Royal Health Care Creates Powerful Data Editing and Decision Tool in PEGASYS


The Challenge


Health Plans struggle with quality in regards to on-line member and provider data entry, and often use back-end data checks to reduce error rates. In the claims area, Health Plans also want to edit certain claims with particular conditions to flag them to an examiner. These conditions may be dynamic. Instead of relying on "hard-coded" logic, Health Plans want to define their own processing rules and have the flexibility to change these rules as needed.


The Royal Health Care Solution


Royal Health Care offers the most powerful rules engine on the market today. User value assignment modules (UVAMS) are the force behind this power. UVAMS are user-defined decision trees within the PEGASYS managed care system that provide the specificity Health Plans need today to manage their unique subscriber, provider, and claims processing rules.


Royal has enhanced its UVAM capabilities with the addition of the Provider, Member, and Claims Edit UVAMS. The Provider and Member UVAMS control the display of user-defined warning messages on these screens. Each Health Plan can set their own messages at the field level for example, "Flash a warning if the value for provider specialty code is blank" or "Do not allow entry if member hire date is earlier than 1/1/05." These powerful editing tools allow each client to custom design quality checks and editing based on their Health Plan's business needs.


The Claims Edit UVAM works in the same way. Over 100 variables are available so that Plans can set up rules that will streamline claims processing. If there are claims with a specific provider Tax ID and diagnoses codes that a Plan wishes to suspend to a specific pend code, this logic can be written into the Claims Edit UVAM. The Claims Edit UVAM can also be configured to create warning messages to the examiners based on entry in a specified field.


This powerful editing logic creates on-line messaging for users, assists in training, reduces manual entry, streamlines processing by allowing certain claims to route based on examiner skill sets, and can assist with claims quality by selecting certain claims with specific criteria for review.


Next: PEGASYS Case Study: NHP