Real-time Adjudication - Conexia

Eligibility

An injured worker visits the provider facility and identifies the reason for the visit is to due to a workers’ compensation claim.

The injured worker provides the provider their claim identifier (via identification card) or employer policy information.

Provider Access Points

Conexia is able to engage providers through a variety of methods and platforms (access points). These access points strengthen the payer-provider partnership, providing the maximum benefits of the real-time connection.
Eligibility for a claim and/or treatment is instantly confirmed as per the injured workers’ claim status because the payer and provider are electronically connected.

If there is no claim on file, the injured worker or provider can submit a report of injury and request treatment.

The provider enters a code for diagnosis.

From Days to Seconds

Reduce Cost

Data Accuracy

Real-time Application of Business Rules

The medical treatment request is instantly processed via the interface, which uses business rules to adjudicate the transaction following evidence-based medical guidelines. This positively and prospectively impacts the patient’s care (as well as cost) by promoting adherence to medical standards at the point of care.

Payers and providers are also able to communicate in real time regarding additional allowances and disputes, supporting communication flows with legal representatives and external entities such as appeal boards or independent medical review organizations.

Approval & Alerts

90% of medical transactions can be adjudicated in real time using business rules.

10% Unusual transactions are routed to auditors at the payer for immediate review.

The provider is instantly notified of the action.

From Days to Seconds

Clinical Guidelines & Medical Audit

Providers have certainty of payment at the time of service because medical services are authorized in real time.

Additionally, alerts notify providers at the point of care (or before) regarding the implications of their care decisions relative to quality metrics, peer performance, and evidence-based / customized clinical guidelines.

Simple Payment

There is no bill for the provider to submit because the medical transaction has been fully approved.

Payment of invoices becomes prompt and simple.

Reduce Cost

From Days to Seconds

Reduce Cost

Key Metrics in Real-time

Indicators & Metrics

Conexia monitors the entire process and generates relevant quality metrics, while the payer has continual and complete oversight of all activity.

Our impact today

20.000.000

BENEFICIARIES

2.000

INTEGRATED PROVIDERS

20.000

TRANSACTIONS PER MONTH

More about our Service Model

 

At Conexia, we use our deep industry experience to optimize the balance between quality of service for patients, administrative costs and medical costs.
Know more about our Service Model for Workers' Compensation

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Put the real-time adjudication solution to work for you

See why Conexia is the leading trusted software vendor in the global payer community.

A trusted leader in the global payer community