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.
 

Optimize Edge Server Data

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.

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.

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.

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.

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.

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

Edge Server Data Transformation and Submission

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.

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.

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.

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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