Our Services
We ensure efficient Prior Authorization, seamless Claims Adjudication and Reconciliation, proactive Disease Management, optimized Utilization Review, robust Fraud Detection, comprehensive Analytics & Reporting, and secure Member Services Contact Center helping health plans, TPAs, and members reduce administrative burdens, eliminate errors, and boost financial performance, With a commitment to Precision. Protection. Performance.
SiriusShield delivers cost-effective, regulatory-compliant solutions across the healthcare ecosystem.
SERVICES
Preauthorization
We streamline the preauthorization process with speed and precision.
Our medically trained team applies industry standard guidelines and payer protocols to deliver approvals that are accurate, compliant, and audit ready.
- Application of InterQual®, MCG, and payer-specific criteria for accurate medical necessity evaluation
- Real-time eligibility and benefit verification across payer systems
- Integration ready with major EHR platforms (Epic, Cerner, Allscripts) for faster processing
- HIPAA compliant workflows maintained from intake through final approval
- Turnaround time optimization to reduce delays in care access
- All reviews conducted by staff trained in U.S. medical policies and URAC aligned procedures
- Consistent audit readiness through structured documentation and approval logs
- Enhanced operational oversight from experienced utilization teams familiar with payer-side expectations
Claims Adjudication and Reconciliation
We deliver thorough claims adjudication and reconciliation services designed to catch errors, validate accuracy, and optimize financial outcomes. Leveraging audit systems and experienced reviewers, we ensure each claim aligns with payer policy, regulatory standards, and settlement goals.
- Detection of gaps, errors, and fraud through expert review and smart flagging tools
- HIPAA and URAC-compliant processes by certified U.S. trained teams
- Clear reconciliation of payments using remittance advice and payer data
- Tracking of underpayments, overpayments, and unresolved claims
- Direct coordination with insurers and providers for faster resolution
- SLA based turnaround with quality logs and audit-ready records
- Led by experts in U.S. claims, reimbursement, and financial integrity
Disease Management
Our disease management programs help patients manage chronic conditions through structured care planning, education, and ongoing clinical support, We focus on reducing complications, improving quality of life, and encouraging long term health commitment
- Condition focused care based on ADA, AHA, and evidence based guidelines
- Managed by medical professionals trained in chronic disease protocols
- Personalized coaching and regular follow-up using secure systems
- Prevention of readmissions through early intervention and care planning
- Education support to improve treatment compliance and lifestyle changes
- Alignment with client specific quality metrics and outcome benchmarks
- Delivered by a team experienced in U.S. care models and patient outreach
Utilization Review & Management
- Prospective, concurrent, and retrospective reviews conducted by trained specialists
Our utilization review services ensure care decisions are medically sound, timely, and fully compliant. We help health plans improve care coordination through structured, policy aligned review processes.
- Full alignment with URAC and NCQA accreditation standards
- Comprehensive documentation review to support authorization accuracy
- Appeals and denial management with collaborative provider communication
- Real-time determinations to reduce delays in care delivery
- Audit-ready workflows with traceable decision-making for every case
- Secure, HIPAA-compliant handling of all clinical and administrative data
- Carried out by professionals experienced in U.S. utilization review policies and metrics
Fraud & Abuse Analysis
We help healthcare plans detect and prevent fraud, waste, and abuse by carefully reviewing claims and analyzing policies. Our trained compliance team detects any violations early and ensures every case is auditable and traceable.
- Detect duplicate invoices, unbundling, and suspicious claim patterns
- Clinical validation of treatments against claims made
- Early identification of inconsistencies and risks of policy abuse
- Audit ready reports designed for compliance, legal, and regulatory reviews
- The team is trained on CMS, OIG, and HIPAA fraud reporting protocols
- Traceable records and secure data workflows for complete transparency
- Operational supervision by specialists with experience in fraud analysis on the payer side
Member Services Contact Center
We provide a dedicated, HIPAA secure contact center that handles every member touch point from benefit questions to prior-auth status so plans can elevate service quality without expanding headcount. Our trained agents become an extension of your team, delivering empathy, accuracy, and 24/7 availability.
- Inbound & outbound support across phone, email, chat, and SMS
- Eligibility, benefits, and claim status inquiries resolved in one call
- Multilingual agents trained in U.S. healthcare terminology
- Integrated CRM + ticketing for full interaction history
- HIPAA compliant call recording and data handling
- Real-time CSAT and First-Contact Resolution tracking
- Overflow and after-hours coverage to reduce abandonment rates
- Continuous QA: call audits, coaching, and KPI dashboards
Analytics & Reporting Hub
SiriusShield’s Analytics & Reporting Hub turns raw operational data into actionable insight. We centralize claims, utilization, and member service metrics to deliver dashboards that drive cost savings, compliance, and strategic decision making.
- Automated ETL pipelines pulling data from claims, PA, and UR systems
- Custom dashboards for SLA, turnaround time, and denial trends
- Predictive models highlighting cost drivers and high risk populations
- Compliance & audit reporting aligned with HIPAA, URAC, NCQA needs
- Drill down views by plan, provider, or service line
- Fraud, Waste & Abuse anomaly alerts integrated with SIEM tools
- Export ready files for finance and regulatory submissions
- Dedicated data analysts available for ad hoc deep dives
Chronic Case Review
We unify years of clinical, claims, and pharmacy data to deliver a single, clinician-signed view of every complex case.
Our chronic-care specialists transform fragmented records into action-ready insights that are accurate, compliant, and audit ready.
- End-to-end review conducted within one consolidated platform for a single source of truth
- Evidence-based assessment aligned with national chronic-care guidelines
- Risk-score stratification and “red-flag” alerts to close care gaps quickly
- Diagnosis-coding validation safeguards risk-adjustment revenue
- Rapid turnaround keeps care plans timely and proactive
- All reviews signed off by U.S. clinicians under URAC-aligned procedures
- HIPAA-compliant workflows maintained from data intake through final summary
- Structured documentation and outcome logs ensure continuous audit readiness