Accounting

Plexis Claims Manager divides the Accounting function into two processes, Payables Batches (payables), and Receivables Batches (receivables).

Use the Payables Batch form to close Adjudication, Capitation, and RVU Capitation Runs and send their run results to Accounting. The form displays basic data about each run, and you can double click on a run to view the appropriate Adjudication, Capitation, or RVU Capitation Processing form for the run.

The Receivables Batch identifies a set of Billing Runs (Premium Billing) to export to Great Plains Dynamics. When the Close Receivables button is pressed, the system gathers all the billing lines from all the Bills in the Billing Runs that are assigned to the Receivables Batch and marks the lines for batch import to Great Plains Dynamics as Accounts Receivables documents. Receivables Batches generate bills for all Benefit Contracts associated with all Payors associated with an Accounting Company, or it can filter by individual Benefit Contract or by all contracts for a specific Payor.

Accumulators

Accumulators allow Plexis Claims Manager to specify Maximum Coverage Limits (Maximum Dollars and Maximum Visits), Out of Pocket Limits,

and Deductible amounts for a Benefit Plan. Plexis Claims Manager tracks the amounts accumulated towards the maximums by each Member. As each Claim adjudicates, the amounts from the Claim that accumulate towards the Benefit Plan limits are stored with the Claim. Before a Claim Approves, Adjudication calculates if the Member has exceeded any of the limits defined on the Benefit Plan.

Plexis Claims Manager sums Accumulators at the these levels:

• Adjudication
• When changing or saving an adjudicated Claim
• When the Claim Adjudicator Entry form displays Accumulators from the Accumulator Info button

Administrative Referrals

The Plexis Claims Manager Referrals grid displays the last 50 Referrals in reverse chronological order. Member Referral information includes Referral ID, Benefit Plan,

Effective Date, Term Date, Referred To Providers, and Status fields.

Authorizations

The Referral & Authorization form is used to enter Referrals for services and to modify and track entered Referrals. A Referral becomes an Authorization once it has been approved.

Auto Adjudication

Plexis Claims Manager's adjudication process adjudicates Claims in real time or in batch mode. The SQL Server initiates and completes Adjudication as a

Server task, all processing occurs on the server. The client needs only to create the Adjudication Run.

Adjudication and Claim payment has three basic steps:

• You create Adjudication Runs from the Adjudication Processing form. Adjudication runs may process immediately, or scheduled for adjudication later.
• After the adjudication process is complete, you close the Adjudication Run using the Payables Batch form.

Plexis Claims Manager generates Claim payments from the accounting system.

Batch Claim Processing

Plexis Claims Manager allows users to create claims and define rules to batch them. Claims can be adjudicated individually or as a batch and billing adjustments are automatically calculated by a batch process on daily / nightly basis.

The healthcare information system also offers the ability to enter data via batch, including but not limited to: group bill reprint (list bill and individual bills), update individuals with new benefits and rates.

Capitation Processing

The Capitation Processing Form initiates capitation processing.
The items directly related to the actual processing are:

• Contract Selection Criteria - There are three items in this section that control which contracts the capitation run from the Assign Provider Contracts form includes.
• Run Cycle - This controls the date for which you want to capitate the provider contracts. You control the Test Date, which displays when you chose a month, through the Plexis Administrator Utility Edit System Environment component Environment Information form. For Test Date methods of capitation this sets the day that the member must be eligible to be capitated.
• Schedule - Defines when the capitation run will process.

Case Managment

Case Management Information Grid
The Case Management Information grid contains Case Management search criteria fields.

Case Manager
Use the Case Manager field to select a Case Manager as Member search criteria. Click the drop-down button to select a Case Manager from the Plexis Claims Manager list. Edit or define additional drop-down list selections in the Plexis Administrator Utility Edit System Tables component Case: Case Managers table.

Level of Care
Use the Level of Care field to select a Level of Care as Member search criteria. Click the drop-down button to select a Level of Care from the Plexis Claims Manager list. Edit or define additional drop-down list selections in the Plexis Administrator Utility Edit System Tables component Case: Level of Care table.

Episode Category
Use the Episode Category field to select an Episode Category as Member search criteria. Click the drop-down button to select the Episode Category from the Plexis Claims Manager list. Edit or define additional drop-down list selections in the Plexis Administrator Utility Edit System Tables component.

Type I
Use the Type I field to select a Type I Episode Category as Member search criteria. Click the drop-down button to select the Episode Category from the Plexis Claims Manager list. Edit or define additional drop-down list selections in the Plexis Administrator Utility System Tables component.

Type II
Use the Type II field to select a Type II Episode Category as Member search criteria. Click the drop-down button to select the Episode Category from the Plexis Claims Manager list. Edit or define additional drop-down list selections in the Plexis Administrator Utility System Tables component.

Note Information Grid
The Note Information grid contains Note information as search criteria fields.

Notes Entered within the last_days
In the Notes entered within the last _ days field, enter a number of days. Plexis Claims Manager searches for Notes created within the entered number of days.

Note Subject
Use the Note Subject field to select a Note Subject as Member search criteria. Click the drop-down button to select the Note Subject Category from the Plexis Claims Manager list. Edit or define additional drop-down list selections in the Plexis Administrator Utility Edit System Tables component Note Subject table.

Owner
Use the Owner field to select a Note Owner as Member search criteria. Click the drop-down button to select a Note Owner from the Plexis Claims Manager list. Edit or define additional drop-down list selections in the Plexis Administrator Utility Edit System Tables component Note Owner table.

Contract Administration

Plexis Claims Manager utilizes provider contract information as part of the auto-adjudication process. It supports multiple fee schedules, multiple networks, specialties, PPO network management fees, multiple contract amount calculations, and more.

Flexible Reporting

Plexis Claims Manager is built on the Microsoft SQL platform. In addition to being able to report on all the activities in the

production system, all types of reports are available through the use of common reporting tools such as Crystal Reports ®, Microsoft Access ®, Microsoft Word ®, and Microsoft Excel ®. Organizations can choose from more than 100 standard reports or customize reports to meet their needs.

Member Services

In Plexis Claims Manager, Members are comprised of two categories: Subscriber & Guarantor and Dependents. A Subscriber & Guarantor is the directly-insured policyholder, the Member is

responsible for policy premium payment. The Member Management and Customer Services form tracks and organizes all Subscriber and Dependent information. In the Member form, you enter Member demographic information, establish Eligibility and Provider assignment, and assign the Member to a Payor, Benefit Contract, Benefit Coverage Level, and Family Tier. The Eligibility and Assigned Providers grids, and the Claims, Patient Folder, Call Tracking, and Referrals buttons make verifying or viewing Member information quick and easy.

Premium Billing

Premium Billing is the process of collecting & calcul-
ating (as a report or bill) charges for member coverage.

In a traditional business model, the insurance carrier handles the premium billing. In a direct contracting model, Plexis Claims Manager performs premium billing for the client. Charges are calculated and distributed to the Payor, or even to individual members. Individual billing occurs when an individual buys an insurance policy without a group, or if the Subscriber keeps the group policy when he or she leaves their job with the employer (as with COBRA plans.)

Plexis Claims Manager computes Premiums for Members either as Subscriber, Dependent, or Subscriber only (if the Billing Method is Family Tier Rates.) Set each Member's billing method on the Member form Eligibility grid and assign the Benefit Contract to the Member. The Benefit Contract form Billing Information tab indicates the Billing Method.

Provider Contract Managment

Each Provider Contract/Payment Contract can hold multiple Fee Schedules. Contract assignment options can be based on a wide

variety of criteria, including Plan Type, Benefit Contract, Provider Network, Client, Line of Business or other user defined criteria. Plexis Claims Manager also allows a provider to be assigned to multiple vendors. The vendor contains the TIN and 1099 information. Vendor assignments can be made using a variety of criteria including practice office, network and line of business. Provider find screens contain many different parameters for locating providers including TINs.

Referrals & Authorizations

The Prior Authorization field displays the Referral Authorization number (if one applies to the Claim). Having entered an Authorization Number in this field, and

saving the Claim, you can use the Additional Information button (spy glass) in the toolbar to view details about the Referral. To see this information, place the cursor in the field and click the Additional Information button. This opens the Referral Information window.

Web Access

Each Provider Contract/Payment Contract can hold multiple Fee Schedules. Contract assignment options can be based on a wide variety of criteria, including Plan Type, Benefit Plexis offers WEBWorks, a web-based portal that allows several real-time transactions to be integrated with your WEB site. This allows on-line transactions such as

eligibility inquiries and claims submissions, as well as access to provider data and medical resources.