports on-line over our website through HIPAA compliant software. In addition to standard reporting, Santa Fe Preferred Healthcare provides extensive customized reporting and data drill down capabilities as highlighted below.

 

• Query reporting: A special unit in our IT area is dedicated to handling requests for query reporting from our clients.  Depending upon run time, most previously developed query reports can be run without additional charge.

 

• Ad-hoc reporting: Our special reporting unit can prepare "one-time" only reports.  These reports can also be transitioned to regular reporting and set up to run on a schedule or upon request. 

 

• Fully programmed reports: We can also support this if a client requests a fully customized report.  

 

 

 

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)

EMPLOYEE RETIREMENT INCOME SECURITY ACT (ERISA) COMPLIANCE

Santa Fe Preferred Healthcare's appointed Compliance Officer reviews TPA and client policies and procedures to ensure clients meet all HIPAA Privacy, HIPAA Security regulations and ERISA standards as follows: 

 

• Monitor changes in HIPAA regulations

 

• Ensure HIPAA compliant policies & procedures are followed

• Ensure that all Policy or IT changes are HIPAA compliant

 

• Performs periodic internal audits

 

• Monitors TPA/client standards of conduct by requiring disclosure of financial and other information concerning the plan to employee benefit plan participants and their beneficiaries. 

 

Santa Fe Preferred Healthcare will be happy to answer your questions.

Please contact us at 1-800-334-1330 ext 306 or click to email