SHMS Medicare™

SHMS Medicare™ is a rapidly-installed application to manage and facilitate all core business processes of a Medicare managed care organization. The SHMS Medicare system is a full Windows© application providing an easy-to-use interface that requires little training for most functional areas.

Business Process Benefits

• A central cohesive approach to all core business processes of a Medicare managed care organization provides executive in-depth visibility into key business performance indicators. ibility into key business performance indicators.
• Consistent approach and flexibility of the system results in improved beneficiary relations and health care outcomes.
• Allows plans to delegate risk by supporting multiple capitated arrangements with providers or external MSOs.
• Claims processing, which can be labor-intensive, is automated; claims are auto-adjudicated based on industry-standard verifiBeneficiary history, including all claims (Part A, Part B, and Part D), lab results, encounters, CMS transactions and payments, and utilization information, is centrally available providing a more complete view of the beneficiary which enables plan to better manage clinical and disease management outcomes.
• Provider relations and network management is simplified with complete contracting, claim status and payments, and line-item EOB generation.
• Extensive reports and ad-hoc reporting tools simplify the management and monitoring of the operational status of any functional area of the system.

Information Technology Benefits

• Rapid implementation due to extensive object-oriented software framework based on Microsoft .NET 2.0. For new plans, implementation could be accomplished in as few as 30 days (depending on any process customization required). For existing plans, implementation may take as a few as 90 days (depending on customization and data conversion requirements).
• Familiar user interface based on common office applications and extensive system documentation allow users to get up to speed quickly.
• State-of-the-art Microsoft Windows Server 2003 and SQL Server 2005 environment greatly simplifies administration of the system, easily integrates into existing IT infrastructures, and also ensures scalability over time. IT staffing requirements are also lower as a result.
• Application security is integrated into Microsoft Active Directory allowing centralized management of access to application features.

Components

• Membership: Demographics, Benefits/Plan Management
• Providers: Contracts, Credentialing,
• Claims: Part A & Part B, Payments, EOB generation, Adjudication Engine, Re-pricing
• Utilization Management: Authorizations, Referrals, Encounters, Case Management
• CMS Interaction: Automatic sync with CMS MARx system for Enrollment/Plan Change/Disenrollment, TRR, MMR, and many more
• Marketing: Prospects/Leads Management, Pipeline reporting, Marketing Campaign results
• Provider Portal: Claim/Payment status, Scorecard
• Member Portal: Eligibility Status, Claim Status