CareManager

Network and Contract Management Software Solutions For Payers in the Health and Human Services Industry

Managed Services, our payer solutions software, is a uniquely adaptable system built to serve the specialized needs of states, counties, Managed Care Organizations, specialty networks, and providers attempting to carefully monitor both at-risk and non-risk contracts. Whether looking at costs by network provider or using the service authorization functions to effectively manage the care provided within your network, we can help you with:

  • Network Management
  • Contract Management
  • Service request management
  • Authorization
  • Capitation (PMPM) revenue management
  • Costs by CPT codes, physician, patient or period
  • Claims adjudication and payment calculations based on negotiated fee schedules
  • Multifaceted contract tracking
  • Integration with electronic claims
  • Payment and/or GL/AP systems

Enrollment

Member status and eligibility verification are entered into the system to begin the enrollment and service process. Eligibility for one or more payer sources are verified and entered into the system either via automated loads or manual data entry.

Screening

Member requests/needs are assessed and evaluated during the screening process to determine the appropriate level of care.

Service Authorization

With payer solutions software, authorizations are linked to Benefits or Contracted Services in the Contract function. Authorizations are referenced for claims adjudication/review, calculated in accumulators for Incurred but not received (IBNR), and reporting on utilization and profitability.

  • Records and tracks authorizations for member services
  • Automatically assigns authorization number
  • Selects benefit through link between Member Plan Assignment
  • Authorizations and contracts with specific plans

Care Management and Coordination

This function allows the user to perform care coordination on an individual member to determine continued level of care required, document notes, and monitor review dates. Authorization extensions are also performed in conjunction with transitions of level of care.

Claims Processing

Claims data is received via industry standard formats and adjudicated in real-time. Our eligibility verification process provides assurance that you can be confident that the care your network is providing is being done according to policies and standards that are in place.

To learn more about our payer solutions, contact us today.

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