Medical Risk Management

General scope of services includes:

  • Medical case management
  • Claims processing
  • International 24/7 call center
  • Preferred provider network access

Technical capabilities include:

  • Paper to EDI conversion
  • Disaster recovery
  • EDI routing
  • Call tracking
  • Ad-hoc and standard reporting

Call center operations

Our call center is available twenty four hours a day, seven days a week. Through our worldwide 24-hour call centers and with the help of extensive multilingual resources, Redbridge provides medical and VIP assistance to individuals and groups traveling outside their home country. We handle all calls including medical referrals, notifications of hospital admissions and general customer service inquiries from members and providers.

Claims system

Redbridge's backend claims system, based on the latest and most powerful Oracle databases, is one of the most powerful claims systems available. Our user friendly interface and EDI processes allow claims to be processed quickly, accurately and easily in real-time. The Redbridge front-end system, ROS (for Redbridge Operations System) is a HIPAA-compliant web-based portal providing comprehensive real-time access point to our internal case management notes, claims claim payments, and customer service interactions.

Key claims services:

  • Length-of-stay validation
  • Billed vs. authorized charge analysis
  • Bill review and/or audit provided by internal claim auditors
  • Fraud and abuse detection
  • Coordintation of benefits and subrogation

Medical Management

The Medical Director's mandate is to deploy best practices in acute episodic care, chronic disease management and wellness programs to optimize the healthcare status of our plan beneficiaries.

Episodic case management includes:

  • Pre-certification
  • Post-treatment follow-up and additional assistance as needed
  • Utilization review, including concurrent review and discharge planning