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Pharmacy Services for Managed Care Organizations  


Plans that participate in Medicare and Medicaid programs find themselves handling multiple functions related to the pharmacy benefit. These functions are governed by state and federal compliance and regulatory guidelines.  MedHOK offers business-configurable, CMS-compliant workflow solutions for processing and tracking coverage determinations, redeterminations, enrollment, Star Quality metrics, CTM, grievance, MTM, 340B and PDE.

MedHOK Solutions are 100% web-based, leveraging cloud computing for scalability. Further, they are HIE ready, and ICD10, 5010 and HIPAA complaint.  MedHOK solutions are 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:

  • Coverage Determination/Redetermination/DMR/IRE: MedHOK 360CDRD® is a CMS complaint, business-configurable workflow solution for processing and tracking coverage determinations (pharmacy prior authorizations), direct member reimbursements, redeterminations and IRE for Medicare, Medicaid and commercial. The system offers a structured workflow system, ensures that cases are processed consistently and correspondence is triggered automatically and attached to the original case. A dashboard allows for real-time monitoring of activity by management and promotes a proactive approach to case load and compliance deadlines. Learn more
  • Complaints Tracking Module: MedHOK offers a business-configurable, workflow solution for processing and tracking CMS Medicare member Part D complaints. The module has integration capabilities with CMS for bidirectional loading of case files. Learn more
  • Quality Measures Management: MedHOK software helps boost PDP Star metrics. MedHOK provides all constituents with an unprecedented ability to proactively design, monitor and share quality and performance data delivered via intuitive tracking tools and dashboard reporting. Learn more
  • 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 the CMS System.  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
  • PDE: MedHOK’s PDE solution is a business-configurable, workflow solution for processing, updating and tracking prescription drug event (PDE) submissions to CMS for Part D payment reconciliation. MedHOK ensures that PDE data is submitted in CMS accepted formats with all required data elements. Learn more
  • MTM: MedHOK offers a workflow foundation for the administration and documentation of medication therapy management (MTM) programs. The system offers a structured workflow solution for the processing and tracking of medication reviews, interventions and therapy changes performed on eligible beneficiaries of the MTM program.  The module identifies beneficiaries at least quarterly for program enrollment based on established MTM program parameters submitted to CMS by Part D plans. Learn more