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Health Plans  


Our integrated care management, quality and compliance platform is designed to work with various types of health plans.  Our clients include:

  • Medicaid plans (including long term care)
  • Medicare (including SNP plans)
  • Commercial health plans

MedHOK offers a comprehensive set of turnkey software solutions for health plans that improve clinical outcomes, care management, compliance and quality measures. We offer workflow management services that help you run a highly efficient organization delivering seamless care and high-quality services to members and clients. The ability to oversee successful enrollment, disease and care management, track complaints, grievances and appeals is essential to ensuring compliance with your contracts.  MedHOK solutions ensure you are seen as a quality health plan by providing you with proactive solutions to improve your quality metrics.  Auto-assignments, quality bonuses and premiums are increasingly tied to the quality outcomes you deliver on behalf of members.

MedHOK Solutions are 100% web-based, leveraging cloud computing for scalability. Further, they are HIE ready, and ICD10, 5010 and HIPAA complaint. MedHOK solutions as designed as separate modules working together using consistent standards, tools, and technologies. This gives our stakeholders the flexibility to implement modules one at a time or all at once. Our modules include:

  • Early detection of uncoordinated care: Identify patients or populations with uncoordinated care patterns to facilitate early interventions that can lead to improved quality and satisfaction scores.
  • Quality Measures Management: MedHOK software helps boost HEDIS, non-HEDIS and CAHPS measures and provides proactive monitoring and identifies gaps to help improve STAR metrics. MedHOK provides all constituents an unprecedented ability to proactively design, monitor and share quality and performance data delivered via intuitive tracking tools and dashboard reporting. Learn more
  • TRR Enrollment to Fulfillment Management: MedHOK’s enrollment solution is capable of handling phone, fax, paper, and EDI application submissions and transmitting TRR data to and from CMS systems.  Capabilities include the ability to push rejections through a predefined workflow process for correction and resubmission by the end users.   Further, all work items are traceable and reportable as needed, while the system is able to handle exception (e.g. Out of Service Area) processing based on business rules and CMS requirements. Learn more
  • Complaints Tracking Module: MedHOK offers a business-configurable workflow solution for processing and tracking CMS Medicare member complaints. The module has integration capabilities with CMS for bidirectional loading of case files. Learn more
  • Risk Adjustment Payments (RAPS) Management: MedHOK Systems process data according to CMS guidelines to facilitate efficient and effective submissions of risk adjustment data.  MedHOK provides end-to-end support to Medicare Advantage organizations for the complete revenue lifecycle management. Our risk adjustment solution accurately captures members’ health status through proper HCC (hierarchical condition categories) management. Learn more
  • Care Management: Health plans can improve patient health by targeting the right members at the right time with the right interventions across the entire health continuum.  Capabilities  include:
    • Business Configurable Workflow: User-configurable templates for various assessments make an ideal solution for rapid deployment.
    • Utilization Management: Functions supported – precertification, prior authorization, administrative notification, concurrent review and discharge planning. The UM module can be delivered as a standalone.
    • Case Management: Functions include candidate identification, automated assessments, automated care plans, integrated workflow, dashboard reporting, intervention, goals and outcomes.
    • Disease Management: Business user-configurable templates for various chronic diseases make an ideal solution for rapid deployment.
    • Predictive Modeling: Identify risk scores and stratify high-risk, high-cost patients. Learn more
  • Encounter Data Management: MedHOK provides a comprehensive solution for encounter data management and meeting state-specific compliance requirements.  MedHOK Systems track provider encounter data submissions, provide a channel for alternate submissions and ensure organizations are maximizing diagnosis code data flow.
  • Appeals and Grievances: MedHOK provides a business-configurable workflow solution for processing and tracking appeals and grievances. The system offers a structured workflow based on individual user roles with responsibilities/functions that define which task can be completed by the specific user. The system-defined workflow ensures that cases are processed consistently and correspondence is triggered automatically and attached to the original case.  Learn more