- Claims processing and adjudication
- Claims editing and auditing
- Member & provider contact center
- Billing and disbursements
- Fulfillment
- Enrollment and eligibility
- Broker portal (mPulse)
- Member Portal (mPulse)
- Provider Portal
- Provider data management
- Payment integrity
- Subrogation (OPL)
- Pricing, benefit configuration
- TPA analytics and reporting
- Encounter reporting & Submission)
- Fraud, waste and abuse
- Automated Patient Communication & Reminders
- Letters/Document Management (note that integration exists in ARC CM tool)
- EDI gateway
- OCR / Document Management
- Claims payment configuration
- DOFR Shared or Full Risk
- Specialty Capitation Payments
- Bonus Incentive Payments
- Fee for Service
- Medicare Pricer/Groupers
- Correct Coding Initiatives
- Flat Rates, Percent of Billed Charges, Per Diems
- Process appeals and grievances
- Compliance/Audit Support
- Utilization Management (Intake, Review, MDs, InterQual)
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- Claims, EMR, ADT, pharmacy, lab, SDoH data aggregation & normalization & reporting
- EMR and HIE integration
- Member and provider reconciliation
- Standard and configurable health plan and provider reports, including all required state and CMS reporting
- PCP & specialist benchmarking with episodes – support contracting/payment for episodes/bundles
- Configured Management Reporting & Analytics
- Initiative implementation planning
- Contractual & incentive modeling
- Panel, provider, member level quality care gap, TCOC & HCC chase lists
- Comprehensive integrated medical management, quality, HCC, UM and Auth workflows integrated with HealthAxis Claims Processing/Adjudication
- RPM integration enabling home-based care and hospital at home – critical success factor for D-SNP
- PCP assignment / attribution
- Network adequacy
- Contract Mgmt (Salesforce)
- Credentialing/Recrendtialing
Services:
- Health Plan CEO/COO, CMO, Medical Management Lead and care management team, Finance Lead/CFO and team, Analytics Lead and team, Network lead and team
- Financial management and actuarial
- Provider contracting including various levels and configurations of VBP and in lieu of / CBO services
- Network management and engagement, practice transformation
- Medical management, quality, HCC, total cost of care and leakage
- Behavioral health
- Medicaid revenue optimization through FQHC, BH programs and alignment, as well as DSH/340b/GME medical management and network based steerage
- “Boots on the ground” care team approach supported by best practice ARC platform, EMR/HIE integration , RPM and telehealth options – with highly configurable centralized versus delegated CM options and models
- Marketing/Brokers and benefit design
- Health Education and Wellness – community outreach
- Reinsurance- Aon
Aligned and Integrated Vendors
- Food as Medicine
- CBO Closed Loop Referral
- E-consult and specialty guidelines
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