About Us

Founded in 2002, Crossroads Healthcare Management LLC is a family owned limited liability company duly organized under the laws of the state of New Jersey and authorized to do business in the state of New York.  At its core, Crossroads is a third-party administrator specializing in the administration of self-funded health and welfare benefit plans sponsored by labor unions…but Crossroads is so much more than a TPA.

Claims Administration

At the core of any quality third-party administrator is claims administration.  Crossroads employs state of the art technology systems to receive secure, HIPAA-compliant claims files from any PPO its clients so choose and to adjudicate those claims in an accurate, compliant, and timely fashion pursuant to any plan of benefits.  

  • Process all claims for benefits pursuant to, and in accordance with the given benefit plan;
  • Provide open lines of communication with each claimant and/or service provider to obtain any and all documentation necessary to promptly and accurately process claims for benefits;
  • Communicate to each claimant the payment or denial of each claim in a detailed explanation of benefits, which includes, among other things, the amount of the claim to be paid, the deductible, copayment, or other out-of-pocket expense to the patient, if any, the type of benefit paid, and the right to appeal any adverse benefit determination and the time limits and procedures for such appeal;
  • Issue checks on behalf of the fund to covered persons or to such other entitled provider of that portion of amounts due under the plan for each claim of a covered person that qualifies for payment under the terms of the plan;
  • Maintain individual records of claims for benefits and payment or denial of claims as appropriate under the terms of the plan and in conformity with applicable legal record retention requirements;
  • Maintain a database of Reasonable and Customary Charges for the geographic areas serviced by the plan to ensure that charges beyond the limitations of the plan are not included in the computation of benefit payments, and administer the plan in accordance with accepted standards for Reasonable and Customary Charges;
  • Track all deductible amounts, out of pocket expenses, and any other services requiring utilization tracking;
  • Provide a monthly claims register of all paid claims in both check number and alphabetical order, in sufficient detail to permit orderly and proper reconciliation of each payment under the plan;
  • Provide a monthly, quarterly and annual accounting of all claims, premiums, fees, and other costs, if any, paid or coordinated by Crossroads on behalf of the fund;
  • Administer state sponsored and other applicable uncompensated claims and other surcharges for covered services;
  • Prepare, distribute, and file all IRS Form 1099’s and other tax returns as required by law with respect to service providers paid on behalf of the fund; and
  • Distribute all appropriate forms, procedures, and any other written communications pertaining to the fund, including member ID cards, claim forms, summary plan descriptions, and summaries of material modifications.

¹ Benefit plans may include, but are not limited to medical, dental, vision, prescription drug, vacation, death, among others.

Support Services

Under the auspices of Support Services falls the departments of Fund Office Support and Member Support. 

Crossroads offers:

Fund Office Support
  • Determine each individual claimant’s eligibility for each submitted claim for benefits filed pursuant to the terms and conditions established by the plan;
  • Maintain individual records of eligibility, including, but not limited to the coordination of benefits with other group coverage, verification of dependent status, existence of qualified medical child support orders, and any other documentation as required by law;
  • Administer all enrollment requirements for new and existing members and their families;
  • Coordinate with the administration of the program of benefits as required by COBRA;
  • Coordinate plan benefits with other plans pursuant to the terms and conditions specified in the plan;
  • Prepare and disseminate employer contribution billing pursuant to the respective collective bargaining agreements; and
  • Oversee the process of collecting amounts owed to the fund, which may include telephone calls, electronic mail, or demand letters communicated to the employer;
  • Work in conjunction with fund counsel to collect any amounts owed to the fund whenever legal action is necessary.
Member Support
  • Provide a toll-free number dedicated to the client that enables client members to contact Crossroads with questions regarding benefits, claims payments, dependent status, and other recurring issues.  The toll-free number is managed by a dedicated team of Member Support staff trained on the healthcare industry and the plan of benefits they service.
  • Provide a full time field representative for on-site membership communication regarding questions, concerns, specific problems, or any other items related to the fund and the services provided;
  • Provide representation, at the request of the fund’s Board of Trustees, to attend membership meetings for the purpose of explaining all medical, dental, and other welfare benefits;
  • Assist in the enrollment of new Members and their dependents;
  • Process any and all written requests, issues, or comments received from covered persons, specifically all appeals of adverse benefit determinations, and forward same to the fund in report format for review and decision by the Board; and
  • Finalize all amounts due and payable as a result of appeal approval, or explanation of denial, in accordance with the written instructions of the Board;
Case Management

Cost containment is what separates Crossroads from all others – and the Case Management department is the catalyst. Through concerted efforts among various parties, the Case Management service facilitates the purposes of applied cost containment, continuity of medical technology advancements, and favorable and measurable financial results for the fund and covered persons alike.  

  • Utilization Review Program is a unique program that oversees a claims flow process not performed by any other third-party administrator.  The program sorts inbound claims by medical discipline with each discipline managed by dedicated staff.  That staff then employs a hands-on approach to medical records review, coding accuracy, and fraud inspection.  This process manages the business aspect of care delivery, which results in a higher level of claims adjudication – reducing the opportunity for error, thereby increasing payment accuracy and ensuring the likelihood of cost containment.
  • Proactive and personalized level of healthcare management by coordinating care, including referrals, care research and assistance, follow-ups, and most importantly compassion when care is needed.
    • Case Manager assigned to every case
    • Coordinate communication between patient and provider to perform intake screenings, assessment and evaluation of inpatient hospital stays and elective procedures, review of medical records, discharge plans and the implementation thereof, including, but not limited to nursing care, home care, social work, infusion therapy, physical and occupation therapy, durable medical equipment, and all other necessary medical services and supplies,.
    • Case review in conjunction with the fund’s retained Medical Director
    • Detailed record keeping and reporting
  • Claims Suspension Program ensures that claims meeting certain criteria are suspended for a justifiable reason.  Such reasons may include, but are not limited to medical necessity, additional information needed,, coordination of benefits, subrogation, and diagnosis and coding errors.  This program results in direct savings to the fund.
  • Inpatient Hospital Delivery Program segments each hospital case or claim independently for review and adjustment, as necessary, and coordination of benefits with other health plans such as Medicare.
    • Coordinate inpatient stays with Utilization Review, including, but not limited to intake screening assessments, prior authorization, and concurrent stay review, which monitors and manages the inpatient hospital stay through its conclusion.
    • Refer patients to In-Network facilities, or alternatively, negotiate fees for Out-of-Network facilities or services where applicable.
    • Negotiate deeper discounts when major cases present themselves, or alternatively, when no discount arrangement exists.
  • Outpatient Facilities Program segments each outpatient facility claim independently for review and adjustment, as necessary, and coordination of benefits with other health plans such as Medicare.
    • Coordinate all outpatient services, including, but not limited to pre-admission screening and assessments, prior authorization, and In-Network referrals.
    • Provide alternative case management for outpatient facilities as a cost containment option instead of inpatient hospital stays.
    • Research, review, and maintain medical protocols that establish and control procedures that can be done in an outpatient setting
    • Refer patients to In-Network facilities, or alternatively, negotiate fees for Out-of-Network facilities or services where applicable.
  • PPO Management Program monitors and coordinates the PPO with the cooperation of the given vendor.
    • Educate the membership on the PPO
    • Refer covered person to In-Network providers and facilities participating in the PPO
    • Coordinate and maintain the benefit design within the structure of the PPO
    • Ensure PPO’s compliance with industry standards and regulations surrounding union sponsored health and welfare funds
    • Identify and advise vendor regarding practitioner service, performance, and potential fraud or abuse
    • Ensure that the PPO, as a carve-out to the plan, is properly integrated with other Case Management programs provided to the fund
    • Provide PPO tracking and reporting
  • Mental Health and Substance Abuse Program provides dedicated patient support to screen and profile patients, and evaluate and assess the given case and assign it to a Case Manager accordingly 
    • Case Manager coordinates care by providing appropriate professional and support group referrals and pre-alerts those professionals or support groups to the patient and his/her needs
      • Follow-up with clinical support staff to confirm diagnosis and approve an appropriate and adequate treatment plan.
      • Negotiate services as necessary
      • Monitor the case on an ongoing basis to ensure adherence to the treatment plan
      • Evaluate and provide referrals for aftercare plan and treatment
      • Arrange pharmacy treatment or intervention as needed
      • Audit claims related to the given case and cross-check all arranged and approved services and fees
      • Coordinate case with permitted family, other healthcare providers treating the patient, and related entities, including, but not limited to state and federal courts and law enforcement agencies, and employer groups
  • Authorization Program is a critical foundation of case management, providing procedural controls to ensure that established medical protocols directly integrate with plan design and benefits delivery – the “hub” for all other case management services
    • Ensures medical necessity is the prevailing requirement of all benefit services
    • Precertification and Prior Authorization procedures provide better management of pre and post service claims adjudication to minimize the opportunity for error and maximize care to the patient and savings to the fund 
    • Intake screenings and profile development
    • Clinical review and assessment of medical records
    • Medical protocol research and application
    • Correspondence with patient and provider documenting agreed upon treatment plans, services, negotiated rates, case updates and monitoring, and the like
    • Coordination with the fund’s retained Medical Director as needed
    • Specialized reporting
    • Interface with claims processing and database systems
  • Special Investigative Unit investigates cases that arise by referral, audit, claims review, and other system-driven flags or identification
    • Claims Suspension Program
    • Apply all investigative techniques at its disposal, including, but not limited to premise visits and inspections, telephonic interviews, medical records review, and NHCAA review
    • Record and document case specifics and notify all parties, in writing, of any fraud case that are built
    • Coordinate NHCAA intervention and assistance, if necessary
    • Render final determination on fraud or abuse and quantify any finding
    • Consult fund counsel, if necessary, and commence recovery actions for findings
Payroll Auditing

As a supplemental service to traditional third party administration, Crossroads offers the following payroll audit services for the purposes of ensuring that the employers have made accurate and complete contributions to the fund on behalf of all eligible members and maximizing the fund’s collections and cash flow:

  • Maintain an accounting of employers that have been audited, the audit periods for which such employers have been audited, and those employers that are yet to be audited;
  • Maintain an accounting of the amount of contributions owed to the Fund as a result of any audits, and any payments that are made in satisfaction of those amounts owed;
  • Schedule appointments with employers for the purpose of inspecting an its books and records;
  • Create and disseminate reports to those employers that have been subjected to an audit;
  • Oversee the process of collecting amounts owed to the fund as a result of an audit, which may include telephone calls, electronic mail, or demand letters communicated to the employer; and
  • Work in conjunction with Fund Counsel to collect any amounts owed to the Fund as a result of an audit whenever legal action is necessary.

In its capacity as healthcare consultant, Crossroads offers the following services:

  • Recommend and design fund and plan structure and the benefits thereunder;
  • Recommend and develop amendments, modifications, or revisions to the plan;
  • Assist in the preparation of all Member communications and disclosure materials;
  • Assist in the development of language to be used in the summary plan description;
  • Provide detailed management reports, on a quarterly basis, of all benefit payments made by, or on behalf of the fund;
  • Prepare and present quarterly comprehensive benefits utilization reports;
  • Assist the Fund’s actuaries, attorneys, accountants, consultants, and/or insurance carriers, in preparation of any necessary federal or state tax returns, reports or disclosures; and
  • Conduct comprehensive bidding, as appropriate, for network providers or other service providers, including, but not limited to discounted fee arrangements or PPO networks for medical, dental, vision, mental health, and pharmacy, and make recommendations for re-hiring or retention of arrangements currently in place.