Health Insurance Claims Adjudication & Backend Customer Support
SHIMNS Global offers a comprehensive suite of services for health insurance providers, ensuring efficient claims processing, accurate adjudication, and superior customer service support. Our approach combines in-depth industry expertise, advanced AI-driven processes, and a commitment to operational excellence that streamlines workflows and enhances customer satisfaction.
Our Health Insurance Services
- Claims Adjudication
- Eligibility and Coverage Verification: We confirm that the claimant meets all eligibility criteria and verify the scope of coverage for each submitted claim.
- Medical Necessity and Coding Validation: Review claims to ensure that treatments are medically necessary and accurately coded, minimizing errors and rejections.
- Benefits Calculation: Calculate payable benefits based on policy terms, including coinsurance, copayments, deductibles, and other plan specifics.
- Fraud Detection and Prevention: Conduct thorough audits and apply AI-driven fraud detection protocols to identify potential fraudulent claims.
- Adjudication Decisions and Payment Processing: Finalize claims decisions and facilitate accurate payment processing to providers, ensuring prompt payment cycles.
2. Customer Service Support (Phone-Based)
- Member and Provider Inquiry Handling: Provide assistance to both policyholders and healthcare providers, answering questions about coverage, benefits, claim status, and payment details.
- Claims Dispute Resolution: Manage and resolve claims disputes efficiently, acting as a mediator between policyholders, providers, and the insurer to clarify details and expedite resolutions.
- Pre-Authorization and Pre-Certification: Guide policyholders through the pre-authorization process, explaining requirements and helping obtain pre-certification when needed.
- Policy Clarifications and Changes: Help customers understand policy terms and assist with changes or updates as their healthcare needs evolve.
- Proactive Outreach: Follow up with members on pending claims, benefit updates, and premium payment reminders to ensure policyholders stay informed and engaged.
3. Health Insurance Branding, Digital Marketing, and Media Monitoring
- Comprehensive Branding and Digital Marketing: SHIMNS Global supports health insurers in strengthening their brand presence and enhancing digital engagement through targeted marketing strategies, including social media campaigns, search engine optimization (SEO), and content creation tailored to the healthcare audience.
- Media Monitoring and Reputation Management: We monitor media channels, review trends, and manage the brand’s online reputation, identifying potential issues or opportunities for positive exposure. Our analysis helps health insurers stay ahead in a competitive market by addressing public concerns, promoting health-related information, and building trust with customers.
- This integrated approach ensures health insurers maintain a strong, consistent brand image across digital platforms, enhancing customer loyalty and credibility in the market.
Why Outsource to SHIMNS Global?
services
The SHIMNS Global Advantage
Reduced Operational Costs
By outsourcing claims and customer service functions, health insurers can cut costs related to training, staffing, and technology.
Enhanced Customer Satisfaction
Our focus on high-quality service metrics, such as CSAT scores, ensures that customer expectations are met, improving policyholder retention.
Faster Claims Turnaround
By utilizing AI-driven processes, we streamline claims adjudication, reducing processing time and increasing payment speed to providers.
Accurate, Compliant, and Secure Services
We follow strict data security protocols to safeguard patient information, reinforcing compliance and client trust.
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