For medical, dental, vision, prescription drugs, and other health-type plans, managed care can be critical to benefit design and overall product success. For a full array of products, our software solutions offer the availability of managed care support for the development of provider networks, fee schedules, discounts, benefit plan provisions, pre-authorization, pre-certifications, and other features.

Administration Capabilities

• Ability to design policies that work in tandem with a designated provider network, or multiple provider networks assigned.
• Flexibility to enroll groups or individuals to a selected provider network or a combination of networks.
• Start and termination dates for eligibility of providers.
• Set-up of requirements for pre-certifications, cost-containment provisions, and other user-defined actions.
• At the insured and dependent levels, the ability to allow selection of primary and secondary providers, and hospital affiliation.

Claims Capabilities

• Claims plans may be designed for standard, dual and triple option schedules with reciprocal benefit provisions.
• Support for both co-insurance and co-pays.
• Automatic adjudication of benefits based on provider relationships.
• Ability to assign provider to multiple networks, and unique payment arrangements or "deals."
• Deals by fee-for-service less discount amount or percent, by scheduled benefit amount for service, by per-diem, and other arrangements.
• Automatic load of network provider lists and schedules or fees.
• Flexibility for providers within a clinic to participate in different deals.
•  Dental pre-estimates, hospital pre-certifications with availability for extensions, and other review features.
• Nurse reviewer notes, diagnosis, prognosis, objective and subjective findings, and other critical data.
• For long term care, capture of ADLs and SPMSQ score.
• Provider problem indicators.
• Availability for automatic calculation using lowest price negotiation when multiple contracts available.
• Quick-pay discounts instead of or in addition to standard arrangements.
• User definable reasonable and customary allowances.
• Comparison of preferred fee against standard reasonable and customary charge.