Solutions For Your Medicare Advantage Program

Our Products And Services
Outlined below is a summary of our products and services. Each of these modules/services is available on a stand-alone basis. Additional functionality is also available - ask for one of our product information sheets to learn more.

E*ENRL™ - ENROLLMENT SYSTEM
(PARTS C & D)

This product is designed to cover all the steps required to enroll and disenroll a member. It will include the following functionality:

  • Accept enrollment, disenrollment, correction, 71 and 72 change transactions, including the new Part D elements;
  • Create Transfer Files to send to CMS and load weekly/monthly response files;
  • Generate both pre- and post-CMS member correspondence;
  • Maintain member information to sync with the Plan’s membership/Legacy system (optional);
  • Track member elections to facilitate Lock-In implementation; and
  • Accommodate MA-PD plans, MA-only Plans, and PDPs.

 

E*LOG™ – REVENUE RECONCILIATION
(PARTS C & D)

This product is a revenue reconciliation system for Medicare Advantage plans. It was designed to identify and track through to resolution any discrepancies between what CMS is paying a plan and what the plan believes it should be receiving from CMS.

E*LOG has the following capabilities:

  • Identify down to the member level the cause of all discrepancies (including Risk Score) and the financial impact of that discrepancy;
  • Track by user, the resolution of all discrepancies for a period of 36 months – and beyond if they are not corrected by CMS in a timely fashion;
  • Provide all applicable reports to ensure CMS compliance;
  • Provide operations with a full revenue management and reporting system; and
  • Provide finance with a full revenue management and reporting system.

MMA Changes for 2006 - E*LOG will incorporate Plan-specific bid rates for both Medical and Part D services for each Plan ID (Contract Number) and county for 2006 and beyond; payment rate calculation will be revised to incorporate the Plan-specific bid rates, rebates, differentiation of MA-PD and PDP and MA and Regional/Local PPO plans as appropriate.

We will also accept the Risk Scores calculated by E*HCC™ and incorporate payment discrepancies without flag discrepancies throughout the program.

E*DATA™ MODULE 1 – ENCOUNTER DATA
SUBMISSION & RECONCILIATION
(PART C)

This product submits, tracks and provides the tools to correct and resubmit encounter data for risk adjustment. E*DATA™ Mod 1 has the following capabilities:

  • Provides up-front edits and cleaning of data, returns front-end rejections (before submitting to Palmetto), tracks encounters through all levels of edits;
  • Converts claims from other formats to M+C NSF format and/or UB-92 format;
  • Provides screens to correct all types of rejections and mark for resubmission;
  • Takes plan’s encounter data as submitted to CMS and reconciles it against CMS’s reports down to the member level;
  • Fulfills the requirements for submission of RAPS data for both Medical (Parts A & B) CMS-HCC risk adjustment and for Part D risk adjustment – submits all ICD-9 codes for claims that meet CMS criteria; and
  • Creates tracking, aging and management reports.

 

E*DATA™ MODULE 2 – RISK ADJUSTED
REVENUE MAXIMIZATION (PARTS C & D)

This product helps Medicare Advantage plans maximize their revenue under risk adjustment by providing the tools to identify additional HCCs and related diagnoses at a member level through the analysis of claims and Rx data.

E*DATA Mod 2 includes the following features and functionality:

  • Identifies providers with the greatest potential for revenue optimization;
  • Identifies from claims data diagnoses that may indicate the presence of other conditions that affect CMS payment;
  • Generates reports & correspondence to send back to the provider and determine if there are other diagnoses that should have been coded/included;
  • Maintains a history of a member’s HCCs;
  • Calculates Risk Scores & revenue impacts by member;
  • Provides reports to track the status & resolution of identified suspects;
  • Provides management reports to monitor financial impact of additional diagnoses confirmed and documentation to support audit; and
  • Supplies the necessary data to allow the Plan to submit additional confirmed diagnoses to CMS.

MMA Changes for 2006 – Rx-HCCs: PDM intends to build a new optional module to E*DATA Module 2 that would identify opportunities to increase Rx-HCC risk scores for Part D revenue. This module would include parallel suspect identification, data collection and reporting functions specifically for pharmacy risk adjustment.

E*PRO™ - SPECIAL STATUS
RESEARCH & RECONCILIATION
(PART C)

This product consists of several modules to assist the Plan to identify, research and submit to CMS corrections for discrepancies in the special statuses of ESRD, Institutional, Working Aged and Out of Area/State & County Code.

E*ESRD™: This module tracks all of the pertinent information necessary to research and correct ESRD discrepancies. E*ESRD performs the following functions:

  • Examines claims data to identify all potential ESRD cases;
  • Coordinates and tracks the applicable data from local dialysis centers, ESRD Networks, and the Plan;
  • Submits and tracks corrections to/from CMS; and
  • Interfaces with E*LOG™ to track the amounts due from/paid by CMS.

E*INST™: This module is designed to assist plans to identify and track institutional members. E*INST performs the following functions:

  • Fulfills all CMS requirements for monthly Institutional certification;
  • Automatically verifies Nursing Home Medicare/Medicaid Certification against CMS’s quarterly file;
  • Creates faxes to send to institutions to request information;
  • Tracks responses and calculates institutional status for members, both monthly and retroactively;
  • Automatically creates the required CMS correction transaction (01) file for monthly submission, as well as the IntegriGuard spreadsheets for retroactive changes.

E*WORK™: This module is designed to assist plans to conduct the annual Working Aged survey and report to CMS. E*WORK performs the following functions:

  • Interactive survey form automatically determines Working Aged Status;
  • Interfaces with CMS for CWF lookups to determine members CMS believes are Working Aged;
  • Provides means of verifying MSP coverage with the insurer for members who indicate they are Working Aged or which CMS has as Working Aged;
  • Calculates Plan’s Working Aged factor based on survey results; and
  • Creates CMS response reports to comply with annual submission requirements.

E*SCC™: This module is designed to assist Plans to verify Out of Area members and correct State/County Code discrepancies. E*SCC™ has the following functionality:

  • Loads list of members who have already been sent an address verification letter, and/or obtains OOA Yes and SCC discrepancies from E*LOG™;
  • Creates Address Verification letters to members and records member responses;
  • Prompts follow-up calls and creates follow-up letters;
  • Uses USPS data to calculate SCCs from residence zip codes, then compares these SCCs to Plan Service Area tables to determine OOA;
  • Constructs a complete 36 month Plan SCC/OOA history for valid addresses;
  • Generates files to send to IntegriGuard to correct SCCs as necessary; and
  •  
  • Creates Termination Reports for members to be disenrolled due to being Out of Area or for no response after 6 months from initial OOA notification, or who have confirmed their OOA status.

 

E*HCC - HCC-LEVEL
TRACKING AND RECONCILIATION TOOL
(PART C)

This product will include the following functionality:

  • Identify Plan HCCs based on accepted RAPS data;
  • Compare Plan HCC information to CMS HCC reports to identify discrepancies
  • Isolate claims that support discrepant HCCs;
  • Provide claim level drill-down on member HCCs;
  • Calculate expected Risk scores based on accepted RAPS data:
    • Fiscal Year (per CMS interim data collection periods)
    • Calendar Year
    • Final Reconciliation
  • Provide management reports to track and resolve HCC discrepancies; and
  • Send calculated Risk Scores to E*LOG for payment calculation.

E*RX HCC - PHARMACY HCC-LEVEL
RISK ADJUSTMENT TRACKING & RECONCILIATION TOOL
(PART D)

This product will include the following functionality:

  • Identify Plan Pharmacy HCCs (Rx-HCCs) based on accepted claims data;
  • Compare Plan Rx-HCC information to CMS Rx-HCC reports to identify discrepancies;
  • Isolate claims that support discrepant Rx-HCCs;
  • Provide claim level drill-down on member Rx-HCCs;
  • Calculate expected Rx Risk scores based on accepted RAPS data:
    • Fiscal Year (per CMS interim data collection periods)
    • Calendar Year
    • Final Reconciliation
  • Provide management reports to track and resolve Rx-HCC discrepancies

E*RXEVENT – PHARMACY EVENT DATA
SUBMISSION AND RECONCILIATION TOOL (PART D)

This product/service submits, tracks and provides the tools to correct and resubmit pharmacy claims data. It will include the following functionality:

  • Load and validate pharmacy claims data according to CMS's drug event file format;
  • Transmit this data to Palmetto;
  • Accept and pass on to the Plan the corresponding Palmetto reply reports;
  • Allow users to resolve and resubmit rejected data;
  • Provide management reports to track submissions; and
  • Provide end-of-year totals that will allow users to validate CMS final settlements regarding Reinsurance, Low-Income Subsidy and other reconciliation processes using their own data.

RETROSPECTIVE PAYMENT ANALYSIS SERVICES –
ANALYTICAL AND REPORTING SOLUTIONS
TO RECONCILE REVENUE QUARTERLY (PART D)

Based on accepted drug event data, member demographics and payment information, PDM would calculate and track:

  • Expected Risk corridor costs, thresholds and related payment adjustments
  • Federal reinsurance thresholds
  • Direct Subsidies
  • TrOOP (true out-of-pocket cost)

For more information on any of the above products and services, please contact Stephen Jackson.

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