Avalon Benefit Services is a third party administrator (TPA) with headquarters in Dublin, Ohio and locations in Athens, Ohio and South Charleston, West Virginia. Avalon Benefit Services and its affiliates serve approximately 100 self-funded clients covering 20,000 plan participants from its Claims Processing Service Center. The Claims Processing Service Center pays approximately $50,000,000 in claims and $12,000,000 in stop loss premiums and administration fees annually.
Claims are processed at both the Dublin and South Charleston locations and the claims centers are collectively called 'The Employee Benefit Service Center', or EBSC. EBSC utilizes the state-of-the-art CliCs Benefit System as its claims and administration computer system, a HIPAA compliant system developed by an independent software vendor. The system is recognized by the industry as a leading system in automated claims processing for medical, dental and other benefits.
Benefit plans are coded into the system to allow automated adjudication of claims. Eligibility edits, duplicate claims edits, benefit coverage determination and claims pricing are all performed automatically by the system. Exceptions are noted for claims examiner review. Once completed, payment checks and explanations of benefits are automatically produced by the system.
The staff at EBSC is thoroughly trained to interact with the system to assure timely and accurate processing of claims. Claims-held reports are produced to help manage the timeliness of pended claims and regularly scheduled audits are conducted to identify errors and error patterns. Claims turnaround time averages 10 days and claims payment error rates average less than 2%. EBSC has been SAS 70 audited according to accounting standards.
Each client account is assigned a dedicated claims examiner with the responsibility of providing high quality service to the plan participants. This leads to highly personalized service and to accountability for results.
WEB ACCESS: Clients, Plan Participants and medical providers have access to their eligibility and claims information on-line on a real-time basis through the Avalon Benefit Services web site. The web site provides individuals the capability to look up eligibility status, review claims status and payment decisions, change enrollment information, and ask questions of our staff using our secure web portal. This unique web site is user friendly and provides capabilities for both clients and Plan Participants to manage their benefit status.