Client Focus: The Argus Group

Island EDI: Creating Solutions for Bermuda Payer’s Challenge

Even in balmy Bermuda, getting healthcare claim data processed can be a challenge. That’s why The Argus Group, part of Argus Group Holdings Ltd., recently engaged EMS Healthcare Informatics.

The Argus Group has been an EMS client since  2015. Its global offices in Bermuda, Gibraltar and Malta process thousands of international healthcare transactions for group health insurance plans, disability plans and more. As the Group began introducing new providers to electronic claim and payment processing, it realized automation might be needed to ensure data consistency and compliance.

“Some medical professionals in island communities were newer to digital claims processing,” said Dave Pontrello, VP of EMS Healthcare Informatics. “The Argus Group explained that claims might be missing required data fields, contain inconsistent patient identifiers, and were not matching up with Argus’ member files.”

The EMS team created an 837 File Processor program that reads each subscriber record in the file and adds the missing data, locates the member’s record in the extract file using enrollment ID and date of birth, then replaces name values in the inconsistent files with the correct values automatically.

The program also modifies the format of the claim files for posting into the Group’s claims system.

“When validation issues are spotted, such as changes needed in select EDI loops and segments, the software automatically modifies the incoming files to ensure the claims can be processed and paid,” added Pontrello.

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