health maintenance organizations (hmo)

1. Health Maintenance Organizations (HMO) Case Studies

2. EDI: B to B Platform for Bulk Transactions • Transactions proprietary format or electronically • For Batch transactions: • 837 P/I (professional / institutional) Electronic Claim files • 835 – Healthcare electronic Remittance advice request form • 834 – Enrollment and disenrollment for Medicaid eligibility • 820 – Electronic response files for premium payments to insurer • For Real time transactions: • 271 / 272 – Member eligibility request / response • 276 / 277 – Claim status request / response • 278 – Authorization and Referrals

3. Managing Website Portal • With Regulatory Content for HIPAA Compliance • Check and / or request member eligibility details • Check claim status • Provide Authorization (manual approval by the HMO) and Referrals (auto approval) • Provide news updates (e.g. change in lab vendor, updates of HMO’s related information, etc.) • Present alerts • Manage own set of users and provide them with respective access rights

4. Standard Reports for CMS and Sponsors • Interaction between the HMO and the vendors’ like the registered pharmacies, laboratories, etc • Inbound folder generates 834, 820 and 835 files to the EDS (CMS represents as the EDS for Medicare and ACHA for Medicaid) • Selects and processes files to outbound folder • HMO can send active member reports to its vendor as a way of outbound file • The outbound folder generates files to the client server application • The EDI database forms the back end store and the EDI console forms the front end store • Any file can be accessed from the EDI console.

5. Medical Research Administration (MRA) • For Medicare Members • MRA dashboard with tests and medications of patients • Chart Review of members enrolled through each of the listed insurance companies • Health Maintenance with various screening details • Care Management for various risk conditions • Admin Reports • Role Management

6. Online Analytical Processing (OLAP) • Design a centralized cube • Suffices the PMPM reports requirement • Provides for business process improvement to identify cost and revenue opportunities using data mining • Various Reports categories: • Membership • Provider • Claims • UM – Utility Management / DM – Disease management

7. Health Risk Assessment (HRA) • Call perspective: Customer service department uses this application as an attempt to provide healthcare by avoiding the patient to go to the provider. Attempt notes are made on the basis of first encounter with the member. The invitation package is dispatched as a first attempt and the follow up is done as a second attempt. • Health perspective: The assessment of various possible health related questions is done to gather first hand information from the patient directly. The customer service department evaluates the survey done to access health risk. Emphasis is also given on Diabetic patients reports

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