Claims Processing

The combination of CCStpa's high-tech claims system with experienced, well-trained claims examiners ensures that your claims are processed accurately and on time. We deliver:

  • 99 percent of claims processed within 14 days and 100 percent within 30 days
  • Claims examiners with an average of 12+ years of experience
  • A claims processing accuracy of 99.6 percent

Electronic receipt of claims

CCStpa currently receives up to 87 percent of claims electronically (submission rate varies from PPO to PPO). Electronic delivery cuts down on your administration costs and speeds processing time.

Claims processing system safeguards

Our systems logic is set up to ensure that clients pay only for appropriate claims, protecting them from erroneous and fraudulent charges. Our edits and audits are designed to catch:

  • Duplicate bills. Our system criteria for duplicate editing is based on procedure code, place of service, date of service, provider and other details. Claims that are exact duplicates are automatically rejected. Potential duplicates are routed to an examiner for investigation.
  • Coordination of benefits. Coordination of benefits information is updated annually. If other coverage is indicated, a system edit routes the claim to an examiner and directs them to coordinate benefits. We coordinate benefits using NAIC industry guidelines.
  • Over age dependent eligibility. When dependents attain the age limit specified in their benefit plan, a system edit pends the claim and routes it to an examiner. The examiner is directed to request information regarding continuation of coverage.
  • Full-time student status. Our claims system automatically sends out a letter once a year requesting updated student status information for the dependent.
  • Extensions of benefits for a disabling condition. Our claims system allows us to process disability claims. All required withholdings can be deducted from the member checks.
  • HIPAA creditable coverage and credit for pre-existing periods. CCStpa applies all creditable coverage (if applicable) for new members and dependents. All claims received for new members are verified for creditable coverage and pre-existing conditions.

  • Possible fraudulent claim/provider. Our ClinicaLogic software bundles fragmented procedures, applies pre- and post-surgical days to the surgical package, and replaces codes according to customized business rules. The software also detects duplicate claims submissions and fraud/abuse situations. A daily report lists high dollar payments, which are audited to ensure payment accuracy.

    Our parent company's compliance assessment department researches all suspected fraudulent insurance activity by providers, which may include misrepresentations on claims. For example:

    • Altered claims
    • Submitting claims for services that were not rendered
    • Submitting an ineligible service as an eligible service
    • Billing for more services than can be delivered by one provider on a given day

    Fraud and abuse tips are filed by customer service and provider service representatives and are also received via our fraud hotline. Audits are conducted on each tip, and the issue is resolved or turned over to outside law enforcement agencies. If a claim is being investigated for fraud, the system alerts examiners to prevent further claims.

  • Possible subrogation claims. Our claims system uses HIPAA-compliant software so claims data for a specific range of accident-related diagnoses is collected and analyzed quicker, allowing possible subrogation cases to be detected earlier and resolved faster. Flagged claims are closed out to pay nothing and a member letter is generated, which request information to determine if third party liability is involved.

    Based on the member's reply, the claim is either processed to pay benefits or forwarded as a subrogation case. Our subrogation partner, Virtual Health Management (VHM) then works with all parties, including attorneys, to compile the information needed to support eventual settlement of the case. You are only billed for subrogation services if dollars are recovered. If litigation is required, you are charged a percentage of recovered dollars plus expenses for items such as court fees.

    CCStpa pursues lower dollar amounts than most traditional subrogation vendors, which provides more opportunities for revenue.

  • Recoveries. When an overpayment or underpayment is identified, the claim is adjusted and automatically processed to recover dollars from the payee. If after 90 days the adjustment remains unsettled, it is referred to dedicated staff for manual intervention.

    After 120 days, if the case is not resolved, it is forwarded for resolution to an external collections agency, an agency with whom we and our parent company share an exclusive relationship.