Process Claims Faster with PLEXIS’ CMS Medicare Advantage Software

Health plans process claims more accurately and efficiently using PLEXIS Healthcare Systems’ Medicare Advantage software. Medicare eligibilities continue to grow, placing burdens on older claims software. The PLEXIS platform accommodates CMS requirements and automates numerous workflows for claims adjudication and core administration. PLEXIS’ integrated financial, clinical, and administrative payer platform positions your organization to meet evolving compliance standards while delivering coordinated, consistent, cost-effective care for all your MA plans. 

PLEXIS’ CMS Medicare Advantage software offers:

  • A rules-based engine to automate workflows for claims processing, auto-adjudication, batch readjudication, benefit administration, enrollments, eligibilities, premium billing, and more
  • A flexible API with full interoperability to integrate your enterprise systems
  • Agile technology built on service-oriented architecture to deliver scalable transaction processing, automated EDI solutions and ICD-10 compliance
  • Proactive customer engagement and transparency through a suite of best-of-breed customer relationship management capabilities
  • On premise installation or remote, secure hosting options available

Paving better payer-provider relationships

Payer-provider partnerships create highly beneficial payment models that drive better care outcomes for patients. Payers and providers rely on the PLEXIS platform’s collaborative tools to provide critical data and communication. Innovative payment models succeed and excel with our data-driven approach to keeping patients healthy and lowering costs.

The PLEXIS platform simplifies Medicare Advantage administration. It allows full connectivity for all the patient-centered big data that provides essential visibility for episodes of care. Then its intelligent dashboards organize the data into actionable intelligence that helps drive better care at lower costs.

CMS specific solutions include:

  • A CMS Data Loader
  • CMS Assistant Surgeon Rules on the payment contract
  • Automated Beneficiary Enrollment / Application Processing
  • Automated CMS-compliant claims processing (DTRR)
  • Flexible fee schedule payment methodologies supported
  • Configurable functionalities for procedure code depreciation and late payment interest
  • Membership and Premium reconciliations
  • Integrated comprehensive fraud waste and abuse with grievances and appeals
  • Integrated CMS certified EDS (electronic data submission) EDI solution for encounter reporting (RAPS/EDPS)
  • National Correct Coding functionality options available
  • Capitation and billing prorated based upon Medicare Rate Cells and categories, including Nursing Home Certified, Working Aged, ESRD, and hospice
  • Automated CMS-certified correspondence, including ID cards, and multiple languages/fonts

PLEXIS’ Medicare Advantage software drives rapid growth

One of PLEXIS’ clients is a third party administrator (TPA) and managed care organization (MCO) that serves commercial, Medicare Advantage, and Medicaid plans. PLEXIS empowers this MCO with auto-adjudication, capitation, and claims processing for annual cost savings of over 1 million dollars. The infographic below depicts the surge in growth this MCO experienced after implementing the PLEXIS platform.

PLEXIS' Medicare Advantage software

Mission-critical claims processing solutions

PLEXIS’ agile, trusted enterprise platform is the most dynamic claims adjudication and benefit administration software solution on the market. Serving all major healthcare payers for the past 20 years, PLEXIS simplifies and automates claims processing and core administration.

Learn more about our rules-based core administration + claims management solution, our suite of readily-configured business apps, and the cutting-edge healthcare core administration services we offer as part of our full-service MA platform solution.

Serving healthcare payers for over two decades

“It paid off to invest in technology with PLEXIS’ advanced core administrative system,” said Todd Galbraith, Chief Information Officer at Avante Health. “The PLEXIS platform supports our business needs for growth, efficiency, and flexibility.”