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Member Engagement
Home / Unified Payer Platform / Member Engagement

Success Begins With A Focus on the Member

Everything about value-based healthcare focuses around the care of the member, and so should your system. MedHOK looks at Member Engagement through the lens of the members’ complete experience. Successful engagement meets the member at all points of contact and through their preferred methods of engagement. 

MedHOK’s Unified Payer Platform provides full-function member engagement through proactive features, such as Health Education and Outreach, as well as a range of responsive functions, such as Member Portal, Customer Relations, Complaints Tracking, Grievance resolution, and world-class service enablement. Plus, MedHOK records every interaction, including all current and archived cases, prior authorizations, interventions, appeals, grievances, complaints, over-the-counter medication, clinical surveys, notes, correspondence, and more, at the patient level for easy retrieval and audit.

With real-time access to member data, MedHOK's Unified Payer Platform enables payers to more effectively provide education and outreach to members, and be responsive to their needs. As a result, high member satisfaction and thus, high Star ratings, are possible.

 

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Complete 360° Member Visibility

Access members’ complete medical and pharmacy history, and all interactions with one click from anywhere in the MedHOK platform, so you can deliver quality care and service

Full Function Member Engagement

Proactive and responsive member engagement — from enrollment and outreach to appeals and grievances — is critical for success with value-based healthcare

PROVEN FORMULA FOR ACHIEVING 5-Star SUCCESS

MedHOK enables workflows that facilitate consistent and compliant member engagement, leading to better overall service, higher quality scores, and increased revenue

Member Engagement Components

MedHOK delivers proactive and responsive member engagement capabilities through health education, outreach tools, and world-class customer support capabilities.

Learn more about the Member Engagement components in MedHOK's Unified Payer Platform by clicking the titles below.

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.

360Member is used by all associates in performing their daily functions. The 360Member Profile includes:

  • Eligibility, benefits, and member demographics
  • Pharmacy, medical and lab claims history
  • All incoming and outgoing communications, including attachments
  • All case history including assessments
  • Member’s risk profile
  • All claims and other history for authorizations, appeals, complaints, and grievances
  • Care plans, vitals, and care gaps

 

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The beauty of the MedHOK Unified Payer Platform SaaS architecture is that access can be managed at the role level for internal and external users. As a web-based platform, any user that requires access to the system can do so with a supported web browser and secure internet connection. Therefore, members can access the system via the embedded Member Portal.

 

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MedHOK’s Member Services Management (MSM) solution is an actionable repository for issues and inquiries where many different data sets can be seamlessly accessed and organized in a single interface, creating one view of a member’s demographic, transactional, and other relevant information. MedHOK’s MSM provides users with the ability to manage and analyze member issues and inquiries with real time reporting tools, including standard reports, a business intelligence tool, and dashboards.

 

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MedHOK’s MP (MarketProminence) Financial Reconciliation module comes out-of-the-box, fully compliant with CMS Medicare and state Medicaid rules and can be easily configured to meet health plan-specific business requirements. This solution is offered as an add-on module for MP Enrollment, providing the most rigorous system in the industry to ensure compliance and timely processing for enrollment reconciliation and billing procedures.

 

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MedHOK's MP (MarketProminence) enrollment and eligibility solution streamlines the enrollment process into Medicare Advantage, Medicare Part D Prescription Drug Plans, and Prescription Drug Plans. The enrollment functionality enforces CMS’ regulations regarding data capture and keeps Medicare Advantage/Medicare Advantage-Prescription Drug organizations and Prescription Drug Plan Sponsors in compliance using sophisticated tracking and audit capabilities.

  • Capture, validate, and track all required CMS election data in a web-based enrollment portal
  • Automate application verification process
  • Track multiple source submissions, including broker, portal, and manual processing
  • Generate Batch Eligibility Query (BEQ) Response File for submission and response processing
  • Manage CMS file accretion and TRR response
  • Generate CMS and Medicaid compliant correspondence and alerts to ensure fulfillment in compliant timeframes
  • Assign and track provider assignments and date spans of all critical CMS components 

 

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Communicating with potential members requires regulation compliance. MedHOK MP (MarketProminence) solution provides tracking and monitoring of marketing and sales activities to ensure compliance with CMS guidelines and measure campaign effectiveness. These activities might include:

  • Overseeing mail and phone campaigns 
  • Quantifying lead generation and qualification efforts 
  • Deploying ongoing re-marketing programs 
  • Managing broker efforts and effectiveness
  • Tracking field lead assignment and disposition
  • Rapid data entry of enrollment applications
  • Real-time or frequent batch load of application information to core enrollment module
  • Validation steps and alerts to ensure capture of complete enrollment information
  • Web-based broker portal with validation

 

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Another functionality of MedHOK's MP (MarketProminence) component of the Unified Payer Platform is Premium Billing. This functionality offers:

  • Dynamic query logic for invoicing groups and members
  • Invoice generation and billing
  • Manage multiple source premiums, including Parts C & D, LIS, LEP, employers, pensions, and individuals
  • Process required CMS files, including monthly members, SSA premium withheld and LIS/LEP
  • Manage and automate ACH banking interface
  • Automate retroactive adjustments based on dynamic member data
  • Collections and delinquency controls for multiple revenue streams

 

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Manage all grievances across the organization with this CMS-compliant structured workflow component of MedHOK's Unified Payer Platform.The Grievances functionality allows you to:

  • Capture all key data elements needed for the processing of cases and routes cases to internal business partners at the health plan to ensure rapid remediation
  • Take-in and process appeals of denied authorizations or claims payment in a timely and compliant fashion
  • Take-in and process grievances from members or member representatives
  • Communicate with external appeals entities and ensure any overturns are implemented
  • Respond to complaints made directly to CMS by the member that need resolution within specified timeframes

 

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MedHOK’s Complaints Tracking Module (CTM) is used to process complaints about dissatisfaction with any aspect of the operations, activities, or behavior of a health plan or its providers. Customers use this solution to respond to complaints made directly to CMS by the members or representatives; provide resolution to CMS within specified timeframes; and communicate with internal and external business partners to ensure the complaint is investigated thoroughly.

  • Connects to HPMS (CMS government website)
  • Automated movement of case through auto assignment
  • Quality review of CTM through Letter Review workflow task
  • Documentation of outreach for complete case file
  • Sub-tasking process for internal business partner review
  • Automated correspondence generated and sent to fulfillment vendor
  • Outbound IVR call
  • Correspondence monitoring, documentation, and manual fulfillment, if necessary


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White Paper

Focus on the Member: The Premise for Value-Based Healthcare

Value-based healthcare requires a focus on the member, quite a shift from the provider-centric, transaction-focused models with which payers are familiar. This paper discusses how a focus on the member will result in better quality, care, and outcomes.

Fill out the form to the right to download the paper now.