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e4e's
administrative infrastructure services can be provided as
a total turnkey product, or as an unbundled set of service
offerings. Please click on the links below to review our administrative
infrastructure services in more detail..
- Eligibility Tracking and
Verification
- Initial and ongoing enrollment
of groups and members/benefits
- Ongoing maintenance of
group and member demographic data
- Coordination of benefits
including TPL/COB
- On-line provider access
to eligibility and benefits through proprietary Velocity
and voice response technology
- Referral Processing
- On-line referral processing/authorization
services through proprietary Velocity and
voice response technology
- Claims Payment
- Electronic as well as paper collection of claims
- Imaging/OCR and processing of claims
- Adjudication of claims based on eligibility/ benefits/
authorizations/ fee schedules
- Generation of checks and EOP/EOBs
- Administration of opt-out benefit plans (dual and triple
option)
- Provider on-line claims payment status access through
proprietary Velocity and voice response
technology
- Full claims inventory/workflow reporting
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- Capitation file maintenance
and payment processing
- Integrated capitation and
eligibility reporting
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- Quality and Utilization
Management
- Development/implementation
of quality and utilization management programs to NCQA
standards
- Implementation of referral
guidelines
- UM and QM Committee Administration
- Full prior authorization/pre-certification
review process with auto approval or review of all requests
for referral authorization
90%+ authorization turn-around in 24 hours
- Regulatory compliant auto-generated
notices/letters sent to providers/patients
- Case management and concurrent
review of inpatient stays
- Review and tracking of
all member grievances, responses, and intervention
- Comprehensive reporting
of outpatient/inpatient utilization/quality statistics
- Customer Services
- Personalized client toll
free number for immediate connection to customer service
representatives
- Full member services including
member outreach in the resolution of concerns and other
activities
- Customer services reporting
/ trending by product, provider, etc.
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- Provider Credentialing
- Credentialing of all providers,
including primary source verification to NCQA standards
- Provider Contracting and
Relations
- Establishment of provider
reimbursement strategies
- Provider contracting and
system set-up and maintenance
- Provider vendor maintenance
- Development of training
manuals for contracted providers
- Initial and ongoing education
for contracted providers
- Provider profiling/education
- Provider Organization Executive
Management
- Initial and ongoing education
for contracted providers
- Board of Directors/Executive
Committee administration
- Managed care strategy development/implementation
- Payor contracting review
and negotiation
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Routine monthly reports prepared to GAAP standards
on an accrual and cash basis include:
- Balance sheet
- Cash flow statement
- Income statement s
- Capitation/FFS expense
detail
- IBNR Specialized (analytical/statistical)
- Identification, reporting
and reconciliation of out of area costs
- Periodic reports with fee-for-services
versus capitation comparison by physician
- Periodic cost reports be
specialty category, product, PMPM costs and financial
volume
- Reinsurance reporting and
monitoring
- Analysis and determination
of appropriate specialty PMPM capitation rates
- Various claims/encounter
utilization reports
- Risk pool monitoring and
auditing
- On demand customized reporting
using Business Objects™ web-based business intelligence
reporting tools
- Investment options
- Insurance services
- Tax planning assistance
- Provider bonus methodology
development
- Development of compensation
methodologies
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