PEGASYS Case Study: NHP Part D Programs

Neighborhood Health Providers Launches Medicare 2006 Using PEGASYS Software


The Challenge


Neighborhood Health Providers (NHP), a New York City based health plan, wanted to grow its membership by participating in the Medicare Advantage program. The Plan needed a software application that could meet CMS requirements, including new Part D requirements for 2006.


The Royal Health Care Solution


NHP was able to use the PEGASYS platform to meet the new Medicare requirements, including:

  • Capture of all required data elements for enrollment and correction files
  • Extracts to CMS for enrollment and correction files
  • BEQ (Batch Eligibility Query) extracts
  • 4RX Pharmacy Data extracts
  • RAPS Encounter Data extracts
  • Required letter variables for CMS letters including the Enrollment Acknowledgement Letter (EAL), Enrollment Confirmation Letter (ECL), and Low Income Subsidy Rider
  • Capture of Part D premium billing fields
  • Extract file for Part D premium billing invoices and A/R for reconciliation
  • ID Card extract file with CMS required fields
  • State and County Code Letter Series
  • Data Capture of Low Income Subsidy Status

PEGASYS was ready to handle Medicare interfaces and requirements, and Neighborhood Health Providers was able to launch its 2006 program and focus its energy on marketing and enrollment. In addition, NHP also launched a Dual Eligible program for Medicaid and Medicare. As part of this program, PEGASYS integrates processes for both Federal Medicare and State Medicaid processing.


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