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| SIM/PLAN: SIMULATED PLAN TESTING BEFORE IMPLEMENTATION |
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Members are all loaded, the various groups are specified, the plan design has been entered and all exceptions have been noted. It's time to move the plan 'on-line' for adjudication. But first, wouldn't it be nice to test the plan? To run it against a few claims to be sure that the plan is verified as accurate? SIM/Plan was designed to do exactly that. Under the SIM/Plan menu, the administrator may create a small group of test claims for adjudication and then have them processed by the system exactly as if they were coming in from a pharmacy! Then, by using SIM/Plan Claims Inquiry, the administrator can see which claims passed or failed under adjudication ... and why. Although the test claims are not maintained or used by the system for reporting purposes, these claims are adjudicated against the real member files, drug files, pharmacy files and plan criteria in the current system. SIM/Plan, the TeleClaim fail-safe module, virtually eliminates the possibility of loading the wrong plan or the wrong group or any other parameter that would cause adjudication to erroneously calculate or completely fail. With TeleClaim SIM/Plan, the administrator has the option to check every detail before approving the plan for on-line adjudication. |
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