MCO Utilization Management Software Simplifies Compliance and Claims Adjudication

Managed Care Organizations (MCO)

Netsmart software for managed care organizations (MCO) helps organizations reduce fraud, waste and abuse. The web-based solution integrates with more than 100 electronic health records (EHR) and electronic visit verification (EVV) apps to aggregate data across providers. As a result, MCOs can check compliance with prior authorizations, verify regulatory compliance and analyze service delivery without time-consuming manual reporting.

Netsmart Medicaid claims adjudication technology uses our business rules engine to pre-screen, scrub and provide all claims submissions in a standard format. The rules engine has the flexibility to support the broad range of services rendered in the home. The solution shows payers which claims match and which need additional information prior to payment. Data aggregation and near real-time processing provide MCOs with financial insights, as well as the ability to manage utilization of prior authorizations, reduce cost of care and improve outcomes.

 

AT A GLANCE

Simplify managing prior authorizations and claims submissions:

Features
  • Web-based solution integrates with 100+ EHRs and EVV apps
  • Supports verification of regulatory compliance and prior authorizations
  • Adjudicates, scrubs and provides claims in a standard format
Benefits
  • Reduces manual reporting
  • Shows which claims match and which need additional information prior to payment
  • Enables MCOs to manage usage of prior authorizations to reduce cost of care and improve outcomes
  • Allows monitoring of network to ensure compliance for clinical and financial aspects
  • Highlights clinical data capture to provide oversight to change in condition measures

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