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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. These silos of information 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:


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.



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.



MedHOK's Pharmacy External Review is a CMS-compliant workflow solution for processing and tracking IRE cases for Medicare and External Review cases for Medicaid and commercial lines of business. The system 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 module facilitates outbound and inbound cases as well as member-requested reviews. The module 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.



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.




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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