Health Plans

In traditional health plans, HMOs and PPOs, ProviderBASE evolves the primary ‘cost containment’ approaches:

1.)  ‘Medical Necessity’ determination (‘Utilization Review’)

– via Clinical Decision Support (CDS) vs. traditional UR/UM

– with self-service ‘triage’ approach, highly automated ‘Utilization Review’, and ‘virtual’ Review Nurse or online Medical Director

2.)  Prior Authorization

– auto-assign status/codes; link with IT/claims systems; notify stakeholders and route to assignees

3.)  Provider Networks and Cost Containment Vendors

– manage contracted Providers/PPOs; optimize pricing & selection; auto-route referrals; schedule; capture discounted rates