A Comprehensive Suite Of
Outsourcing Solutions To Help
Our Clients Meet Their Goals

Claims

Processing claims accurately and timely is essential to provider satisfaction. Calibrated has the claims adjudication expertise to process claims in line with client specifications and regulatory requirements for both quality and timeliness. Calibrated offers all claims processing services including:

• Claims adjudication for all lines of business: CMS, MediCal and Commercial
• Provider Dispute Resolution and Appeals
• Encounter Data Processing
• Claims Quality Assurance
• Paper claims scanning and conversion to EDI

Population Health Management

Calibrated's goal is to enhance members lives by assisting them in accessing care in a coordinated and hands on approach. Calibrated staff will work directly with your members and providers to help members live healthier lives and improve outcomes. Our continuum of Population Health Management services include:

• ECM (Enhanced Care Management)
• Care Coordination
• Health Risk Assessments
• Transition of Care
• Nurse Advice Line
• Disease Management

Medical Management

Calibrated's experienced clinicians conduct authorization services according to your medical criteria. Our team works with your providers to assure an effective cost control process is consistent and timely.

• UM Intake for both Inpatient and Outpatient
• Inpatient Clinical Reviews/Prior Authorization
• Discharge Planning
• Outpatient Concurrent Review
• Home Health Reviewers
• Emergency Department Care Coordination

System Configuration

Accurate system configuration is the foundation for increased claims automation and accuracy. Calibrated has configuration expertise for all product lines to match provider agreements for accurate payment and reporting. Systems configuration services include:

• Provider and Vendor Setup
• DOFR (Division of Financial Responsibility) Setup and Maintenance
• Benefit Setup and Maintenance
• Fee Schedule Maintenance
• Auto Adjudication Optimization

Member Data Management

Member data is processed timely to ensure information is readily available for all member interactions and transactions:

• Enrollment/Eligibility Processing
• Capitation Management

Coding Services

Medical coding supported by documentation is essential to ensure that payments and revenue are in line with the services delivered. Our team of coders are experts in HCC chart abstraction as well as HCC accuracy audits. For hospital claims, our coders can validate that the DRG being billed is supported by the medical record documentation.

• Medical Record Review
• HCC Coding: Coding Abstraction and Chart Audits.
• Hospital DRG Code Validation

Provider Credentialing

Our team knows that thorough credentialing is the starting point for safe, quality healthcare delivery. Our highly experienced professionals ensure that each application is primary source verified and any deficiencies are reported.

Document Management Services

Calibrated's document management services include a full-service inbound and outbound mailroom.
The inbound mailroom scan paper claims, medical records, and contracts to name a few.
The outbound mailroom prints and mailout member authorization letters, misdirected claims, member enrollment, and many other documents.

Healthcare Management Consulting

Calibrated's Executive Management has over 20 years of health plan and MSO experience. We strive to improve performance and drive down costs:

• MSO and Health Plan Start Ups
• Operations Efficiencies
• Provider Network Management
• Business Processing Outsourcing