Claims & Benefit Administration

Cedar Gate’s EZ-Suite is the software solution for payers and healthcare organizations taking delegated risk that need a complete end-to-end technology to manage operational and administrative processes. EZ-Suite is the only comprehensive software solution delivering a highly configurable, scalable, and flexible platform supporting multiple lines of insurance business, including Medi-Cal, Medicaid, Medicare Advantage, Carve-Out, and Commercial populations.

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Capabilities of EZ-CAP

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Support a variety of models

It is challenging in today’s market to manage an array of existing models while embracing emerging value-based models. EZ-CAP® has the flexibility to easily configure and maintain multiple lines of business in one seamless infrastructure.

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Benefit from Intelligent Automation

A highly regulated environment can only be successful with smart automation for auto-adjudication and workflows. By maintaining history for every transaction with role-based security, EZ-CAP enables you to compete and lead in highly competitive markets while staying compliant.

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Experience the Efficiency of Integration

EZ-CAP’s comprehensive set of integrated capabilities meets all critical risk-based needs. It spans eligibility and benefits, DOFR, providers and contracts, an unlimited array of payment and capitation models, care and utilization management, and member and provider customer service, including a provider portal and powerful, graphics-driven analytic support.

Core Components
of EZ-CAP

Focus on member and provider experience with operational efficiency, cost reduction, and quality of care.

Eligibility and Member Management

You get all pertinent member data in one place, including:

  • The ability to set QuickAlerts for member-relevant information
  • Configurable user-defined fields to customize data capture and workflow
  • Full utilities for PCP, PCF, plan affiliation and enrollment, and member opt-in/out privacy options for all communications

EZ-CAP functions as a highly configurable single source of truth for benefit plans. It streamlines administration and maintenance across multiple lines of business through unique user-configurable categories. You get the flexibility to configure your ever-changing business, enabling you to grow faster.

A single provider ID enables the management of multiple contracts. You can leverage box 32 to determine the location for payment and use Geo-Adjust Payment to adjust payment by carrier or locality. Integrated document management enables you to store electronic copies of signed Provider Agreements and manage multiple addresses and configurable plan affiliation.

Take fee schedules to the next level. With EZ-CAP, you can adjust data based on geographical location using box 32 and implement automation to have multiple contracts and service locations under one provider ID.

EZ-CAP’s powerful capitation provides complete flexibility to determine how best to pay capitation, including:

  • Age
  • Gender
  • Condition code
  • Primary Care Physician
  • Primary Care Facility
  • Contact capitation
  • Percentage of premium
  • Risk-adjusted
  • Tiered physician membership

Specialty capitation can be paid based on specialty pool, line of business, health plan, health plan/option, service area, or any combination. And you can configure retroactivity to meet your business rules.

You can realize increased operational efficiency with a customizable configuration of auto-adjudication, including the use of user-defined, labeled, and formatted fields. File off of 837 and push to payment or create a workflow with a specific data element.

EZ-CAP enables you to increase incentive payments by using a customization built to support the Bundled Payments for Care Improvement (BPCI) initiative. We make this process simple so you can focus on delivering quality patient care.

Electronic Data Interchange

Harnessing the Value of Your Data

Our EZ-EDI product offers the latest advancement in electronic data interchange (EDI) to easily retrieve information and perform transactions in real time directly into EZ-CAP – without going through a clearinghouse. With the complexities of today’s HIPAA EDI formats, EZ-EDI is designed to reduce the time and effort it takes to implement an EDI solution. HIPAA formats are not uniform, requiring multiple modified forms of the standard data sets. While most vendors require expensive custom maps that are difficult to decipher and translate, EZ-EDI puts the power of graphical mapping into your hands. With a simple drag-and-drop feature, you can easily map inbound and outbound HIPAA standard files to and from your EZ-CAP data sets. The in-loading and processing of these files can be automated to virtually eliminate manual interaction, increasing productivity and reducing human error.

Inbound Processing

  • Supports HIPPA x12
    • 270/271
    • 276/277
    • 278
    • 834
    • 835
    • 837P, 837I and 837D
  • Support for both HTTPS and SFTP file submission
  • Includes EZ-Cap Proprietary Formats for easier construction of eligibility, authorization, initial claim and paid claim in-loads
  • Track and report on Inbound and Outbound files
  • Easily search by Transfer Mode, Transaction Type, Receipt Dates and others
  • Visually identify parsing success and status
  • Quickly track the status of inbound transaction batch processing and posting
  • Authorization, Eligibility and Claim Processing
  • Drill down into batch detail
  • Launching page for error review and correction
  • Real time view into inbound batch details
  • At-a-glance batch summary
  • Batch summary by provider
  • Detail reporting at all or individual status levels
    • Processed
    • Validation Errors
    • Posted
  • User friendly interface for reviewing and correcting validation errors
  • Clear error descriptions
  • Hot links move directly to the error for quick correction
  • Color changes from red to green if correction made
  • Bach correction can apply a single change to all similar errors within the batch
  • Schedule and generate outbound transactions for
    • 834
    • 837
    • 278
  • Extensive selection criteria to include or exclude only the data you want to send
  • Additional outbound transactions supported
    • 271
    • 277
    • 835
  • Receive and translate transaction response files into a user friendly format
  • Correct and resubmit rejected data
  • Hotlink to source record in EZ-CAP
  • Customize inbound and outbound transaction maps
  • Conform to companion guides without programming
  • Drag and drop interface
  • Powerful data manipulation capabilities for transforming data

Grouping/Pricing Integration

This integration bridge generates accurate, complete and compliant coding in a sophisticated, yet easy-to-use with any selected grouping or pricing tool. Pricer Connect drives speed and flexibility using a batch and individual claims processing option for coding and reimbursement integrated into EZ-Suite. With the frequent changes in payment rules in today’s dynamic healthcare reimbursement market, staying up to date is crucial. Cedar Gate makes it possible with flexible options to drive compliant grouping and pricing.

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Provider Portal

Complete Provider Satisfaction

EZ-NET is an [ST2] internet portal that facilitates timely, cost-effective sharing of clinical and administrative information between a healthcare organization, network providers, and health plans. By communicating and performing administrative tasks via EZ-NET, you expedite information flow and improve data accuracy. Important information is made accessible in real time via the internet without compromising security, putting critical data where it is needed – in the hands of providers – while ensuring a frictionless patient experience.

Allow your providers to attach documents to an Authorization, including (but not limited to):

  • Chart Notes
  • X-Rays
  • Lab Tests
  • Communicate via Notes between external Providers and internal UM Personnel
  • Auto-Approval Tables provide immediate Approval & Letter

Universal API

Aligning Client Needs By Exposing Access to Cedar Gate’s Internal Applications

EZ-PARTNER enables software vendors to interface existing systems with EZ-CAP. This Application Programming Interface (API) is an expert modification tool for developers to format request and response file transactions. Vendors continue to offer users one point of entry through their systems while seamlessly integrating the EZ-CAP managed care capabilities with no visible transitions.

Cedar Gate’s application-driven API approach leverages security to establish a trusted connection, data selection to ensure queries for necessary information and data response scope, and return format to maximize automation and provide the highest value.

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Serving

payers

Payers

Manage risk more effectively and obtain greater value for every healthcare dollar.

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providers

Providers

Act on emerging opportunities to transform operations and improve financial performance.

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employers

Employers / ASOs

Recognize high-value innovation opportunities in healthcare with our help.

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Discover More

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EZ-EDI – Administrative Simplification

Harnessing the Value of Your Data

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EZ-CAP – Core Administration

EZ-CAP is part of a comprehensive software platform…

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EZ-NET — Provider Portal

Streamline with Provider Self-Service

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EZ-PARTNER

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SOLUTIONS

Cedar Gate’s enterprise performance management analytics and administration platforms reduce risk, enhance financial performance, and improve patient outcomes for healthcare organizations across the value-based care continuum.

Enterprise Data Management

Capture, organize, and utilize all valuable data sets securely and easily.

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Empower your team with timely information to take action and reach performance goals

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Transform the way you report on your business with these intelligent tool sets.

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Support medical management activities across the care continuum.

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Manage patients effectively from chronic conditions to transitions of care.

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Administer retrospective and prospective bundled payment arrangements with clinical excellence.

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Operate multiple lines of business with claims and benefits administration, eligibility, capitation reconciliation, financial management and more.

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Extend your effectiveness with managed, professional, or advisory services.

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