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Eligibility Verification

MediLink’s extensive electronic network allows service providers to check member eligibility in a matter of seconds -- by scanning a QR code, verifying a card (chip or magnetic stripe), or inquiring via an online facility. Since eligibility status is returned in real-time, payors are able to maintain visibility and control over utilization.

Payment Guarantee

In cases when Payors require pre-authorization, MediLink provides escrow services to guarantee payments to Providers, while ensuring that services are rendered according to Payor-prescribed -guidelines, such as allowable conditions or benefit limits.

Claims Processing

MediLink allows providers to submit claims electronically with a verified approval code. Thereafter, claims are processed in accordance with the member’s health plan. Providers may electronically submit claims that are associated with an approval code. Claims are adjudicated using business rules and artificial intelligence algorithms to monitor and prevent fraud.

Payment Processing

Prior to authorizing electronic payments, our decision support system confirms that the claims presented by providers fall within the member’s benefit limits. Thereafter, payments are settled with providers on behalf of payors. For transparency, the electronic proof-of-payment are visible to both the payor and provider through their respective online portals.

Analytics

MediLink’s analytics services are used by our clients to gain insight on utilization from a variety of dimensions (e.g., member demographics, industry, geography, provider level, type of service, clinical diagnoses, clinical procedures, etc.)
These insights could be used to identify key utilization cost drivers as a reference to develop targeted utilization management programs.

Machine Learning

In addition to rules, MediLink employs a variety of machine learning techniques to identify suspicious patterns and detect potential fraud. Suspicious transactions are investigated and once verified as fraud, the knowledge is used to refine the algorithms.