Our Services
The Advantage360o System provides accurate, reliable, and cost-effective access to Medicare entitlement verification and enrollment.
Our Services include:
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Plans use Member360o web site to verify eligibility for potential members.
- Real-time access to CMS provided data (MBD)
- Multiple ways to access data
- Online (web site)
- Batch (manual upload or automated upload)
- Web Services (XML)
- Reply within two minutes
- Reply provides critical eligibility related data (see Exhibit A)
- Customer Support
Value to Plans:
- Availability of Eligibility System (at least 23.5 hours per day, 7 days per week)
- Flexibility (three methods by which eligibility verification can be done)
- Critical demographic data is provided within the reply that can be used to determine status of eligible beneficiaries and assist Plan in determining how a Beneficiary should be enrolled. Access to this information prior to enrolling the Beneficiary ensures more accurate enrollments and eliminates problems later on. The demographic information supplied on the reply includes data elements such as:
- Medicare Status
- Medicaid Indicator
- Election History to determine Election Limits for the new "Lock-in" rules starting in 2006
- State & County Code
- "Live telephone" telephone during regular business hours Monday through Friday 5:00 am PDT to 6:00 pm PDT
- Knowledgeable support staff will assist users with any questions or problems they encounter with our system
- Also assist in resolving CMS related issues and getting answers to questions that you may be having trouble obtaining at CMS
- Support staff has access to both technical and business knowledgeable staff at CMS and can often get answers faster than the Plans
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Plans use Member360o to edit/validate, and submit enrollment related transactions to CMS. Member360o uses CMS provided edit criteria and MBD validation to determine the status of transactions staged for transmission to CMS. Transactions that fail the edit/validation process are returned to the Plan. Transactions that pass the edit/validation process are transmitted to CMS for processing:
- Extensive edits performed on each transaction using CMS provided Beneficiary information from the MBD
- Plan can expect a 99% assurance that a transaction that passes our edits will pass CMS edits
- Reply available within 15 minutes of submission of transactions
- Any transactions rejected can be corrected immediately and re-submitted
- Multiple ways to submit transactions
- Online (web site)
- Batch (manual upload or automated upload)
- Submission of transactions to CMS
- Retrieval of CMS generated reports and files
- Transaction Maintenance Facility
- Provides for the correction/deletion of transactions submitted during the current month prior to transmission to CMS
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Provides data extracts containing different views of MBD data for current members of a Plan. These extracts can be requested with every new MBD extract received from CMS.
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This process creates a report that groups all of the enrollment related transactions with the weekly and monthly CMS Transaction Reply Reports (TRR). It gives the Plans insight to the status of transactions submitted to CMS and aids in their attempts to reconcile their enrollment transactions submitted to CMS.
Number of Plans contracted for this service: On request. Available at no cost.
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This process enables the Plans to submit Coordination of Benefits information for their members. Plans have two ways in which to get this data to CMS using our services:
- Online - web screen enables real-time entry of COB data
- Plans can upload their file using our web File Transfer Screen.
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Provides the tools necessary to aid the Plan's in the reconciliation of payments from CMS. Recon+ also helps the Plans to remain in compliance with CMS mandated monthly attestation. The service is run on a monthly basis and compares the Plan membership data with CMS Beneficiary data. Any discrepancies found in Plan data and CMS data are reported. Beneficiary payments are calculated and compared to the payments received from CMS. All payment discrepancies are reported as well. A series of reports and extracts are made available to the Plan. The payment received from CMS makes up a very large portion of the revenue collected by the Plans. We help them to ensure that they receive the correct payment for each Beneficiary. Recon+ is used for the medical benefits provided under Part C of the new MMA.
Product Overview
- Financial and Compliance Focus
- Web based - Intuitive Navigation
- No hardware/software costs
- No startup or annual licensing fees or training fees
- HIPAA Compliant
- Can be operational within one month
- Downloadable reports (text/PDF)
- Interface to Integriguard, HCC systems
- Always compliant with all latest CMS directives
- Over 90 MA clients currently use our products
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Provides the tools necessary to aid the Plan's in the reconciliation of payments from CMS. RxRecon also helps the Plans to remain in compliance with CMS mandated monthly attestation. The service is run on a monthly basis and compares the Plan membership data with CMS Beneficiary data. Any discrepancies found in Plan data and CMS data are reported. Beneficiary payments are calculated and compared to the payments received from CMS. All payment discrepancies are reported as well. A series of reports and extracts are made available to the Plan. The payment received from CMS makes up a very large portion of the revenue collected by the Plans. We help them to ensure that they receive the correct payment for each Beneficiary. RxRecon is used for the Prescription Drug benefit provided under Part D of the new MMA.
Product Overview
- Financial and Compliance Focus
- Web based - Intuitive Navigation
- No hardware/software costs
- No startup or annual licensing fees or training fees
- HIPAA Compliant
- Can be operational within one month
- Downloadable reports (text/PDF)
- Always compliant with all latest CMS directives
- Financial information at the Beneficiary level and Plan level summaries
- Can be configured to reconcile even if customer only has partial data available
- Financial reports providing financial outlook - accrual and aging type reports
Part D Payments Tracked
- Direct Subsidy Payments
- Beneficiary Premium Payments & Penalties
- Low-Income Cost-Sharing Payments
- Reinsurance Payments
Part D Discrepancies Tracked
- Beneficiary Demographic and Risk Adjuster Data
- Part D Payment Components
- PDE Data
Direct Subsidy Payments
- Calculate payment for each member
- Bid data & rates
- Age & gender
- Risk Factor
- Risk Factor add-ons
- Risk factor multipliers
- Reconcile calculated payments against MMR each month
- Generate discrepancies in system
Premium Payments & Penalties
- Use LI indicators and FPL level indicator
SSA/RRB/OPM Withhold
- Calculate premium for all categories
- Reconcile when premium file is received from CMS
LICS Payments
- Distinguish between premium/penalty LICS vs. other
- Use PDE data to accrue LICS payments
- Accumulate LICS estimated payments
- Use PDE response file to allocate estimated payments to member
- Reconcile with CMS reconciliation report
Reinsurance Payments
- Use PDE data to accrue Reinsurance payments
- Accumulate Reinsurance estimated payments
- Use PDE response file to allocate estimated payments to member
- Reconcile with CMS reconciliation report
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Revenue360o accepts PDE transactions from the Health Plan or Pharmacy Benefit manager (PBM) and will submit to Palmetto (CMS contracted entity) on behalf of the Health Plan. The PDE file can be uploaded via our web site, or an encrypted FTP connection. Revenue360o will obtain a submitter ID from Palmetto for this purpose, as well as test and certify the file to ensure transmission accuracy. Health Plans can take advantage of the following features:
- Multiple methods for uploading data
- Ability to handle very high volumes of data
- Built in error detection
- Edits increase acceptance rate
- Immediate responses to plan
- Online screens to search & view records
- Reporting tools
- Data Archival, Storage and Security
- Real-time response identifying accepted and rejected transactions
- Resolve PDE data issues more quickly
- Online screens for viewing accepted and/or rejected transactions, and search capabilities
- Reports designed to help plans identify missing response records and understand rejected transactions
- Able to receive files from the Plan or the Plan's Pharmacy Benefit Manager (PBM)
- Multiple methods of secure transmission of the Plan's PDE transactions:
- Upload to Web site via HTTPS (Internet)
- FTP
- VPN
- All response files from Palmetto are transmitted back to the Plan
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Revenue360o accepts RAPS transactions from the Health Plan and will submit to Palmetto (CMS contracted entity) on behalf of the Health Plan. The RAPS file can be uploaded via our web site, or an encrypted FTP connection. Revenue360o will obtain a submitter ID from Palmetto for this purpose, as well as test and certify the file to ensure transmission accuracy. Health Plans can take advantage of the following features:
- Upload RAPS submission through our upload processes
- Submit the RAPS submission file to Palmetto
- Perform basic high level edits against the submission and reject if we find errors
- Send receipt file back to client noting if errors are present or if sent to Palmetto
- Archive files
- Receive return and report files from Palmetto
- Download return and report files back to client
- Wipro or CMS-RAPS format
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