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A complete, end-to-end, core capitation adjudication toolset, purpose-built to support capitated payments and their underlying fee-for-service components. Easy to configure, electronic data interchange (EDI), claims processing, provider payment, and overall contract management.
Our Capitation Adjudication application offers a complete suite of tools for managing delegated risk. From contract configuration and eligibility management, through adjudication and payment, it features a comprehensive capability set to administer capitated and fee-for-service payment models. Robust EDI capabilities and support for standard and proprietary data formats ensures continuity between existing systems and the partner ecosystem. We believe our applications are differentiated by their self-service functionality, which keeps overhead at a minimum.
Ensure correct coding, grouping, pricing and payment is administered based on the partner contract. Automatically attach authorizations to the claim, generate letters, auto-adjudicate the claim, and track activity for compliance reporting.
Process fee-for-service claims in addition to capitated claims, with member benefits eligibility and automated authorization and referral workflows, letter generation, and auto-claims adjudication.
Calculate payment and interest, and batch claims for final payment. Verify payment amount by reconciling actual payments with expected payments on a per member per month basis.
Determine eligibility and automate workflows for common authorization and referral scenarios, including denials, appeals, and reviews. Automatically create letters for members and monitor compliance.
An independent physician association (IPA) client faced a challenge connecting and supporting a large, geographically dispersed provider network—comprised of 3,550 physicians and 1,300 Medicare Advantage (MA) providers—with a very diverse patient population. This IPA’s goal was to remain profitable, while improving administrative and care management efficiency in state Medicaid and Medicare programs, and to grow in market share.
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A new generation of payment technology tools is needed to manage today’s complex alternative payment models. Efficient, flexible, and proven, our core payment technology processing tools are purpose-built for value-based payment models. They simplify the contract management and adjudication process for complicated reimbursement structures, including bundled and capitated payment arrangements. Support for common and proprietary data exchange formats and robust interfacing capabilities ensures a seamless integration experience with existing systems and partner ecosystems.
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Together, we are the change. Ready for a demonstration?
Let’s discuss the possibilities.
Act on emerging opportunities to transform operations and improve financial performance.
ExploreThe right solution for your value-based journey is only a click away. Our modular technology is quickly and easily integrated into current systems and complements existing IT investments so that we can grow with you. Learn more today!
