HPS Total Administrator:
Created exclusively for self-insured health plans, HPS Total Administrator is a completely user-friendly, hands-free software application that not only transmits and receives transactions in a HIPAA-compliant format but also provides unprecedented functionality for virtually every aspect of ERISA administration. HPS Total Administrator provides claim processing, contribution accounting and eligibility, pension and annuity administration, and much more.
As one of the elite group of companies to have its software certified by Claredi, a national third-party organization accrediting entities that send or receive HIPAA-regulated transactions, Health Plan Systems proven software makes HIPAA compliance a simple and easy part of everyday business.

a) Provider Credentialing

  • Detailed data collection on each provider
  • Entry of information submitted with the application
  • Primary source verification
  • Letter writing and report generation
  • Recredentialing - application print-out using available data
  • Tracking expiration of licenses
  • Identification of groups and billing information
  • Provider applications and agreement online
b) Utilization Review
  • Pre-authorization for admissions, referrals and procedures
  • Concurrent and retrospective review
  • Case management and disease management
c) Member/Subscriber Information
  • Enrollment of members and dependents
  • Premium billing and collection
  • Member complaints module
  • Employer file
  • Member contribution allocation
d) Health Plan
  • Define services by individual product or level- Conform to Plan Description
  • Fee-for-Service set up by Geographic location of provider
  • Define covered services by Current Procedure Terminology (CPT)
e) Medical/Surgical Claim Entry
  • Encounter entry and Claim entry
  • Claim Adjudication - Medicare Criteria (or any other criteria to be defined)
  • Global days verification
  • Payment to Assistant
  • Bilateral Procedures rule
  • Multiple surgical procedures rule
  • Medicare coverage of Procedures (defined by CPT and HCPCS codes)
  • Cross reference CPT to ICD-9, Place of Service, Specialty &
    Unbundling codes
  • Claim file cross reference to Pre-authorization file, Utilization module and Credentialing modules.
f) Dental Claims Entry and adjudication
g) Prescription Drugs claim entry and adjudication
h) Hospital Claims entry and adjudication
i) Check File - List of all claims payment
j) Disability and Death Benefit maintenance and payment
k) Pension Plan maintenance and payment
l) Annuity Plan maintenance and payment
m) Utilization Reports & Provider Utilization - by Group & individual provider
  • Member Utilization - by Family and Individual
  • Utilization by CPT Codes
  • Utilization by ICD-9 codes
  • Utilization by CPT & ICD-9 codes
n) Member Eligibility Module
  • Track member eligibility
  • from initial enrollment and monthly updates
  • PCP information tied to member & dependent file with archive
    Cross reference to Provider file
o) Fee Schedule File
  • Create Medicare Fee Schedule for any part of the USA
  • Create fee schedules based on RBRVS and Medicare criteria
  • Fee adjustment by type of service
  • Create fees for individual provider or groups
p) File Maintenance CPT files for each year
  • CPT Modifier file
  • ICD-9 file Specialty code file
  • Place of Service file
  • Type of Service file
  • Claim reason code file
  • Zip Code file
q) Medical Director Folder
  • Medical Director communication (two-way) from Utilization module and Claim module
r) Directory Query and Printing Functions
  • Query a provider based on location, specialty, sub-specialty and Expertise
  • Print Directory of providers based on county, specialty, etc.
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