Government Programs
PGBA's record of providing administrative services to government health plans is unparalleled in the industry. Our success is rooted in a comprehensive knowledge of the vast nuances that distinguish these programs from private health plans.
We have served as the largest processor of TRICARE claims for the United States Department of Defense, and we currently are the only medical claims adjudication contractor for the United States Department of Justice Federal Bureau of Prisons with a contract to adjudicate claims from all 109 federal correctional facilities. Our knowledge and experience with Medicare Advantage products allow us to provide a number of private fee-for-service and coordinated care products based on our customer's needs.
Medicare Advantage
PGBA has provided administrative solutions for the Medicare Advantage program since its inception in 2002. We bring a highly scalable solution to Medicare Advantage payers as a result of our ability to offer a wide range of staff support and technological solutions. This modular approach gives clients the right mix of administrative support to compete in a highly competitive and increasingly regulated environment.
Our proprietary technological platform for Medicare Advantage expedites the claims management process in full compliance with CMS guidelines for Medicare Advantage PFFS and PPO claims processing. Dedicated and specifically trained Medicare Advantage teams put an unmatched level of knowledge in CMS compliance to work for PGBA clients.
Federal Bureau of Prisons
Just like other governmental healthcare payers, prison healthcare services are increasingly coming under more pressure to maintain the level of service and quality required by their contracts. This includes providing qualified contracted healthcare professionals, rendering utilization management services, claims adjudication and invoice processing and continuous emphasis on cost containment.
PGBA has brought its experience and performance in electronic claims handling to serve the Federal Bureau of Prisons, allowing the bureau to significantly improve the efficiency and effectiveness of its claims adjudication process. We are currently putting into place our comprehensive suite of technological systems and service protocols to help move the bureau into an entirely new realm of operational efficiency, while ensuring that quality patient care is continuously upheld.
Department of Veterans Affairs
PGBA provides administrative services to Humana Veterans Healthcare Services under the Veterans Affairs HERO demonstration project. In this capacity, we deliver HIPAA compliant claims processing and customer service functions for the four Veterans Integrated Service Networks (VISNs) authorized under the program.
As a part of our suite of services, PGBA provides a scalable and flexible platform that includes pre-authorization/referral and provider information management, along with imaging and financial systems that support the accurate processing and payment of claims in accordance with the VA's unique requirements.
Health Net Federal Services
Humana Military Healthcare Services
PGBA has served in a number of capacities for the North and South regions of the TRICARE health plan, administered by Humana Military Healthcare Services and Health Net Federal Services, respectively. We processed more than 34 million in TRICARE claims in the last year alone, responding to almost 1 million pieces of correspondence and more than 2.7 million phone calls. Our call center to support the North Regional TRICARE contract was named one of the top call centers in the country by J.D. Power and Associates. And our award-winning myTRICARE.com web site has won numerous national awards, recognized by health communications professionals for its web-based claims submission and customer service capabilities.