Claims
GCS understands how claims processing can become a costly and time consuming challenge. That’s why we provide a dedicated team of specialists who review, validate, and process claims efficiently ensuring accuracy, compliance, and timely reimbursement in alignment with payer guidelines and member benefit plans.
Claims School Curriculum Overview
Training on processing professional and facility health plan claims in California, emphasizing compliance with California DMHC regulations
Introduction to the Healthcare System
Claims Processing Fundamentals
Claim Submission Essentials
Claim Adjudication Processes
Claims Delegation Oversight/Reporting
Risk Management & Continuous Improvement
External Relations & Provider Communication
Compliance with DMHC Regulations
Denials & Appeals Management
Technology in Claims Processing
Payment & Compliance
Payment Determination:
Calculate reimbursement based on adjudication, provider contracts.
Consider deductibles, copayments and bundling rules.
Denial/Adjustment Process:
Common denials: medical necessity, coding issues, coverage problems.
Providers notified with Explanation of Benefits (EOB) and appeal instructions.
Payment Issuance:
Payments via checks or electronic funds transfer (EFT).
Remittance advice (RA) sent detailing payments and adjustments
Monitoring and Reporting:
Track metrics: Turnaround time, denial rates, provider feedback.
Compliance and Technology:
Adhere to California regulations, ACA, CMS guidelines.
Use Claims processing systems and analytics for continuous improvement.