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Coverage Determination  


360CDRD® is a workflow solution for processing Coverage Determinations (prior authorization requests), direct member reimbursements (DMR) and redeterminations (appeals) for commercial, Medicare and Medicaid plans. The system provides a structured workflow and captures all key data elements needed for the processing of cases. The system offers a structured workflow based on individual user roles with responsibilities/functions that define which task can be completed by the specific user. The system-defined workflow 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 administering case load and meeting compliance deadlines.

Key Features:

  • Web Based System: Allows users the flexibility to work from multiple locations and access the information based on their assigned role and responsibilities.
  • 360-Degree View of Member: This improves the quality of care for the member based on all healthcare information being available under the member in one defined area. All cases, prior authorizations, claims, notes, correspondence, etc. are retained at a member level so the MedHOK user is able to have a 360-degree view of the member.
  • Business Configurable: Defined business users have the capability to configure roles, workflow, drop-down lists, service level agreement times, etc. This eliminates the need for IT involvement in updating changes in the system.
  • Structured Workflow Based on Roles and Responsibilities: The system uses designated roles and queues to route cases through the workflow.  Each user role is assigned the ability to perform specific functions. The system controls the route and workflow of the cases to ensure compliance and consistency in how the cases are worked.
  • SLA: All service level agreement timelines are auto-calculated based on the type of case and the priority assigned. These timeframes can be configured by the business for different lines of business.
  • Auto Assignment of Cases: System can be configured to have tasks automatically assigned to users when logged into the system. Associates are assigned a queue based upon their user role that will incorporate what tasks can be performed and what cases are assigned. Cases are assigned based on roles, line of business and compliance due date.
  • Duplicate-Case Check: Can be configured to run a duplicate-case check when the pharmacy technician is starting to work a new task. The duplicate check is set to look for similar cases that have been received in the last 7 days (timeframe is business defined).
  • Decision Trees: Allows for consistency in the drug decision-making process and immediate implementation of protocol changes with minimal associate learning curve.
  • 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.
  • Correspondence Automation and Archiving: The system has a full correspondence module that can automatically generate faxes and letters to members, AORs and providers. Faxes and letters can be configured to trigger as part of the workflow process and can also be sent ad hoc.  Any correspondence that is sent from the system is automatically stored with the case and as part of the member’s 360-degree view. The system will record the date and time the correspondence took place as well as a copy of the fax or letter.
  • Alerts: The module is configured to send proactive alerts to key business users to notify them of any possible issues.  Alerts are sent via email and through case color changes (red and yellow). Alerts can be set to monitor queue case threshold volumes as well as compliance case due dates.
  • Audit trail: The system keeps a record of all changes made to any data field pertaining to a case.  Users can perform an audit trail on any case within the system to identify who and what was changed. All data is user and date-time stamped.
  • Metrics Dashboard: Provides ongoing status snapshots, including a tailored set of performance metrics, to measure current program performance against multiple baselines, including historical performance.
  • Reporting: The module has a reporting feature that has a library of canned reports and a built-in business intelligence(BI) tool that allows users to create ad hoc reports and store for future running.