MHC Health Plan Administration System

Designed to handle multiple benefit structures and multiple reimbursement arrangements, the MHC system allows health insurers and managed care organizations to streamline administrative functions for any combination of health plan product lines.

DST Health Solutions' MHC application is a fully-integrated UNIX-based health plan administration system. MHC supports all membership enrollment functions, employer group billing, utilization management, claims processing, provider maintenance and contracting, and financial information for businesses managing single or multiple healthcare product lines.

MHC is designed for flexibility and future business expansion. The system is scalable and can support virtually any type and size of health plan, from start-ups to large health insurance carriers with millions of members. Designed to handle multiple benefit structures, the system allows managed care organizations and integrated delivery systems to streamline administrative functions for any number and combination of health plan product lines.

In addition, MHC offers specialized functionalities for processing government healthcare business (Medicaid, Medicare).

Features:

• Data fully integrated between core and ancillary modules
• Fully integrated inpatient and outpatient utilization review
• Flexible and sophisticated benefit structures
• Varying provider contractual agreements, such as provider fee reimbursements by product line
• Extensive utilizations and financial reporting capabilities.

Compatibility

The MHC base system and application software modules and fully transportable across a wide range of UNIX-compatible hardware platforms and is currently being run on hardware from Hewlett-Packard, IBM, Data General and Sun Microsystems.

The MHC software is enhanced by the SB+ application system environment shell developed by System Builder Corporation. This software supplies an easy to maintain user environment and flexible, user-defined security access for all software programs. This software supplies an easy to maintain user environment and flexible, user-defined security access for all software programs. This environment also provides the following advanced benefits:

• PC look and feel
• Advanced menu navigation
• System administration utilities
• DOS/UNIX communication capabilities
• Office automation utilities

Membership

MHC has been designed to track maximum information on employer groups and members, while maintaining ease of use and quick data entry. A member inquiry menu provides rapid access to 10 of the most frequently used member-related inquire screens from throughout the system. All membership information is date-specific, allowing for past and future changes. Employer group billing functions and flexible and sophisticated benefits have been developed to meet the changing needs of managed care plans. Premium and ASO billing are fully integrated with accounts receivables in MHC.

Claims Processing

Claims for medical services are controlled through one point of entry in Claims Processing. Claims adjudication integrates enrollment, benefit, authorization and financial data. The claim entry process verifies member coverage and automatically applies the appropriate co-payments, coinsurance and deductibles. MHC allows claim item pricing based on user-defined adjudication tables which can be assigned by line of business, employer group or insurance carrier. The system also distinguishes between capitated and fee-for-service charges and prices the claim accordingly. In addition, MHC provides automatic matching of authorizations with claims to streamline processing and reduce errors.

Financials

Accounts Payable, Accounts Receivable and General Ledger systems are fully-integrated with the MHC system. Payment information resulting from capitation, general, and pharmacy claims is systematically updated to Accounts payable.

Statement information resulting from the group billing process is likewise updated to Accounts Receivable. Receipts can be entered in Accounts Receivable and associated with the appropriate group statements.

The General Ledger module automatically accepts transactions from Accounts Receivable and Payable and supports a comprehensive set of financial reporting functions, including a user-defined balance sheet, income statement and cash-flow statement. The financial statements can be produced to reflect current month actual, current budget and current month variance, in addition to year-to-date actual, budget and variance.

Providers

MHC offers comprehensive automated provider credentialing capabilities, eliminating the current manual record-keeping process. MHC tracks relevant information about providers, based on NCQA standards. Credentialing capabilities are supported by automatic and on-demand letter generation and numerous report formats.

MHC's provider reimbursement functionality is sophisticated, table-driven and very versatile, providing a high degree of flexibility. All providers can be defined as being capitated, non-capitated (fee-for-service) or a combination of the two. In addition, the system provides advanced copying capabilities which provide simplification and time savings in setting up providers. This includes both the addition of new providers and the expansion of existing providers to include new lines of business, regions, etc.

Medicaid Processing

Specialized screens allow easy entry and streamlined tracking of the specific member information required by state Medicaid programs. Key data is driven by effective date to accommodate the complex dynamics of Medicaid membership processing and turnover.

Medicaid data management is automated to support transmission of demographic/eligibility information via UNIX file or tape, with cross references by recipient ID, alternate ID or social security number and automatic disenrollment of non-eligible members.

To allow variation of Medicaid eligibility, individual family members can each be defined and then linked via the case number (or "head of household"). Head of household information track the name and address for correspondence - such as EPSDT reminders, membership cards and general mailings - regarding Medicaid recipients who are minors.

Documentation

Easy-to-ready, Microsoft Word-based reference and training documentation features full indexing for rapid access to critical information. In addition, the system offers on-line help functionality throughout to aid in data entry.

Ongoing Support and Services

In addition to a comprehensive support and maintenance program, DST Health Solutions offers a wide range of customer services to support the MHC system. These include strategic business planning, management and technical consulting, training, project management, custom programming and electronic data interchange services. A customer support hotline is available Monday-Friday, 8:00 a.m. to 8:00 p.m. (Eastern Time). In addition, DST offers a wide range of outsourcing service options for your consideration.

Additional Modules

The following optional modules offer expanded capabilities and are available with MHC:

• Capitation module
• Coordination of benefits (COB)
• Customer support and inquiry module (CSIM)
• Digital voice assistant (DIVA)
• DirectConnect electronic data interchange
• Laser forms solution (RxLASER)
• Medicare reconciliation module
• Utilization review module

For more on MHC Health Plan Administration System: inforequests@dsthealthsolutions.com