| For medical, dental, vision, prescription drugs, and other health-type plans, managed care can be critical to benefit design and overall product success. For a full array of products, our software solutions offer the availability of managed care support for the development of provider networks, fee schedules, discounts, benefit plan provisions, pre-authorization, pre-certifications, and other features.
Administration Capabilities Ability to design policies that work in tandem with a designated provider network, or multiple provider networks assigned. Flexibility to enroll groups or individuals to a selected provider network or a combination of networks. Start and termination dates for eligibility of providers. Set-up of requirements for pre-certifications, cost-containment provisions, and other user-defined actions. At the insured and dependent levels, the ability to allow selection of primary and secondary providers, and hospital affiliation. Claims Capabilities Claims plans may be designed for standard, dual and triple option schedules with reciprocal benefit provisions. Support for both co-insurance and co-pays. Automatic adjudication of benefits based on provider relationships. Ability to assign provider to multiple networks, and unique payment arrangements or "deals." Deals by fee-for-service less discount amount or percent, by scheduled benefit amount for service, by per-diem, and other arrangements. Automatic load of network provider lists and schedules or fees. Flexibility for providers within a clinic to participate in different deals. Dental pre-estimates, hospital pre-certifications with availability for extensions, and other review features. Nurse reviewer notes, diagnosis, prognosis, objective and subjective findings, and other critical data. For long term care, capture of ADLs and SPMSQ score.
Provider problem indicators. Availability for automatic calculation using lowest price negotiation when multiple contracts available. Quick-pay discounts instead of or in addition to standard arrangements. User definable reasonable and customary allowances. Comparison of preferred fee against standard reasonable and customary charge. | |
