A Comprehensive Revenue Management System for Payers
Recon+ (Part C) and Rx Recon (Part D) enable you to reconcile CMS monthly membership and payments to Plan membership and system calculated plan expected payments. Reports are produced to identify and correct enrollment, demographic, and payment discrepancies. CMS adjustments and Plan adjustments are processed to resolve the discrepancies.
Online-screens, batch reports, and extracts are available for your reference and audit purposes. Our Revenue360 tracks CMS and Plan payments and discrepancies at the Plan, PBP, and member level. Account receivables extracts can feed your financial system directly.
RA-Expert, which is driven by Recon, tracks current HCC status from RAPS submissions and performs financial impact analysis of HCC-related financials, providing financial projections at both the Member and the Plan level. Historical HCC information is maintained and presented for comparison with the current HCC status. RA-Expert also provides a RAPS audit trail for clusters that produce HCCs.
RA-Expert groups HCC data by payment year, including payment projections for the next payment year based on current year RAPS submissions.
Annual Reconciliation process reconciles previous and current year's estimated payments compared to the Plans actual PDE information.
RAPS-Expert processes claims data, editing for acceptable sources and reformatting edited data into RAPS format for submission to Palmetto.
RAPS-Expert prevents duplicate cluster submissions while tracking the source of the duplicate clusters. Common enrollment timing errors are held in suspense and flagged for automatic resubmission once the member is recorded as enrolled. Member and claim information can be viewed online, with all sources of data for a RAPS cluster cross-referenced back to their originating source.
EDPS ( Encounter Data Processing System) is a CMS and HIPAA compliant 5010 claims encounter processing system. EDPS uses existing claim formats and sends them through an Extract, Transform and Load (ETL) processing to produce CMS-compliant outbound 5010 encounters.
EDPS receives your files, transforms the data, and transmits edited 5010 encounters to CMS. A custom extract of CMS responses is created, identifying named errors in plain language for easier correction, and formatted for use in a correction and resubmission workflow system.
