Hospital Clearinghouse. Blue Cross has established electronic connections with over 400 hospitals in California. The hospitals send their claims to Blue Cross. The Blue Cross system then validates utilization based on pre-authorization and prices the claim based on the facility’s contract. ClaimExchange retrieves the repriced claims from Blue Cross and uploads these claims into the client’s batch adjudication system for payment.

Professional Claims Re-pricer. Blue Cross of California has a fully automated method of applying network discounts for professional claims. Professional claims are received and keyed by the payer and then forwarded on to Blue Cross through ClaimExchange for re-pricing. Once re-priced, the claims are returned to the payer through ClaimExchange for payment.

Clearinghouse. WebMD/Envoy is a clearinghouse providing connectivity services and related value-added products to providers and facilities. WebMD/Envoy is the leading processor of both batch and real-time transactions, including all payer-to-provider transactions addressed in the final HIPAA regulations. ClaimExchange idownloads encrypted claims, loads the claims data and sending an acknowledgement back to WebMD/Envoy.

Empower. WebMD/Empower is an EDI-enabling middleware that gives health care payers the ability to automate real-time communication with their providers. They accomplish this by hosting a real-time server and loading eligibility and claim status data sent through ClaimExchange daily.

ClaimExchange sends Pacificare Behavioral Health HIPAA compliant eligibility data and receives accumulator information on claims payment.

ClaimExchange sends ExpressScripts HIPAA compliant eligibility information including information on Coordination of Benefits to insure that the card used at a pharmacy is the primary insurer’s card.

The MultiPlan Network is the nation’s leading independent PPO network with 4,000 acute hospitals, 86,000 ancillary facilities and 360,000 individual practitioners. MultiPlan offers professional and institutional claims re-pricing capability through HealthASPEx. HealthASPEx works with ClaimExchange to exchange, reprice and track both electronically received and claims keyed by the payer.

The Centers for Medicare and Medicaid Services coordinate health care benefit payments between insurers and Medicare in accordance with Medicare Secondary Payer (MSP) regulations and the Medicare Modernization Act. ClaimExchange sends CMS an eligibility file in their proprietary format and in exchange CMS sends an 837 file of the claims that they have paid as primary.

GTESS Corporation is a leading provider of business process outsourcing solutions. ClaimExchange sends GTESS data scrubbing information which GTESS uses to OCR paper claims. GTESS then returns these paper claims in the 837 format for electronic adjudication.

TRPN is a secondary PPO network. ClaimExchange sends TRPN claims that fall out of the primary network for repricing as a secondary network. TRPN returns the claims in the 837 format with repricing information included.

The First Health Network is one of the nation's largest PPO networks. ClaimExchange sends First Health medical and professional claims in the 837 format and receives the claims back in the 837 format with pricing information.

SHPS offers Wellness solutions. ClaimExchange sends SHPS a weekly eligibility file and a monthly claims file, which SHPS then uses to make suggestions for health promotion.

ENS, an Ingenix company, is a clearinghouse. ClaimExchange sends ENS 837 files which are then routed to the appropriate payer.

Medco is a leading pharmacy benefit manager. ClaimExchange sends Medco eligibility information in the 834 format. Medco sends ClaimExchange a proprietary file containing Pharmacy data on claims paid for their participants.

VSP offers vision care nationally and overseas. ClaimExchange sends VSP eligibility information in the 834 format.

Delta Dental is one of the largest providers of dental benefits with more than 3.4 million members nationwide. ClaimExchange sends Delta Dental eligibility information in the 834 format.

The Illinois Department of Healthcare and Family Services administers the Medicaid program in the State of Illinois providing health care assistance for adults and children. ClaimExchange sends IDPA an 837 file containing professional claims outsourced to various agents.

Cedars-Sinai Hospital and Medical Center delivers world-class medicine to the community, and to patients from across the United States and around the world. ClaimExchange has a unique program with them to exchange information beneficial to both our insurer and the hospital.