Managed Services

Thanks to the Segic platform, clients have a practical, innovative set of tools for self-managing one or more collective health plans. Normally, internal staff must be tasked with administering the plan, handling adjudication and processing payments.

Segic’s managed services free you from that constraint and guarantee a high level of healthcare-service delivery for your plan members.

Our team of specialists will help you optimize management of your collective insurance plan. Our managed services have two distinct components:

Administering one or more plans

Our administration service is aimed primarily at unions. We work closely with our client, broker and actuary partners on agreements and financial management.
When you work with us, you have access to support delivered by a dedicated, attentive team and a technology platform designed to facilitate all the transactions involved in administering your plan.
Thanks to our unique, innovative concept, you will have a single point of contact for the management and administration of your plan. The result is highly customized service.

Key features

  • Managing participants: enrollment, changes, termination
  • Demographic and other reports as needed
  • Participants’ portal-usage statistics
  • Annual renewal and student certification campaigns
  • Billing of premiums
  • Multi-insurer billing
  • Source-deduction reports
  • Performance indicators
  • Communication strategy (news releases, forms, documents, guides)
  • Customer service
  • Demographic data ownership

Adjudication and claims processing

Our team is staffed with seasoned people equipped with the expertise and experience needed for correctly processing claims for everything from pharmaceuticals and medical procedures to dental care.

Key features

  • Adjudication of claims using the management rules defined by your plan
  • Fast, efficient processing of claims for reimbursement of medications, medical procedures and dental care
  • Real-time submission of claims for reimbursement of pharmaceutical products and dental care
  • Simplified submission of paper claims through our mobile portal
  • Processing is extensively automated, minimizing human error
  • Preauthorization-based handling of reimbursement requests for exception drugs or medically indicated healthcare services
  • Fraud-prevention service

We also have access to high-level experts for the analysis of more complex cases

Consulting pharmacist

Our consulting pharmacist’s mission is to provide a different perspective for evaluating the appropriateness, effectiveness and safety of medications prescribed by a healthcare professional. The consulting pharmacist assesses:

  • Treatment duration
  • Planned medical follow-up indicated in the file
  • The choice of treatment
  • Communication of relevant information to the patient regarding their treatment and all available options.

The consulting pharmacist works with scientific and clinical data to evaluate each case and develop the drug coverage plan.

He works with our team to prepare the list of medications eligible for reimbursement. A cost-benefit analysis supports the consulting pharmacist’s decisions.

The consulting pharmacist also participates in Segic’s audit process to confirm that reimbursements of eligible medications and pharmacists’ professional fees are fair and reasonable.

 

Consulting dentist

The consulting dentist’s role is to ensure that dental procedures performed on patients are medically necessary and consistent with the profession’s code of ethics. He also verifies that expenses submitted for such procedures are consistent with the billing standards set by the applicable dental association.

As part of his work, he communicates directly with dental professionals when he deems it necessary to review additional information such as x-rays or other relevant information in order to complete an assessment of the file.

If the insurance policy has an alternative treatment clause, the consulting dentist authorizes reimbursements based on the least expensive adequate treatment.

The consulting dentist has the power to deny reimbursement for procedures deemed non-essential from an insurance perspective, while ensuring that approved reimbursements do not exceed reasonable fees as defined in the insurance policy.

In case of doubt, the consulting dentist may also serve as an expert for fraud detection purposes.

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