Health Maintenance Organizations (HMO)

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Health Maintenance Organizations (HMO)

• Case Studies

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EDI B to B Platform for Bulk Transactions

• Transactions proprietary format or electronically
• For Batch transactions
• 837 P/I (professional / institutional) Electronic
  Claim files
• 835 Healthcare electronic Remittance advice
  request form
• 834 Enrollment and disenrollment for Medicaid
  eligibility
• 820 Electronic response files for premium
  payments to insurer
• For Real time transactions
• 271 / 272 Member eligibility request / response
  
• 276 / 277 Claim status request / response
• 278 Authorization and Referrals

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Managing Website Portal

• With Regulatory Content for HIPAA Compliance
• Check and / or request member eligibility details
  
• Check claim status
• Provide Authorization (manual approval by the
  HMO) and Referrals (auto approval)
• Provide news updates (e.g. change in lab vendor,
  updates of HMOs related information, etc.)
• Present alerts
• Manage own set of users and provide them with
  respective access rights

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Standard Reports for CMS and Sponsors

• Interaction between the HMO and the vendors like
  the registered pharmacies, laboratories, etc
• Inbound folder generates 834, 820 and 835 files
  to the EDS (CMS represents as the EDS for
  Medicare and ACHA for Medicaid)
• Selects and processes files to outbound folder
• HMO can send active member reports to its vendor
  as a way of outbound file
• The outbound folder generates files to the client
  server application
• The EDI database forms the back end store and the
  EDI console forms the front end store
• Any file can be accessed from the EDI console.

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Medical Research Administration (MRA)

• For Medicare Members
• MRA dashboard with tests and medications of
  patients
• Chart Review of members enrolled through each of
  the listed insurance companies
• Health Maintenance with various screening details
• Care Management for various risk conditions
• Admin Reports
• Role Management

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Online Analytical Processing (OLAP)

• Design a centralized cube
• Suffices the PMPM reports requirement
• Provides for business process improvement to
  identify cost and revenue opportunities using
  data mining
• Various Reports categories
• Membership
• Provider
• Claims
• UM Utility Management / DM Disease management

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Health Risk Assessment (HRA)

• Call perspective Customer service department
  uses this application as an attempt to provide
  healthcare by avoiding the patient to go to the
  provider. Attempt notes are made on the basis of
  first encounter with the member. The invitation
  package is dispatched as a first attempt and the
  follow up is done as a second attempt.
• Health perspective The assessment of various
  possible health related questions is done to
  gather first hand information from the patient
  directly. The customer service department
  evaluates the survey done to access health risk.
  Emphasis is also given on Diabetic patients
  reports

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