PACE CLAIMS PROCESSING

WHAT IS PACE CLAIMS PROCESSING?

PACE stands for Program of All-Inclusive Care for the Elderly.  Reliance assists PACE organizations by managing the business functions that drive reimbursement revenue and utilization costs as well as PACE health plan functions.

Through our claims processing services, we provide PACE organizations with claim settlements, processing and payment based on the authorized services and provider
contracts.

Additionally, Reliance has a robust data management system to help PACE organizations track accounts payable, claim expenses, utilization, diagnoses and encounters and provides monthly reporting to the PACE organization.

MAINTAINING ENROLLMENT & ELIGIBILITY

Reliance Community Care Partners will maintain your enrollment and disenrollment information as provided by the client. We also will issue one insurance card per member plus maintain an up-to-date enrollment activity file for each participant.

MEDICARE RISK ADJUSTMENT PROCESSING (RAPS)

Reliance will submit risk adjustment data at least quarterly to the Center for Medicare and Medicaid Services (CMS) based on claims and clinic encounters received from the client. We also will assist with, correct, and follow-up on any errors in risk adjustment data. Any return files will be submitted.

HOW WE HELP

We have worked as a partner with the Care Resources PACE program since 2006 and assist with the following claim processing, reporting, and payment services:

  • Process all claims received for services provided to PACE enrollees
  • Provide weekly reports of unauthorized claims
  • Generate payment and remittance advice
  • Adjust claims based on client authorizations
  • Generate denial letters
  • Generate pre-check register and check register
  • COB Processing
  • Process new & updated contract information
  • Update claims system pricing schedule for non-standard coding
  • Communicate with providers to ensure proper payment
  • Answer calls to verify eligibility/enrollment
  • Create & deliver claim payment and vendor files
  • Generate claims aging reports
  • Submit Incurred But Not Reported (IBNR) reports