Edge Complete™

An end-to-end data lifecycle claim management solution for payers that want to streamline workflows, simplify status reporting, and facilitate timely delivery to meet ACA Edge Server requirements.

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Optimize Edge Server Data

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Enhance data visibility with Collection Process Tracking and Outbound File Monitoring. Dashboard views validate data sources, show status, and display files sent to the required counter-party for visibility into submission resolution.

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Reduce data drop-off and minimize orphaned claims with enrollment pre-validation processing. This function looks for potential enrollment data problems such as duplicate members, new or dropped IDs, and unexpected masked IDs.

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Facilitate error-resolution activities with intuitive error management tools aligned with operational workflows. Risk adjustment and reinsurance insights support error prioritization and client-driven error assignment.

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Leverage professional management of edge servers. Minimize challenges and resources to take advantage of the expanded reporting set including the baseline dashboard, orphaned claims management, and pre-enrollment validation.

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Seamlessly receive, process, translate, and analyze return response files. For edge servers, Edge Complete provides translation and viewing for all CMS xml reports including risk adjustment and IVA reporting.

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Identify and manage orphaned claims to help mitigate risk to revenue.  Analytics reporting for interim billing supports collaborative final bill creation.

Data Transformation and Submission

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Inbound file process summary

  • Allow risk managers to monitor and access claim data for use with improvement opportunity plans with member enrollment and supplemental Inbound File Process Summary screens.
  • Review statistics across the submission life-cycle including valuable insights in to claims, member enrollment, and supplemental acceptance and rejection rates.
  • Confirm that monthly file sets were received, successfully processed, and error rates are within expectations.
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Baseline dashboard

  • Gain direct insight into the edge server responses at summary and commercial insurer levels.
  • Leverage quantity evaluation metrics for enrollment and claim count baselines, acceptance and rejections, orphaned claims, and re-insurance information.
  • Track and manage progress toward the critical CMS baseline.
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Error management

  • Assign and track errors to staff members for error resolution with a workflow friendly tool.
  • Prioritize errors for maximum risk adjustment impact.
  • Filter risk adjustment eligibility based on CMS published rules and the procedure and bill type codes with Data Claim Look-Up.
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Reporting and analysis

  • Present members with reinsurance opportunity through the “Reinsurance” feature in the “Analysis” module, which includes analysis results such as the largest contributing factor to maximize the opportunities.
  • Access a listing and drill down information for all the translated XML files that are run from the edge server with the “CMS Edge Reports” module.
  • Cross-reference member IDs to masked member IDs with multiple search options with the Edge Complete “Reference – Masked Members”.

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