Services

Northern Illinois Health Plan offers a broad array of services, including TPA and Care Management Services, to complement your benefits program and keep you cost competitive.

Third-Party Administration (TPA)

Our TPA provides employers a full array of third-party administration services for the efficient and effective management of benefit programs. The cornerstone of these services is the partnership created with each individual employer. No process is so structured that it can't be customized to meet the needs of your business.

• Leading-edge medical/dental/vision claims processing system with a 10-day turnaround goal
• Prescription drug card services
• HIPAA certificate administration
• Flexible (tax-free) spending account administration
• COBRA administration
• Short-term disability administration
• Network and re-pricing manager for out-of-area and wrap-around nationwide PPO services
  • Over 713,000 physicians and 50,000 facilities represented nationwide
  • Negotiations for every out-of-network claim
• Sizable discounting to reduce overall costs
• Performance guarantees
• Benefit plan design consultation
• Assistance with employee communication materials
• Participation in employee orientation, enrollment meetings and benefit fairs
• Online services, including enrollment
• Summary plan description development and administration services
• The latest technology to help access, analyze and manage plan specifics

The NIHP TPA thoroughly investigates each claim and evaluates appropriateness of payment. Areas reviewed include:

• Coordination of Benefits
• Usual and Customary
• Coding Accuracy
• Duplication of Billing
• Unbundling of Procedures
• Medical Necessity

Application of plan provisions are also thoroughly reviewed for pre-existing conditions, yearly and lifetime maximums and subrogation (third-party liability).

Customer Service Representatives may be involved at any point during the claim process and have instant online access to this information to determine the status of a claim.

We use Associated System's COMPLETE Health Benefits Administration Software system for managing health plans. It provides online, real-time claims adjudication that immediately updates files when data is entered or edited. The system allows for referral linking, duplicate claims checking, coordination of benefits and access to member inquiries. In addition to adjudicating claims and determining payments, the system:

• Maintains membership information and supplies flexible membership statistical reporting
• Records and tracks referrals both within a provider network and outside of it
• Allows for a great deal of flexibility for benefit plan and account structure to meet individual client needs
• Tracks customer service issues and provides a tickler system for follow up
• Provides a wide variety of detailed standard reports and unlimited capabilities in creating customized, special reports

Our goal is to accurately process claims within a 10-day period — a goal NIHP consistently meets or exceeds. In fact, we've processed over 100,000 claims in the last 12 months, with 99.7% processing accuracy (see How We Measure Up).

Care Management Services

Our Care Management professionals focus on one objective: advocating for members when they most need healthcare help.

We assist our patients, their families and their providers when health issues are encountered. Especially during serious illness, we can help them navigate through all aspects of their care. Our involvement helps ensure appropriate quality, minimize stress, maintain cost-effectiveness, and achieve the best possible outcomes.

• Utilization review
• Pre-certification
• Case management
• Disease management
• Sound decisions by MDs and RNs, based upon nationally recognized criteria