IPA Managed Care Management

Web-based business management solutions for IPA, MSO Services, and Managed Care Organizations

Administration

Users

  • Stores usernames and passwords
  • Users are assigned to IPAs
  • Security Settings establish user access rights to programs and reporting

Security Group Permissions

  • Program and database access may be established by groups, i.e., user roles
  • User roles include: Admin, User, Provider, Vendor, Provider & Vendor

Referring Specialist/Vendor Access

  • Referring doctors or vendors may be granted access to your database with a username, password, and security permissions

Member Uploads

  • IPA and Health Plan uploads include: Member eligibility, PCP transfers, PCP uploads, and Health Plan Cap uploads
  • Specialized functionality for CAL OPTIMA health plans
  • PCP uploads and Member downloads- Auto Assignments

Licensure / Departments

  • User-defined licensure and user position/department are stored here

e-Signatures

  • e-Signatures are uploaded to our web servers for use when medical documentation has signature requirements

Care Coordination Lists

  • User-defined lists for use in the Care Coordination module include: Authorization lists for both in-patient and out-patient authorizations; Case management; CCS Management; and Case Tracking & Monitoring

EDI

  • EDI receivers are assigned
  • Submitter Ids are stored and used for preparing electronic claim files
  • Member 270/271 eligibility verification
  • Claims / Encounter 837I and 837P

User-defined preferences

  • Provides user-defined customization of controls for Claim Approval Codes and Specialty Taxonomy Codes

Logs

  • User logs include additions, changes, deletions, general activity for: Logins, Authorizations, Claims, Providers, Members, and User Activity

Authorizations (Out-Patient & In-Patient)

Search Page

  • Approve authorizations from summary list

Review Log

  • Quick list of authorizations waiting for approval by reviewer

IBNR

  • IBNR Reporting

Remote Entry Direct Authorizations

  • Allows remote authorization requests with validation rules in place for Direct Authorizations

Utilization Review

  • Tracks online medical director reviews
  • CCS auto Pend

Claims

Import/Export

  • Import claims from providers and export claims to health plans
  • Import claims from Scanning Service
  • All imported claims adjudicated and set to "To Pay" status
  • Refund System
  • AB1455 letters and reports using ICE standards
  • Claims scrub
  • Export selected claim data
  • Check Void system

Remote Entry by Provider

  • Providers may enter claims remotely with a username, password, and permission

Check Printing to Vendors

  • Checks are paid to vendors, who are linked to service providers or facilities
  • 835 ERA and wire transfer of funds

Export to Financial Programs

  • Explain claims information to bookkeeping software applications

Messages

Intranet Messaging

  • Messages may be sent to and received from any user with permissions to access the messaging system, via the Web Application
  • User defined alerts for UM and Member Svc
  • SSL protection
  • Remote messaging to providers and offices
  • POP3

Databases

ICD-9 Codes

  • A custom library of ICD-9 codes with category and classification indicators
  • Used when requesting authorizations or when adjudicating claims
  • Standard edits
  • Alerts

Procedure Codes

  • A custom library for codes with category and classification indicators
  • Used when requesting authorizations or when adjudicating claims
  • RVU's for Facility and Non
  • ASC groupings

IPAs

  • IPA contact information
  • Default Payment Schedules
  • Preferred Labs
  • EDI settings

Health Plans

  • By Lines of Business: Stores information such as UM/CM Contact data; Eligibility Contact Data; Claim Denial Contact Data
  • Stores Contract Type, Stop Loss Amounts
  • Plan Code Benefit Index by Specialty for both Medical and Dental claims
  • EDI settings

Vendors

  • Checks paid to vendors

DOFRs

  • DOFR data stored by IPA, Health Plan, Contract Type, Revenue Code
  • Used during authorization entry and claims adjudication

Capitation Rate Codes

  • Cap Rate Code data stored by IPA , Health Plan, Provider, and Aid Code
  • Used when paying member capitation
  • Capitation paid by Health Plan
  • Comparison Cap paid to PCP vs. Paid by Health Plan

Providers

  • Provider contact data and working location information
  • IPA Assignments, including contracting
  • Health Plan Crosswalks
  • Credentialing
  • Remote access settings
  • Capitation Tracking by IPA, Vendor, Health Plan

Contracts

  • Stores contracts, which include IPA/Health Plan-specific default Contracts
  • Stores Provider-specific contracting information
  • Used when creating authorizations or when adjudicating claims

Members

Registration

  • Member contact information
  • Current Coverage Summary
  • Member coverage or health alerts
  • Full member uploads all Health Plans
  • Detailed logs

Demographics

  • Ethnic/Race demographic information and employer information

Guarantor

  • Member responsible party information

Coverage

  • Health Plan coverage; IPA history; and PCP history

Capitation

  • Paid Capitation history by IPA, Health Plan, Provider, and Plan Code

Authorizations

  • History of Member In-Patient and Out-Patient authorizations

Claims

  • History of Member In-patient and Out-Patient claims

Care Coordination

  • Components comprising this module including Case Management, CCS Referrals, Case Tracking & Monitoring

Care Coordination – Case Mgmt

  • Case Management functions include: Initial Referral; Referral Evaluation; Initial Assessment; Risk Assessment; Contact list; Initial ICP; ICP Update; Case Manager Notes

Care Coordination – CCS Mgmt

  • CCS Management includes: Historical CCS Referrals; and IPA Referrals
  • IPA Referral includes: CCS Decision and CCS Manager Notes

Care Coordination – Case T & M

  • Case Tracking & Monitoring functions include: Outpatient Surgery; Linked Services; ESRD / Dialysis; Birth Outcomes; HIV / AIDS; Transplant Solid / Transplant Bone Marrow; Synagis Activity; Health Education; and High Cost

Reports

IBNR Standard Report

  • By Member, rendering doctor, referring doctor: Lists services requested and authorization status by authorization date

IBNR Special Report

  • By Authorization Count and Dollars: Tracks date Claim Received; Entered; Paid; IBNR Status; and Current to Over 150 day Lag Time Aging
  • Auto close of IBNR
  • Claims paid to Authorization

Stop Loss

  • By IPA, Health Plan, In-Patient/Out-Patient; and Plan Code

Database Report Writer

  • Allows user to query database for specific data, which may then be downloaded into a comma-delimited format for use in Excel or other spreadsheet productivity program
  • HEDIS reporting - DSH Reports
  • Export of data
  • Import of non claim data