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Health plan oversight of medical care is a vital part of delivering quality, cost-effective member care. Many health plans operate on many different systems, often with each functionality on a different system. This creates silos of information that can challenge health plans from delivering the best quality care. MedHOK was built from the ground up to incorporate all functionalities across the continuum of care on a single platform. While you can use MedHOK for one or two functionalities, all of our clients -- some of the nation's largest and most prestigious healthcare payers -- find the power of MedHOK's Unifed Payer Platform to deliver tremendous benefits beyond using one system.

Explore the different components by clicking the name below:


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 clinical criteria, and is fully integrated with Milliman Care Guidelines CareWebQI®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 built its Care Management module to 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 to 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 Service and Support provides state-based Medicaid compliance 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.




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


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