System Overview

WLT’s MediClaims system offers a cost-effective, straightforward, and efficient approach to benefit and claims administration. WLT’s rules-based architecture and integrated EDI processes allow claims to be processed quickly, accurately, and easily.

A Comprehensive Benefit Management Solution

MediClaims’ administration and processing capabilities encompass a range of benefit and claim types from Medical, Dental, Vision, and Prescription Drug to Consumer Driven Healthcare, Disability, and Capitation processing. With WLT’s MediClaims system, you have the flexibility to configure your groups for a single line of coverage or for complex benefit packages with multiple lines of coverage.

  • Claims processing for medical, dental, vision, and prescription drug plans
  • Claim precertification, referral, and case management functionality
  • Capitation maintenance and payment processing
  • Consumer driven healthcare benefit administration, including FSA, HRA, and HSA
  • COBRA administration
  • Eligibility administration
  • Customer service contact management
  • An extensive library of standard and custom reports
  • Disability processing for both short and long-term benefits
  • HIPAA-compliant EDI 5010 and legacy 4010 transactions
  • Premium billing and agent commissions
  • Easily configurable system security

The core system offers flexibility with processing functions to facilitate the administration of fully insured, self-funded, and partially self-funded health plans.

Advanced System Technology

No plan can work efficiently without support from adequate information systems. WLT makes a point of always working with the best, providing you with the most sophisticated and flexible system available today.

MediClaims is a native Windows® application which is user-friendly and easy to use. For the database, we have partnered with Oracle® who has one of the most powerful databases available today.

Claims Processing & Editing

WLT’s user-friendly interface and EDI processes, in conjunction with our processing engine, allow claims to be processed quickly, accurately, and easily in Real-Time.

MediClaims’ processing and editing capabilities encompass a range of claim functions from standard Medical, Dental, Vision and Prescription Drug to FSA, HSA, HRA, Disability, and HMO Capitation. Utilizing our state-of-the-art EDI processes allows users to attain Real-Time auto-adjudication rates as high as 90%. Electronic Funds Transfer improves cash forecasting and cash flow, streamlines transaction processing, reduces operating costs and improves your business relationships.

By utilizing our Work Flow Processing, claims can be routed from EDI to editing and auto-adjudication processing. Claims that fail the editing process can be automatically assigned to the appropriate claims adjuster for review.

Integrated unbundling of Medical and Dental procedures prevents unnecessary payment for procedures that should not have been billed separately. The Out-of-Network Repricing feature lets you submit your non-network claims to a clearinghouse (or other repricer) for repricing.

Administration & Billing

The MediClaims system’s intuitive user interface simplifies the administrative duties of the Benefit Administrator. Precertification, Eligibility, PPO Administration, Letter Writing, and Call Tracking are just a few of the many features designed to save you time and money. WLT’s flexible plan design allows you to have multiple plan options at the group and individual level.

The Premium Billing & Agent Commissions portion of the system allows you to effortlessly bill for premiums and collect the payments. Billing can be performed at the group, location, or even the individual level. Distributing commissions for collected premiums is just as easy. You have the ability to maintain an unlimited number of agents participating in a single collected premium, and the ability to establish and utilize agent hierarchies in the calculation of commissions.

COBRA administration is integrated with Premium Billing for the billing and collection of premiums associated with COBRA coverage. Claims payments can be suspended for unpaid premiums. In addition, the COBRA administration features of the system incorporate the generation of COBRA notification letters for the initial eligibility notification, end of election eligibility, end of COBRA eligibility and termination notices.

Compliance & Reporting

WLT understands that a critical aspect of a benefit administrator is its compliance with various federal laws. Therefore, WLT continuously monitors the evolving federal compliance requirements to determine how we can help automate the processes through system functionality.

Some of the features available are:

  • COBRA Qualifying Event Notification Letters
  • HIPAA Certificates of Creditable Coverage Letter
  • ACA Reporting for PCORI and Transitional Reporting
  • 1094-C & 1095-C Forms and Electronic Filing
  • HIPAA EDI Compliance
  • 835 CAS Reason Code Mapping
  • 835 RARC Code Mapping
  • 1099 Forms and Electronic Filing
  • W-2 Forms and Electronic Filing

WLT’s reporting capabilities include over 100 standard and custom reports. In addition, data is stored in the award-winning Oracle database and is exportable in virtually every format (Excel®, Word®, PDF, HTML, etc.), enabling almost unlimited reporting capability for your ad hoc reporting needs. To augment your reporting options, the MediClaims extension, Benefit Plan Informatics, provides additional business intelligence reporting.

Consumer Driven Healthcare

The popularity of consumer driven healthcare plans has been on the rise in recent years. WLT’s MediClaims system has the ability to easily administer these plans and incorporate the benefits with your health plan. Some of the features of our Consumer Driven Healthcare (CDHC) module include:

  • Flexible Spending Accounts (FSA)
  • Health Reimbursement Arrangements (HRA)
  • Health Savings Accounts (HSA)
  • Automatic FSA payments for health plan out-of-pocket expenses
  • Build HRA benefits into your existing health plans
  • Coordinate HRAs with your FSA plans
  • Administrative reporting and member statements that are specific to your FSA, HSA, and HRA plans

In addition to the above features, an integrated benefits card is available. The MediCard Benefits Card can be used by your members to settle point-of-service transactions directly from their available CDHC funds.

Would you like to see how our systems can work for you? Request a demo today! Request A Demo
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