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Accelerate Progress


From enrollment through risk adjustment, augment your core administration system with additional features to speed processing.


The options you need to extend functionality of your core system, fully integrated and immediately effective.

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:

  • Automate encounter, Risk Adjustment Processing System (RAPS) and risk adjustment data submission.
  • Facilitate interactions between the health plan and Centers for Medicare and Medicaid Services (CMS).
  • Speed up and maximize reimbursements.
  • Quicken response to regulatory changes.
  • Improve acceptance rates.
  • Meet timely submission requirements, reducing the risk of potential CMS penalties.


  • Enrollment Administration Manager and Workflow

    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:

    • Automate member eligibility verification directly with CMS Batch Eligibility Query (BEQ).
    • Generate robust Transaction Reply Reports and CMS edits to improve acceptance rates.
    • Streamline the out-of-area verification process.
    • Gain a clear view of daily enrollment work in progress.
    • Ensure compliance with CMS regulations.
    • Automate the routing and assignment of work items based on specific roles, queues and priorities for issue enrollment and issue resolution.
  • Financial Reconciliation Manager

    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:

    • One system for Medicare Part C and Part D payment reconciliation.
    • Assists management with work assignment, workflow management and discrepancy aging.
    • Ensures that your organization has the necessary tools to remain in full compliance with CMS regulations for financial reporting.
  • Encounter Data Manager

    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:

    • Tracks submitted data, internal pends (scrubs) and external pends (rejections).
    • Has user-configurable Scrub and Business Rule toolkits.
    • Holds claims it would normally reject so the issue can be resolved.
    • Includes an online provider editing tool within the application that can edit encounter provider data on a claim or batch level. 
  • Claims Data Manager

    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:

    • Pre-submission edits to improve CMS acceptance
    • Conversion into RAPS format
    • Creation of batch files for Palmetto Customer Service and Support Centre (CSSC)
    • Loading and reconciliation of RAPS response files 
  • Pharmacy Data Event Manager

    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:

    • Pre-screens records format and content per CMS edit criteria.
    • Creates a CMS PDE file format for records to be submitted. It also tracks and appropriately updates adjustment and deletion records for resubmission.
    • Imports CMS's return files and Drug Data Processing System (DDPS) reply files from Prescription Drug Event (PDE) submissions and updates record statuses and error codes.
    • Allows users to edit and resubmit records from within the application.
    • Provides and manages reports by file, batch, status, error code, plan benefit package (PBP), etc.
  • RX Reconciliation 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:

    • Calculates and reports on each of the following Medicare Part D retrospective reconciliation measures:
      • Low income cost sharing subsidy
      • Reinsurance subsidy payment
      • Risk corridor
    • Harnesses the data processing and tracking capabilities of:
      • Financial Reconciliation Manager (FRM) for prospective revenue reconciliation
      • PDE Data Manager (PDEM) for PDE data processing, submission and management
  • Risk Score 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.

    Features include:

    • Identifies member Hierarchical Condition Category (HCC) and Rx HCC by payment year and data collection period based on a plan’s accepted RAPS and Encounter Data Processing System (EDPS) data.
    • Compares plan's HCC information to CMS information on a member and payment year
      basis to identify discrepancies.
    • Calculates plan’s Part C and Part D risk scores using plan, CMS demographics and HCC data.
    • Identifies claim/diagnosis level RAPS in cases where CMS is missing accepted HCCs/Rx HCCs.
    • Provides detailed risk score and HCC-related management reports.


  • Risk Adjustment Manager

    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:

    • Automates key processes, from assessment of member data through creation of reports that support RADV audits.
    • Manages the workflow related to organizing prospective candidates for adjusted risk scores and requesting changes.
    • Tracks impact of chart audit results on both Medicare Part C and Part D risk scores.
    • Includes a prospective evaluation tool that conducts assessments on members by evaluating their health prior to claims submission.




Comprehensive, flexible and scalable core administrative solutions that enable the digital transformation required for success in the commercial market.

Individual & Small Group

Supports the economic advantage and efficiency needed to administer an individual line of business and participate in public and private insurance exchanges.


Flexible IT solutions to address requirements with customizable functionality.


Functionality that adapts to meet the complexities and demands of the Medicare Advantage market.


Functionality that adapts to meet the complexities and demands of the Managed Medicaid market.


Flexible solutions to coordinate multiple compliance requirements and ease administration burdens.


Business Process Services

Services that offer meaningful, business outcomes.

Business Consulting

Unparalleled healthcare business consulting expertise.

Next-Gen Technologies

Leverage the power of next-generation technologies to build a stronger, agile business.

Infrastructure Services

Services to manage your infrastructure so you can manage your business.

IT Professional Services

Unrivaled resources and healthcare expertise to meet your IT business needs.

Services/Benefits Administration

Software, technology, expertise and proven methodologies to help you manage your business more effectively.



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