Medicare Advantage Software offers sophisticated claims adjudication on a powerful payer platform

As Medicare Advantage (MA) expands in the marketplace, healthcare payers involved in Medicare and Medicaid are increasingly challenged to optimize and modernize their core administrative processes. Manual processes and legacy administrative systems are costly and inaccurate. Payer organizations are increasingly aware that leveraging automated claims adjudication software is the single greatest step they can take to process claims with sufficient speed and accuracy to reduce or eliminate duplication errors for an accelerated ROI. The comprehensive PLEXIS platform allows you to meet evolving standards for regulatory compliance while delivering coordinated, consistent, cost-effective care for all your MA needs. 

As the CMS continues working to improve delivery models for dual eligibles, and as the aging U.S. population increases the number of Medicare eligibilities, PLEXIS has kept pace by expanding our platform solutions to accommodate CMS initiatives and automate workflows for medical/care managers. PLEXIS’ integrated clinical, financial, and administrative payer platform empowers health plans with the performance you need at significantly lower operating costs for the MA population.

The critical components of PLEXIS’ Medicare Advantage software include:

  • A rules-based engine to automate all workflows for claims processing, auto-adjudication, batch readjudication, benefit administration, enrollments, eligibilities, premium billing, and more
  • A flexible API integration with the full interoperability to connect all your enterprise-wide systems.

 Medicare Advantage administration, simplified with:

  • 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 procedure code depreciation functionality
  • Configurable Late Payment Interest functionality
  • 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 deploys mission-critical claims processing solutions

PLEXIS’ comprehensive enterprise platform is the premier 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 operations. PLEXIS’ agile, trusted technology is eminently configurable to empower you to manage all aspects of claims onboarding and integration.

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