02 — Capability · BC-1870
Health Plan Operations
Run a health plan's medical and pharmacy coverage end to end, by enrolling members, configuring benefits, building and keeping a provider network, deciding and paying claims correctly, reviewing use of services, protecting payments from error, fraud and abuse and meeting government program obligations. Selling plans and member contact centers use the core capabilities.
- Payer Operations
- Health Insurance Operations
- Managed Care Operations
- Health Plan Administration
In scope
- Member enrollment, eligibility and premium billing
- Benefit plan configuration, accumulators and coverage policies
- Provider network contracting, credentialing and directories
- Claims adjudication, utilization management and payment integrity
Out of scope
- Submitting and following up claims as a provider (see BC-1840.30)
- Member contact center and case handling (see BC-450.20)
- Selling plans to employers and individuals (see BC-430)
- Cash application and receivables accounting (see BC-250.40)
Realized by · 13
- ServiceNow · Healthcare and Life Sciences Service Managementpartial via BC-1870.40.40
- Salesforce · Health Cloudpartial via BC-1870.50.10
- Epic · Payer-Provider Exchangepartial via BC-1870.50.10
- InterSystems HealthShare · Provider Directorystrong via BC-1870.30.40
- HealthEdge · HealthRules Edge Claims Administrationcore via BC-1870.40.10
- HealthEdge · HealthRules Language Configurationcore via BC-1870.20.10
- HealthEdge · Membership and Enrollmentstrong via BC-1870.10.10
- HealthEdge · Home and Host Processingpartial via BC-1870.40.10
- HealthEdge · Payment Accuracy Edgestrong via BC-1870.40.20
- HealthEdge · Clinical Edge Utilization Managementcore via BC-1870.50.10
- HealthEdge · Clinical Edge Appeals and Grievancesstrong via BC-1870.40.60
- HealthEdge · Provider Atlas Edgepartial via BC-1870.30.40
- HealthEdge · Revenue Align Edgepartial via BC-1870.70.10
Used in · 9
- Enroll-to-Care · 01 Enroll via BC-1870.10
- Enroll-to-Care · 04 Connect to Care via BC-1870.30
- Claim-to-Payment · 01 Receive & Validate via BC-1870.40
- Claim-to-Payment · 02 Check Authorization via BC-1870.50
- Claim-to-Payment · 03 Adjudicate & Price via BC-1870.40
- Claim-to-Payment · 04 Screen Payment via BC-1870.60
- Claim-to-Payment · 05 Pay & Explain via BC-1870.40
- Claim-to-Payment · 06 Resolve Appeals & Disputes via BC-1870.40
- Claim-to-Payment · 07 Recover & Settle via BC-1870.60
Build it · 1
- technology Health Plan Core Administration Systems via BC-1870.10
Decomposes into · 7
- BC-1870.10Member Enrollment & EligibilityEnroll members from employers, exchanges, government programs and individuals accurately and on time, keep each member's eligibility and coverage dates current, and bill premiums to whoever owes them. A provider checking a patient's coverage is patient access.
- BC-1870.20Benefit & Plan ConfigurationDefine each plan's covered services, cost sharing, limits and coverage rules once, and configure them so every claim, accumulator and member document applies the same terms. Choosing which plans to offer and at what price is product strategy and pricing.
- BC-1870.30Provider Network ManagementBuild and keep a network of contracted providers large enough to meet access standards, credential them, load their agreements and data correctly, and publish a directory members can trust. The provider's side of payer contracts is revenue cycle.
- BC-1870.40Claims AdjudicationDecide every medical claim correctly and on time against the member's eligibility, benefits and the provider's contract, pay it, explain the decision, and hear appeals and disputes. Pharmacy claims are pharmacy benefit administration (BC-1870.20.50); submitting and following up claims as a provider is revenue cycle.
- BC-1870.50Utilization ManagementMake sure members receive covered services that are appropriate and in the right setting, by reviewing requested services before, during and after care against published criteria and deciding within regulatory time limits. A provider requesting authorization is patient access.
- BC-1870.60Payment IntegrityPay each claim once, at the right amount and only when the plan truly owes it, by catching errors, fraud, waste and abuse before payment where possible, recovering overpayments after, and pursuing other parties who should pay first. Employee misconduct is compliance.
- BC-1870.70Government Program OperationsMeet the obligations of running Medicare and Medicaid managed care plans, by submitting risk adjustment and encounter data, reconciling what government programs pay, filing bids and required reports and overseeing the entities the plan delegates work to. The obligations register itself is compliance.