More on Plexis Software Solutions for PACE Organizations

Plexis Healthcare Systems helps PACE organizations across the country reduce administrative costs and stay ahead of industry changes. Plexis provides automated claims processing, benefits administration and encounter reporting for the nation's largest PACE organizations. Plexis' award-winning Plexis Claims Manager healthcare software provides the tools and flexibility to handle the unique business needs of PACE organizations in today's evolving healthcare environment. Some examples of Plexis Claims Manager's functionality specific to PACE organizations are listed below.

Export RAPs Encounter Data to CMS

Health plans are required to submit Hospital Inpatient, Outpatient and Physician encounter records to CMS. Plexis generates data sets in the prescribed CMS RAPS format from claim records. The claim records carry an indicator that a RAPS record was generated at a particular date and time to avoid generating duplicate records. The person responsible for sending encounter data is able to reset the indicator should re-transmission of a particular claim be necessary. The RAPS encounter information is based on diagnoses. Up to ten diagnosis clusters can be submitted for each encounter. No procedure codes are included.

Plexis also created the ability to reconcile encounter data submissions by importing the RAPS return files and matching them against the original claims, recording line items, which are "clean."

Export Capitation Invoice to State

NYSDOH requires capitation invoices to be submitted in the ANSI X12 837 format. Using Premium Billing functionality, we accurately created a bill based on several tier levels for different rate structures (Medicare, DMS Score, Location, etc). The Premium Bill was used to create a claim and exported in an 837 format.

Export Encounter Data to the State is Required in a Custom Format

Claims data was held in two systems so Plexis created an API and mapped the export from there. The claim lines were marked in Plexis Claims Manager with a flag in order to avoid duplicates sent to the state.

Custom Exports and Imports were created to accommodate various projects that are not required to comply with HIPAA rules. Custom exports and import functionality has included the following:

• Member import into Plexis Claims Manager
• Export financial info to client's accounting software
• Export vendors to client's accounting software
• Export claims info to API
• Export premium bill info to client's accounting software

Surplus is Handled by Creating a Benefit Contract with Member Rate

The member rate is linked in the member file for each member where surplus applies. A premium bill is run on a monthly basis and sent to the member.

Members are Loaded at the Time of Application

Members' eligibility is recorded as a Fee For Service until the state notifies the group of the capitated coverage. The FFS eligibility has limited benefits and can even pend all claims if a group requires manual review. Members have multiple IDs (Medicare, Medicaid, & Medical Record). Plexis Claims Manager handles this in the eligibility line on the member form. It can also be handed on the member form with different plan types.

PCP Assignment Can be a Location

Providers that are capitated can also have a fee for service equivalent contract assigned for contract negotiations.

Provider Fee Schedules include Medicare with GPCI

• Where there are Gap codes, a flat rate was loaded in the fee schedule.
• DRG was handled outside Plexis Claims Manager with the DRG pricer.
• CMS Inpatient Rehab pricing is handled outside of Plexis Claims Manager.

Patient Schedules are Handled in the Referral Form

• This allows multiple providers of services with dates and comments.
• Diagnosis can be handled for current and highest level of specificity. PCM contain rules for the client to select (allow, pend, deny).
• NAMI is handled by entering a negative claim line on the nursing home claim.

Plexis Claims Manager Technology

• True Microsoft system with all of the inherent advantages
• Very conducive to additions to the software -we encourage clients to develop adjunct capabilities to the system. In fact we provide you with the tools and training you need to do this.
• Works with Microsoft Office products today (such as Word, Excel, Access, and Outlook)
• Provides an electronic portal to develop EDI relationships with other systems and companies -accounting systems, trading partners for items like Claims (such as the ability to accept a HIPAA 837 claim from Kaiser), OCR systems, Practice management or EMR packages.

 Learn More About Plexis Claims Manager

Software for Health Insurance Co. • Software for Managed Care Orgs • Software for PPOs, PHOs, IPAs • Software for PACE Orgs • Software for TPAs