> AG: Appeals & Grievances Module

Transcription

1 > AG: Appeals & Grievances Module /Auth Systems Portals Document Management Authorizations Member Services Scanners Employer Groups REGULATORY GUIDELINES User Defined AG MODULE Create Appeal or Grievance Establish Priority Link to Claim or Auth Tasks Automatically Created Attach Documents Route to Others Make Determination Escalate to Maximus or Further Review Unlimited A&G Types for Members and Providers and Lines of Business Turn Around Time Tracking Resources Manage Appeals & Grievances according to Regulations Efficient routing of cases for any department in the organization Supervisory reporting to ensure compliance

2 > CM: Care Management Module Pharmacy Labs CM MODULE EHR/ADT Analytics Portals Guidelines Patient Education Messaging QUALITY GUIDELINES NCQA Evidence Based A Attach Identify/Stratify Documents Care Plans/Tasks Meds Reconciliation Alerts Security/Roles/Queues Programs Care Plans/Tasks Member Contact 360 View of Member / Report Builder Patient Education Patient Engagement Automated care plans tailored for each patient/member Efficient routing and collaboration of cases and interventions across the continuum of care (internally and externally) Complete clinical and administrative documentation

3 > CS: Customer Service Module Benefits CM/UM/PM Portals Phone System Data Warehouse Document Management CRM System Medical Management CS MODULE Take call or greet walk-in member Create a new call/issue for a member or provider Document Issue Look up information Document notes Attach documents Route issue to appropriate department Provide info to member or provider 360 View of Member Resources One-stop shopping portal for Customer Service reps Immediate answers for members and providers Eliminates the need to look in multiple systems for information

4 > PM: Population Health Management Module EHR/ADT Analytics Labs Pharmacy Analytics Hospitalizations PM MODULE Patient Education Messaging POP HEALTH GUIDELINES Unlimited Client Business Needs HEDIS Identify Build Campaigns Automated Member Outreach Security/Roles/ Queues Attach Documents Alerts Tasks Member Contact 360 View of Member /Report Builder Patient Education Target at-risk populations for intervention Develop worklists for any department Automated member correspondence

5 > UM: Utilization Management Module Guidelines Pharmacy Labs UM MODULE Document Management Portals Messaging QUALITY GUIDELINES NCQA InterQual MCG Create Authorization Apply Rules Medical Necessity Attach Documents Authorization Routing Make Determination Send to Authorization Classes Rules Engine Integrated Guidelines 360 View of Member Resources Manage hospitalizations with inpatient review Workflow tightly integrated with quality guidelines Automated authorization and compliance

6 > A 2 : Advanced Analytics Module A 2 MODULE Pharmacy Provider Network FOUNDATION Johns Hopkins Adjusted Clinical Groups (ACG) NYU Avoidable ER algorithm, developed with the Robert Wood Johnson Foundation FEATURES Customizable Dashboards and Homepages Drill Down Metrics Bookmarkable Views Member Dashboards Predictive Analytics based on Johns Hopkins ACGs HEDIS Measures Population Health Management HEDIS Management Tool Gaps in Care Cost and Utilization Savings Opportunities Capitation Leakage Provider Performance Metrics Hospital Cost & Utilization Admissions & Readmissions Avoidable ER Maternity Analyze clinical and financial population data with a multi-stakeholder approach Reduce costs per member with actionable analytics Drive behavior change

7 > BI: Business Intelligence Module Case Management Appeals & Grievances Utilization Management Population Management External Data Sources Enterprise Data Warehouse BI MODULE Customizable Dashboards User-friendly Report Builder Charts Gauges Pivot Tables Scheduled Delivery Ad Hoc + Saved Reports Inventory Trends Productivity Management Dashboards User Dashboards Highly configurable BI tool that doesn t rely on IT to support Knowledgeable management and user base

8 > P 2 : Provider Portal Module Pharmacy Labs P 2 MODULE EHR/ADT Guidelines HIE/Data Warehouse Document Management QUALITY GUIDELINES NCQA Evidence Based My Panel Case Summary Tasks/Interventions Prior Authorization Attach Documents 360 View of Member Care Plans/Tasks Problem List / Correspondence Member Contacts UM Auths and Referrals Links to Resources Coordinate care across the continuum Participate in ACOs, PMCHs and s CCM Program Securely exchange HIPAA-compliant documentation Auto adjudication of auths/referrals