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Our TPA services provide a complete end to end solution, from billing and collection (including direct to the insured), policy administration, through to claims adjudication and payment. We can provide any of these services on a stand-alone basis.
We have the capability to provide our services in English, French and Spanish. This is part of our commitment to providing exceptional service to all of our clients.
Claims Services
Sutton Special Risk has been paying Medical, Dental, Disability,
Life and Accidental Death Claims in Canada and USA for
over 25 years. Our multilingual professional Claims Adjudicators
are fully trained and experienced in all Benefit areas.
Our claims adjudication systems have been developed to
ensure prompt service, secure data, and useful and timely
management reporting. Services include;
- Timely and accurate Claims Processing of Major Medical
and Dental, Life, AD&D, Waiver of Premium, Short
Term and Long Term Disability Benefits
- Prescription Drug Card Service
- Pro-active Disability Claims Management Services
- Multilingual forms and correspondence
- Toll free, multilingual claims inquiry service
- Medical case management
- Comprehensive Activity and Cost Control Reports
- Cost-plus claims administration of uninsured benefits
In addition, our sophisticated US Claim Payment Software
gives us the ability to offer the following services;
- Detailed data tracking, including diagnosis, procedure,
provider type, units of time, reasonable and customary
charges
- Auto adjudication
- Electronic claims reception, processing, and remittance
capabilities
- Compliance with all US Regulatory and Reporting
requirements, (COBRA, HIPAA, IRS)
A key component to effective U.S. claims management
is cost containment. Our services include;
- Effective cost containment through access to Preferred
Provider Organizations (PPO)
- Utilization review
- Centres of Excellence Program
- Out of Network claims negotiations.
Administration Services
Our dedicated team can provide a full range of administration
services to our clients in Canada and the USA, including;
- Premium Billing, Collection and Remittance
- Toll free multilingual call centre services
- Processing of Evidence of Insurability
- Life Insurance Conversion Assistance
- Sophisticated enrollment and eligibility tracking
tools
- Comprehensive activity and cost control reporting
- Compliance with all US regulatory requirements (COBRA,
HIPAA, IRS)
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