Credentialing

Tracks all aspects of the clinician credentialing process in accordance with NCQA standards. It includes primary source verification and follow-up letters; certification/licensure compliance and periodic renewal tracking. Also included is an extensive data set of clinician demographic, professional education and training, publication, and curriculum vitae information.

Member Services

Manages customer service functions for quick access to member's eligibility, benefits, referral, and authorization data, as well as member-initiated and staff-initiated phone calls, correspondence, faxes, and pages. Member inquiries, complaints, and grievances are monitored in accordance with NCQA criteria.

Referral System

Matches managed care members to credentialed network practitioners, provider groups, and clinical facilities using a wide range of credentials data, including clinician demographics; preferred modality or intervention; aggregate outcome measures; indicators of clinical competency; patient satisfaction profile; clinical training; education; licenses and specialties.

Provides geo-encoded address data for network practitioners, provider groups and clinical facilities and displays their location on a detailed map to facilitate referral of members to a provider within a contractually-mandated distance.

Call Center/Triage

Handles calls from members and providers and acts as the front door for Member Services and Provider Relations. A snapshot of eligibility, a quick risk assessment, and scheduling a follow up contact are all at a care manager's fingertips.

Care Management

Enables care management staff to track member-initiated and staff-initiated contacts, with automated reminders to prompt care managers for a timely response. Tracks requests for information, in- and out-of-network referrals, complaints, billing, and authorization inquiries. Utilization reviews can be automatically triggered at scheduled times and/or at time of service, at pre-established periods, or on an on-going basis.

Provider Relations

Facilitates provider network management functions by tracking all contacts between staff members, practitioners, provider groups, and clinical facilities, with particular attention to clinician and member-initiated complaints and grievances. It supplements the credentialing dataset with provider satisfaction surveys, referral targets, and provider contract management.