PLEXIS' Optimization Apps

Optimization

PLEXIS’ optimization apps

PLEXIS delivers rapid speed-to-value with industry-leading optimization and scaling applications

PLEXIS can seamlessly integrate two business apps: PLEXIS Alerts™, and PLEXIS ReClaim™, to deliver automated business activity monitoring and batch readjudication.

PLEXIS Alerts™

Automate workflows with the industry’s best app for BAM: PLEXIS Alerts™

PLEXIS delivers business activity monitoring (BAM) like never before. PLEXIS Alerts is an advanced app for flexible, intelligent BAM that sends customizable, automatic notifications to a wide variety of devices, including mobile devices. Ready-to-use events and automatic email management are easy to set up with the PLEXIS Alerts Wizard. Advanced functionality is included with configurable, automatic standard and exception reporting and other advanced features for all ODBC-compliant sources.

Learn more about of the benefits and features of PLEXIS Alerts:™

Managed Care Online recently reported that according to a recent employee survey¹ regarding management of their health, 65% of those surveyed want their health plan to send them reminders about critical health actions such as prescription refills and annual health exams. PLEXIS Alerts enables health plans and TPAs to set up “events” associated with data in PLEXIS software to schedule and send such reminders – via email, text, or other communication methods. These alerts help improve overall population health and help minimize the risk of chronic illnesses—and by extension, large dollar claims down the road.

PLEXIS Alerts includes cross-application analysis, alerts, and responses. Its wizard has a simple interface that easily configures appropriate events. Standard features and benefits:

  • Email monitoring can be set up to automatically ensure that valuable data is identified, captured, and acted upon in a timely manner.
  • Healthcare payers can be instantly notified of important issues such as an impending change in customer status, past due accounts, or claims billed over a predetermined amount.
  • PLEXIS Alerts can automatically deliver a letter notifying members of an important update such as a change of benefits.

Powerful extended functionality

One of the most powerful tools within the PLEXIS Alerts app is the IT-workflow configuration. This tool has the capacity to call/trigger another computer program or code to automatically execute additional functions. This “Advanced Event Design” feature enables technicians to extend functionality for sophisticated, site-specific requirements. Mission-critical IT functions are automatically monitored with corresponding alerts.

Plays well with others

PLEXIS Alerts can notify a configurable variety of media devices such as a cell phone, pager, PDA, email or fax recipient(s), an FTP, or a web portal. Reports are delivered in a variety of available formats including HTML, PDF, Excel, Word, and Crystal Reports. Various reporting options include the Microsoft MBS suite, Sage Software products, and many others.

¹Survey conducted by HealthMine

PLEXIS ReClaim™

Harness the power of automation when readjudicating and reprocessing batches of claims with PLEXIS ReClaim™

The PLEXIS ReClaim tool can find pended claims and lines and automatically re-adjudicate them; find closed claim lines, negate them or optionally add copies of the original lines and adjudicate the new lines. With over two decades of market experience, PLEXIS understands payers’ needs for a readjudication tool that is easy to deploy yet includes the advanced functionalities to cover every aspect of batch readjudication and reprocessing.

With advanced configurability, PLEXIS ReClaim delivers the following business values:

  • Increase adjudication efficiency by minimizing manual intervention
  • Streamline workflows for claim reprocessing projects
  • Reduce technical requests to your IT group with our batch-friendly search tool
  • Deliver better data quality with faster response times

Learn more about of the benefits and features of PLEXIS ReClaim:™

The three principal functions of ReClaim are to search, change, and process:

Search: claim, member, provider

You can search for claim lines based on a variety of criteria, including but not limited to:

  • Claim information (claim type, status, received date, place of service, claim ID)
  • Member information (member ID, payer, benefit plan, date of birth)
  • Provider information (provider ID, medical group, network, specialty, vendor)
  • Diagnosis (diagnosis code on the claim, primary diagnosis, other diagnosis & admit diagnosis, POA indicator)
  • Claim line (claim line status, date of service, service code, procedure code, modifier, billed charges, units, COB)
  • Adjudication (payables batch, adjudication run, payment contract, fee schedule, EOB)
  • Payment (payment method, check number, allowed amount, deductible, copayment, coinsurance, net amount).
  • Comparison options for criteria selected can include: equals, not equals, greater than, less than, between, in set, not in set.

Additionally, a list of claim lines can be imported into PLEXIS ReClaim to be processed. Identified claim lines can also be exported from PLEXIS ReClaim for tracking purposes or later use.

Change: delete, adjust, correct

Once the claim lines have been identified and pulled into PLEXIS ReClaim you can configure what changes you want to occur. You can choose to process or move the claim lines to another adjudication run and set them to adjudicate. You can delete the claim lines or claim from the database. You can negate or adjust the previously paid claim lines. Additionally, you can copy the original claim line and adjudicate. PLEXIS ReClaim can be used to delete EOBs from claims lines as well as add additional EOBs.

Process: test, process, undo

PLEXIS ReClaim will list the claim lines that meet the parameters that you have set, allowing you to exclude any claim line from processing. A test run of the claim processing can be done on one of the claim lines, allowing you to verify your outcome within PLEXIS Claims Manager and “undo” the changes if needed. As ReClaim processes the claim lines a status will be displayed on the screen, letting you know which claim line have completed and the outcome. Projects can be saved and reused in PLEXIS ReClaim which will save the query criteria, processing settings, and the identified claims for future use.

Cutting-edge program/software optimization services

PLEXIS has an outstanding record delivering horizontal and vertical scaling, incorporating disparate systems to create a higher synergy value. PLEXIS offers a host of business services, including program/software optimization, performance tuning, and other aspects of performance analysis.