Meeting the complex data processing and compliance requirements of Medicare Advantage, managed Medicaid and Commercial Exchanges in a timely manner is critical to your company’s success. Our Elements suite of capabilities extends the functionality of your core system with the features you need, providing critical capabilities from enrollment through risk adjustment, to efficiently administer these lines of business.
These standalone products integrate well together, as well as with our core systems Facets and QNXT. With the Elements integrated products, it is much easier and faster to share information and speed processing.
With Elements you can:
Ensuring that members are eligible to enroll and that health plans have all required data to support that enrollment requires a lot of communication and documentation among health plans CMS. The Enrollment Administration Manager, along with the workflow capabilities of Enrollment Administrative Manager Workflow, support health plans all along the path from enrollment to acceptance.
Enrollment Administration Manager automates workflows to streamline the many steps in the process toward Medicare Advantage enrollment. Moreover, Enrollment Administration Manager is constantly updated to reflect CMS regulatory changes, and can pass data to both Facets and QNXT, making it a critical part of a complete solution. The workflow capabilities help manage the overall enrollment process, improving visibility and tracking throughout the enrollment lifecycle.
With Enrollment Administration Manager and Workflow, you can:
Reconciling the amount you have been paid by CMS with the payments received in your system is a monthly task required of every health plan with a Medicare Advantage component. When it goes smoothly, it is a routine task that requires little thought. However when the numbers do not match, the work gets harder and health plans must do whatever it takes to research and resolve discrepancies.
Financial Reconciliation Manager (FRM) streamlines and automates this process, comparing plan and CMS membership data to calculate payments and flag discrepancies. The system prioritizes inconsistencies with the greatest financial impacts and provides key reports and data to resolve discrepancies quickly. Other features include:
Collecting the data relevant to a specific claim from both core and ancillary systems, as well as reviewing charts and other information sources are critical to satisfying CMS, various state agencies and Exchange Encounter reporting requirements. Properly formatting the information in a way that is acceptable to CMS and state agencies is important as well. Encounter Data Manager (EDM) collects all of this data and automatically transforms it into the required format for submission. Along the way, it manages the entire encounter submission and response file process. EDM also:
CDM is a solution that streamlines and simplifies a health plan’s requirement for submitting timely RAPS data for Medicare Advantage member. More specifically, CDM supports the RAPS process by processing, filtering, formatting and submitting claims data to CMS for Medicare Advantage.
CDM performs these tasks:
When a pharmacy vendor sends a health plan a list of Medicare Advantage claims rejected by CMS, it is often time-consuming and cumbersome to sort through the issues, determine the reasons for rejection and correct them for resubmission. Pharmacy Data Event Manager automates the workflow around pharmacy claim rejections from CMS, providing a clear view into the type of rejections being received and ensuring they are corrected.
Pharmacy Data Event Manager:
Without full visibility into payment and reconciliation activity of Medicare Advantage Part D, it is difficult to determine whether you have overpaid or underpaid for your members’ drug coverage. Rx Reconciliation Manager is a tool you can use to fully understand both your financial and reconciliation activity and that of CMS with regard to Part D. With this visibility, your plan can better anticipate payment adjustments and make changes for Part D benefits in the future.
Rx Reconciliation Manager:
Understanding how your members’ risk scores may change over time is critical to forecasting how CMS payments to your health plan will change. Risk Score Manager analyzes data submitted by Claims Data Manager and Encounter Data Manager and calculates the risk scores your health plan can expect to be reimbursed for based on the diagnoses submitted to CMS. It then reconciles those scores against monthly CMS data on reimbursement scores and payments—by member—from the RAPS response files. With Risk Score Manager, health plans gain visibility into risk scores, which allows them to better forecast payments over CMS payment periods.
Often, the risk score assigned to specific members remains the same over time, even if those members may have acquired additional conditions. A diabetic, for example, may be at increased risk of heart disease. Risk Adjustment Manager (RAM) runs a series of algorithms to identify possible additional diagnoses that are appropriate for members based on their claims history. With that information, health plans can take action by understanding if additional diagnoses have been made via their providers. Armed with that information, health plans can request CMS to adjust risk scores for specific Medicare Advantage members.
Risk Adjustment Manager also:
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