prior authorization by sun knowledge

Prior Authorization

SUN KNOWLEDGE OVERVIEW

Key Facts Awards, Affiliations & Certifications

2Sun Knowledge © 2015-16 Private & Confidential

‘Onshore /Offshore’ KPO & BPO Services Serving US healthcare industry since 2007 Robust & scalable infrastructure State-of-the-art technology and systems Highly skilled and trained staff with good

communication skills and in-depth knowledge of process

Structured training, feedback and coaching HIPAA-HITECH compliant State-of-the-art office inbuilt with all redundancies –

power, infrastructure and others

ISO 27001:2013 and ISO 9001:2008 certified CMMi-SVC implementation in progress under KPMG

guidance Member of NASSCOM, the Governing Industry body for

IT/ITES in India Awarded ‘Best Emerging BPO Company of the year 2010’

by The Economic Times, India Recognized as one of the foremost 'Emerging companies in

Eastern India' by NASSCOM in 2011 Awarded Asia-wide “Healthcare BPO Provider of the Year”

at the Asia BPO Excellence Awards ceremony hosted by Asia BPO Summit on 14th February 2013 in Mumbai, India

Awarded the prestigious “Outsourcing Service Provider of the Year” award in the Asian Outsourcing Excellence Awards ceremony hosted by CMO Asia on 1st August 2013 in Singapore

Awarded “Highest New Job Creator (IT/ITES)” by STPI (Software Technology Parks of India) on 3rd December 2015

41 Madison Avenue, 25th Floor, New York, NY 10010, USA

SUN KNOWLEDGE SERVICE PORTFOLIO

Provider SupportMember SupportMember Retention ProgramClinical Help Desk

Contact Center

Utilization ManagementMedication Therapy ManagementHospital Re-admission

ManagementTherapeutic InterchangeFormulary Management

Clinical Services

Medical Coding & BillingClaims AdministrationEnrollment Processing &

MemberFulfillmentCredentialing Premium billing and collections

Administrative Services

Analytics

Telemedicine ServicesRemote Patient MonitoringApplication Development & SupportTechnical SupportTechnical Documentation

IT Services

Claims /Drug Utilization AnalysisPDE AnalysisRAF AnalysisPayment Reconciliation

We provide services to

Providers – Physician/Hospital/DME/P&O/Home Health Care, Commercial Plans, MA Plans, Medicaid

HMOs, MAPD/PDPs, IPAs, MSOs, TPAs, PBMs and RBMs

3Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA

PRIOR AUTHORIZATION


PRIOR AUTHORIZATION – INTRODUCTION


“It’s a nuisance, time-consuming and often not in the patient’s best interest!”

– George G. Ellis, Jr., MD Internal medicine physician &

Medical Economics editorial advisor


PRIOR AUTHORIZATION – A CONSUMMATE SOLUTION


Sun Knowledge provides a comprehensive array of prior authorization services for awide range of healthcare areas such as:

Hospitals

Nursing Homes

DME

Orthotics & Prosthetics

Physicians’ Offices

Radiology/Imaging Services

Dermatology Practices, and many more!

Our services are designed to take the pain out of prior authorization and free you from the need to engage your resources or spend precious time in tedious prior authorization tasks.

PRIOR AUTHORIZATION – SERVICE PORTFOLIO


Full range service, comprising Authorization Request Follow-up Approval

100% HIPAA-HITECH Compliance

Low prices with no hidden cost

Highly streamlined, fast and accurate service

• DME• Hospitalization• Outpatient Surgery requiring general anesthesia• Skilled Nursing • Organ, Bone Marrow, Stem Cell Transplants and other similar procedures• Inpatient rehabilitation – Treatment for alcohol or drug abuse• Other conditions

We cater to


NO AUTHORIZATION


Certain procedures require prior authorization

Submitting a request does not guarantee approval

If an authorization was not previously requested, a retro-authorization may be requested for services already provided

The same guidelines as for requesting an authorization prior to service are followed

Dates specific for retro-authorizations are used

Once the authorization is approved, the bill is resubmitted


AUTHORIZATION EOB CODES


EOB code 529 – Case is denied

EOB code 530 – No authorization on file

EOB Code 531 – Authorization for claimant, not for provider

EOB Code 532 – Authorization for claimant and provider, not for dates of service

EOB Code 533 – Authorization for claimant, provider, and dates of service; not for procedure


FULL SERVICE PORTFOLIO


SERVICE PORTFOLIO


PRACTICE MANAGEMENT

Order Entry

Eligibility & Authorization Verification

Prior Authorization


HIPAA COMPLIANCE


HIPAA COMPLIANCE SUMMARY


SL. COMPLIANCE ASPECT HIGHLIGHTS

1 Physical Access Authorized access only | Bio-metric access | Proximity card system | Photo ID cards | Access log review

2 General Security 24 hour security personnel | Logging of visitor details | Physical register retained for 10 years

3 Monitoring CCTV monitoring (with recording) of production area | Daily review of recording

4 Vendor Access Signing confidentiality agreement before accessing sensitive areas | Accompanied by security personnel/employee during all times

5 Mobile Phones All employees (except managers) are required to deposit mobile phones in the locker box before entering facility

6 Personal Baggage No backpacks or other bags allowed | All baggage to be deposited in locker box before entering facility

7 Network & Application Usage

Unique user IDs created using Microsoft Active Directory | Access to storage devices, shared drives, USB/mass storage devices, printers – controlled by Domain Group Policy | No wireless access points

8 Firewall Unified Threat Management System | Internet traffic regulation using multiple filters | Network Address Translation (NAT) | Intrusion Prevention Systems (IPS) | Port-mapping for traffic between Virtual LANs | Default setting to deny all traffic

9 VPN (Virtual Private Network)

Site-to-site IPSec VPN tunnels | Authorized access via client-to-site VPN connections | Access authorization controlled by Active Directory's authentication service

10 Redundancy Management

Fully redundant network stack | Two ISP links configured in active-active mode | Power backup supplied by 130 KVA UPS and 750 KVA generator | 22 KVA UPS backup for server and network systems

11 Virus & Malware Protection

Central anti-malware system | Automatic updates | Extra protection by gateway firewall | Centralized OS patch management system (using Microsoft's WSUS server)

12 Other Measures Fire extinguishers at key areas | Half-yearly fire drills


SUMMARY OF BENEFITS


Very Little Risk• Proven track record in providing healthcare BPO/KPO services

• Experienced in providing services to both payers and providers

• Experienced working with various software platforms

• Quick and efficient resource for special projects requiring technical and process expertise

Significant Upside Potential• Great understanding of the Healthcare Industry. Operation scale-up with a short notice

• Extremely competitive rates, greater productivity, improved quality, increased member and provider satisfaction

Proven Process Performance• Low denial rate reduced collection time increase in revenue collection

• Billing & Coding Accuracy > 99.9%; TAT: 24 – 48 hours

• Adherence to CMS billing requirements

Clear Communication and Quick Response Time at All Times

ISO 27001:2005 & HIPAA Compliance for End-user Data Privacy and Protection


TESTIMONIALS


CLIENTSPEAK


“We have had the pleasure of working with the Sun Knowledge team throughout the few months utilizing their services for patient data entry and eligibility verification. They are a devoted and responsible team that is highly experience in what they do. They are always concerned about the client’s needs and are always there to help. I highly recommend the services offered by Sun Knowledge.”

COO of a leading medical billing and credentialing company in New York

“Your team amazed me with the manual and the amount of info you provided with that short training session.”

Practice Manager of a major Dermatology group in New York and New Jersey


CLIENTSPEAK


“My firm has evaluated an outsourcing transaction with Sun Knowledge. They provide superior service at a very attractive rate and have demonstrated to us their commitment to this partnership. Their expertise across various process areas in the PDP/MAPD domain and unique cost structure puts them in an incredible position to work with plans throughout the healthcare industry.”

Chairman, President and CEO of a major New York based Health Plan

“Our company is very pleased with the administrative, and business analytical solutions which Sun Knowledge delivers to our company from a quality & cost perspective. They have been a true partner in bringing industry expertise, and innovative solutions to the table. Their ability to grow with our evolving needs for higher end services such as clinical services is a significant differentiator among healthcare business process outsourcing firms.”

Executive Vice President of Operations of a leading MSO


CLIENTSPEAK


“I was always against the idea of outsourcing our back end claims processing work but I was wrong. Sun Knowledge provided extraordinary deliverables on a timely basis which led to cost cutting considerably for us.”

CEO of a leading MA-PD Plan

Ronnie Hastings(646) 661-7853Email: [email protected]

Sun Knowledge41 Madison Ave., Suite 2511, 25th Floor

New York, NY 11001, USA

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