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All Critical Continuum of Care Applications in One Platform

The transformation to value-based healthcare from traditional fee-for-service is being driven by dynamic regulatory requirements, which are driving quality-based outcomes across medical and pharmacy care. Where point solutions were acceptable in a provider-centric model, value-based healthcare is all about the Member. By unifying data across the continuum of care, a more complete profile of the Member is created, allowing for better clinical decision-making, quality, and revenue preservation.

MedHOK is the only healthcare management software platform that unifies both medical and pharmacy care throughout the continuum of care and across all lines of business into one system, disintegrating the typical departmental silos of information. As a result, MedHOK delivers an unparalleled 360-degree view of the Member, with real-time access to members’ complete medical and pharmacy care history, eligibility, benefits, demographics, provider info and all activities, interactions, documents, etc. in one repository, accessible from anywhere in the MedHOK platform.



Bring Medical and Pharmacy history into one, unified system for compliance adherence and Member service success.



More than just the continuum of care, MedHOK's applications span care and quality through all lines of business.



MedHOK enables Payers to serve all major lines of business, including Medicare, Medicaid, Commercial, and Exchange.



It's all right here. All continuum of care and compliance applications are within one unified platform.

Click each title below to learn more about the Medical/Rx Care components in the MedHOK Unified Payer Platform.

MedHOK’s Unified Payer Platform includes a fully integrated Utilization Management (UM) component, which ensures CMS compliance with out-of-the-box compliant fields and drop downs for Medicare, Medicaid, and Exchange, and is easily configured for other lines of business. The component includes multiple intake channels, auto-population of eligibility data, and structured workflows, tasks, and work queues triggered by business rules to ensure consistent application of rules, requirements, and medical necessity standards.

MedHOK can support business clinical criteria, and is fully integrated with Milliman Care Guidelines CareWebQI® and McKesson InterQual and Integrated Coordinated Care Content. The integration enables efficient use of MedHOK’s Utilization Management and Case/Disease Management components to support clinical decision-making.


The MedHOK Unified Payer Platform includes a fully integrated Care Management solution that encompasses both case management and disease management functionalities. The component includes numerous auto-generated workflows based on industry best practices that are launched based on answers to assessments with problems, goals, interventions, and care plans. It includes comprehensive workflows with unlimited queues and project management to assign tasks to fulfill and monitor care planning. MedHOK enables offline assessments in conjunction with Model of Care, Long-term Care, Care Gaps, and our integrated 360Member functionality.


The Care Management component, combined with Risk Management features, provides a holistic solution to identify and stratify members into risk categories and proactively intervene in care to promote quality and reduce costs.  MedHOK has built its Care Management module against accreditation requirements and CMS’ Model of Care regulations.


MedHOK enables evidence-based stratification and predictive modeling within the Unified Payer Platform. With MedHOK's Predictive Modeling and Risk Stratification functionality, you can use historical claims to identify at-risk members and target for intervention. These algorithms automatically identify and trigger members for Care Management program screening as an entire population or by specific line of business, such as Medicaid.

The stratification component includes a standard list of rules and can incorporate any business-specific rules.


Medical Appeals is a workflow solution for CMS-compliant processing and tracking medical appeals received from a member and/or provider. The system offers a structured workflow based on individual user roles with responsibilities/functions that define specific user tasks.

The system-defined workflow ensures that cases are processed consistently and timely. Also, the appropriate correspondence is triggered automatically and attached to the original case. The dashboard allows for real-time monitoring of workload by management, promoting a proactive approach to both workforce management and adherence to regulatory requirements.


Long-Term Services and Supports provides state-based Medicaid compliance for for institutional and community based long-term care programs. MedHOK provides comprehensive functionality to enable assessments for CBS, LTCSS and full MLTC, including the ability to set service levels in all categories and configure by state and program. The MedHOK Unified Payer Platform enables full NFLOC budget neutrality, including auto-budget calculations. 
  • Full CBS, LTCSS and MLTC assessment functionality for online and offline capability.
  • Ability to auto-generate UM event within MedHOK UM module.
  • Full NFLOC budget neutrality functionality including auto-budget calculations.
  • Configurable to state specific program requirements.
  • Complete care plan summary functionality for member and provider.


External Review is a CMS-compliant workflow solution that tracks and processes out of compliance cases and systematically routes them into the IRE/External Review workflow to be auto-forwarded to the IRE/External Review entity for processing. The IRE/External Review component facilitates outbound and inbound cases as well as member-requested reviews. The component allows for key data input and tracking of cases sent to the IRE/External Review entity as well as their decisions, documentation and associated effectuation dates. All IRE and External Review cases are linked to the original appeal to support quick, efficient review of information related to all aspects of the process.


The Medication Therapy Management (MTM) component 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 software identifies beneficiaries at least quarterly for program enrollment based on established MTM program parameters submitted to CMS by Part D plans. The system measures and reports on the number of comprehensive medication reviews, number of targeted medication reviews, number of prescriber interventions and changes in therapy directly resulting from performed interventions.


Pharmacy Appeals is a workflow solution for processing and tracking redeterminations/ pharmacy appeals for Medicare, Medicaid, and commercial lines of business. The system offers a structured workflow system, ensures that cases are processed consistently and correspondence is triggered automatically and attached to the original case. Dashboard and proactive alerts allow for real-time monitoring of activity by management and promote a proactive approach to caseload and compliance deadlines. The real-time dashboards can be shared with your clients to promote transparency. Electronic Prior Authorization streamlines the process and reduces operational costs.


Pharmacy Prior Authorizations is a fully CMS compliant workflow solution for managing Rx prior authorizations for Medicare, Medicaid, and commercial lines of business. The component includes multiple intake channels and electronic prior authorization, auto-population of eligibility data, capture of all key data elements needed for processing the case and structured workflow with individual user roles and responsibilities. 

  • Supports prior authorization, step therapy, quality limits and exceptions.
  • Drug by drug decision trees to ensure consistency in the drug decision-making process and immediate implementation of protocol changes with minimal associate learning curve. Correspondence is triggered automatically and attached to the original case.
  • A dashboard allows for real-time monitoring of activity by management (internal or external) and promotes a proactive approach to administering caseload and meeting compliance deadlines.
  • Automation of Prior Authorization allows for real-time auto-population of prior authorizations into the PBM claims adjudication system. This ensures members are able to receive their prescriptions in a timely manner.

Alerts are configured to send proactive alerts to key business users to notify them of any possible issues. Alerts can be sent via email and are highlighted in the queue through case color changes (red and yellow). Alerts can be set to monitor queue case threshold volumes as well as compliance case or task due dates.


MedHOK’s Specialty Pharmacy component gives Specialty Pharmacies the ability to operate patient-specific clinical programs that center on medication management to improve patient drug adherence and clinical outcomes. The solution utilizes an intelligent workflow system that optimizes the resources used to manage and perform drug, disease management and manufacturer programs for patients.

Our business-configurable software solution allows for the creation, processing, and tracking of patient/drug assessment programs to be performed in a structured workflow that automates the calendaring of assessments and the triggering of evaluations and interventions based on individual needs and program parameters. Reporting functions are available for all data collected in the system via standard  reports and business intelligence (BI) tool.


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No Assembly Required Value-Based Healthcare

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