| As part of our overall approach to health benefits administration and claims adjudication, Apex Data Systems also offers support for managed care and hospital pre-certification. With these special features, you maintain flexibility in plan design and gain the greatest level of control in the management of your point-of-service, PPO and EPO dual- and triple-option healthcare and hospitalization programs.
Administration Capabilities
Using the data structure of our enrollment hierarchy, the special managed care features offer greater flexibility for cost containment options tied to the group or individual. All of the standard administration features are offered including enrollment, billing, collection, pending, correspondence, agent maintenance, and reporting, plus additional functions designed especially for managed care programs. These features include: A dynamic enrollment structure that allows for integration with special managed care processes such as the hospital pre-certification options for patient static information including relation to insured, patient code, date of birth, and gender, plus employer verification. Flexible billing features including the ability to capture multiple coverages per insured or an array of managed care products per group, giving you the opportunity to process multiple HMO, PPO or other healthplan specialties. Open selection by insured of primary and secondary providers along with a designated hospital affiliation. Customization options to include provider affiliation data and pre-certification phone numbers on ID cards, and as part of eligibility output. Rating discount factors for preferred plans. Notepad medical history that can be maintained for verification during investigation of pre-existing conditions, rescission of coverage if necessary, and for free-form diary notes. Design and maintenance of any number of provider networks, each with the capability for almost limitless negotiated contracts. Primary care providers and specialists can each be associated with the appropriate "deal." Ability to tie individual policyholders and groups to an unlimited number of networks and contracts so that you can offer multiple financial arrangements under the same plan, and can easily cover wide ranges of territories. Claims Capabilities
The Utilization Review menu is the entrance to the various managed care features available as add-on modules to the claims adjudication system. Global features such as online eligibility verification, pending and correspondence modules, online adjudication by user-defined plan tables, issuance of multiple payments to the insured or multiple payees, detailed claims history, actuarial and lag studies, premium/claims analyses, and other reports are all part of our total solution. PPO and EPO options augment medical, dental, prescription, vision, and other health plans. In addition to Hospital Pre-Admission Authorization, other cost-containment programs can be added such as Concurrent Review, Second Surgical Opinion, Case Management, and Utilization Review Reports.
Some of the available features available with U.R. include: Acceptance of the initial pre-authorization request with documentation to the file. Claims adjudication office codes allowing entry of data for multiple processing sites. Capture of objective and subjective findings including interpretation of multiple diagnoses with ICD codes and descriptions offering data for detailed reporting. Special maternity and newborn information. Attending physician data including treatment plan, CPT, procedure description, and the indications calling for the procedure or admission, so as to assist with authorization and ultimately a length of stay assignment, if applicable. Hospital admission information including the ID of the admitting physician, ID of the admitting hospital, reason for admission, admission type, expected date of admission, and whether there was a previous admission for the same diagnosis. History of supporting services utilized such as 2nd opinion information or pre-admission testing. Capture of proposed convalescent time and requested length of stay, plus approved and actual LOS, to allow both prospective and retrospective reviews. Dates for action including discharge date, authorization date, and extension date. Capture of nurse reviewer and free-form notes.
Extension of stay and concurrent reviews. A correspondence system allowing you the flexibility to establish letters and automatic follow-ups based on user-defined parameters. User-defined claims plan setup allowing for dual- and triple-option deductible, coinsurance, co-pays, and other provisions. Capture of contract service discounts, schedules, quick-pay discounts, daily allowances, and other calculation parameters by PPO/EPO network and contract. | |
