Managed Care
Our MCO solution enables managed care organizations to collaborate with service providers to enroll clients, confirm eligibility, submit, process, and adjudicate claims, and receive funding for services. Optimizing the workflows shared between MCOs and their provider networks reduces administrative burden and allows providers to focus more efforts on person-centered care.
Improve workflows with our complete system that allows MCOs to:
- Enroll clients, manage enrollment documents, and perform eligibility checks
- Maintain a list of rendering provider staff and allow them to upload/download billing documents
- Enter claims manually or electronically to be billed to Ohio MITS and all Medicaid Managed Care Plans
- Process and adjudicate non-Medicaid claims according to pre-set or custom rules
- Allocate funding sources in the correct priority to pay non-Medicaid claims
Key Functionality
Enrollment and Eligibility
MCOs can both create new enrollments and update existing enrollments. The system allows users to collect additional information, such as monthly income or family size, needed to submit a claim, plus validate and approve a client enrollment before claims are submitted. Agencies can easily see the status of enrollments, such as submitted or pending. They can also identify changes that have been made and use them to update Payer Spans and Master Enrollments.
Claims Processing and Adjudication
Provider claims can be entered manually or submitted electronically using an 837 billing file. The system can process and adjudicate both Medicaid and non-Medicaid claims and uses a library of over 100 Benefit Rules and code sets to help agencies correctly pay for claims submitted by their providers. Providers can also reverse and rebill claims.
Customization
Each customer has their own system that can support all their providers and can be customized to best service their needs in regard to:
- Funding selected services for their contracted providers
- Ensuring a client needing services is eligible
- Applying sliding fee copayment based on income and family size
- Applying funding sources to pay for claims
- Reporting claim usage and utilization
Reporting and Analytics
A data warehouse can be purchased to provide a comprehensive overview of data from different sources. It can find the most important data, display it in one place is an easy way to understand, and assist in making data-driven decisions. MCOs use the dashboard to show measures on enrollments, claims, service code usage, agency contract usage, diagnosis usage, funding sources, and any other data they want insight on.