Medicaid Management Information Systems on a Powerful Payer Platform

Healthcare payers with Medicaid lines of business are increasingly upgrading their Medicaid Management Information Systems (MMIS) to optimize and modernize their core administrative processes. As commercial insurance companies and payers conducting multiple lines of business increasingly add on Medicare and Medicaid lines of business, PLEXIS streamlines payer workflows for the dually eligible and numerous network management and configuration requirements. The PLEXIS platform enables payers to simplify electronic workflows, ensure regulatory compliance, and integrate care management to lower utilization rates and improve patient outcomes.

PLEXIS’ agile, scalable solution for Medicaid enables you to:

  • Enhance provider networks: PLEXIS’ MITA-aligned platform streamlines workflows for provider engagement. PLEXIS automates support for network management for multiple reimbursement arrangements allowing you to enhance collaboration with providers and members.
  • Meet State/MMIS requirements: PLEXIS’ interoperability with MMIS standards includes industry-leading configurability for flexible benefit plan administration. PLEXIS supports State Medicaid provider fee schedules, State-specific enrollment files, HEDIS data, and Medicaid recipient categories.
  • Lower utilization rates and close care gaps with coordinated care: PLEXIS can integrate care management, UM/UR, and disease management to enable powerful, preventative, outcome-based wellness. We include capabilities for medical management negotiations, data-driven utilization review, wellness services, and monitoring/management of high-dollar claims.
  • Model and predict costs: PLEXIS can integrate powerful business intelligence + business analytics (BI/BA) to deliver actionable insights. Predict outcomes and reduce risk as PLEXIS’ BI models the effects of different reimbursement configurations, the financial impacts of state regulatory changes, CMS retroactive changes, and more.
  • Manage your capitation contracts in addition to provider capitation arrangements.
  • Meet cost containment objectives: PLEXIS automates complex benefit calculations to drive high auto-adjudication rates and minimize the risk of paying claims incorrectly. Payers recover significant savings and reduce utilization costs by leveraging PLEXIS’ real-time alerts, automatic audits, responsive reporting, and more.
  • Simplify electronic workflows: PLEXIS’ powerful EDI hub delivers enterprise-wide efficiencies with end-to-end workflows for claims, encounter data, and more. Extensible functionality empowers payers to implement an enterprise data warehouse to track key performance metrics.
  • Connect and communicate: PLEXIS’ real-time portals connect you to members, providers, and all essential stakeholders. With PLEXIS’ self-service healthcare portal, members securely access eligibility, provider information, ID cards, claims history, and other configurable data fields – all from their computer, tablet, or smartphone.
  • Enhance automation and efficiencies: PLEXIS empowers efficient fraud, waste, and abuse (FWA) detection and automated claim editing.
  • Enhance transparency for evolving compliance requirements: Accelerate growth while minimizing risk through end-to-end transparency and centralized premium and claim data. PLEXIS provides holistic visibility for compliance requirements and helps reduce/eliminate duplication errors for an accelerated ROI.