Effective tools that support today’s complex provider network and care management initiatives.

Network and care initiatives are integral to today’s self-funded plans. These are the areas where cost and quality of care can be tracked and managed. A number of modules are available to support these initiatives—providing deep integration with QicLink core processes to ensure that the right discounts are applied at the right point in time, claims are accurately repriced and that appropriate care is being delivered.

• QicLink PPO™ Management lets users efficiently re-price negotiated benefits to contracted providers. It offers all the administrative functions necessary to process PPO benefits, populate reports and track discount information. Administrators can establish point-of-service plans as well as unique contracting arrangements on a provider-by-provider basis, or on a provider-to-many-master basis. The application supports a wide variety of fee schedules, including custom and Medicaid, and facility/hospital benefits can be defined using per diem or case rates. Out-of-area benefits can be established and assigned a different pay schedule from standard benefits.
• QicLink HMO™ Management captures encounter information for each member per month utilization by specialty, primary care physician (PCP), procedure performed and procedure category. The module also supports multiple direct-capitation relationships such as member to provider, as well as indirect capitation relationships, including PCP to member, or all members to a lab. Users can set up multiple accounts for financial tracking and have access to financial liability monitoring and balancing reports.
• QicLink Utilization™ Management lets administrators manage any type of service (inpatient stay or specific procedure) for any setting. Referral and authorization data from external sources can also be accepted—with authorizations automatically linked to the appropriate claim payments. In addition, discreet episodes of care or treatment, as well as continued treatment requests for those episodes, can be established and linked. Create user-defined treatment types, including unit of measure, to serve as the basis for tracking services provided and to generate meaningful reports on authorized services.
• Additional third party-based QicLink-integrated Network & Care components can be found under the QicLink Premier Partners category.