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Avatar MSO
Avatar Managed Services Organization (MSO) Software
for Case Management
Avatar Managed Services Organization (MSO) is a uniquely adaptable system which
serves the specialized needs of states, counties,
Managed Care Organizations, specialty networks, and
providers attempting to carefully monitor both at-risk
and non-risk contracts. Key features include:
- Contract tracking (patients, providers and other)
- Service
request management
- Authorization
- Case management documentation
- Capitation (PMPM)
revenue management
- Costs by CPT codes, physician,
patient or period
- Claims adjudication and payment
calculations based on negotiated fee schedules
- Multifaceted contract tracking
- Integration with
electronic claims
- Payment and/or GL/AP systems
Enrollment
Member status and eligibility verification are
entered into the system to begin the enrollment
and service process. Eligibility for one or more
payor sources are verified and entered into the
system either via automated loads or manual data
entry.
Screening
Member requests/needs are assessed and evaluated
during the screening process to determine the appropriate
level of care. The user has the ability to create
their own assessments using the RADplus tool set.
Service Authorization
Authorizations are linked to Benefits or Contracted
Services in the Contract function. Authorizations
are referenced for claims adjudication/review,
calculated in accumulators for IBNR, and reporting
on utilization and profitability.
- Records and tracks
authorizations for
member services
- Automatically assigns authorization
number
- Selects benefit through link between
Member Plan Assignment
- Authorizations and contracts
with specific plans
Case Management
This function allows the user to perform case management
on an individual member to determine continued
level of care required, document notes, and monitor
review dates. Authorization extensions are also
performed in conjunction with transitions of level
of care.
Claims Processing
Claims data is received from the provider via electronic
file, log data, or paper claims, and are input
into the system for validation and adjudication of
service data against authorization data. A payment
recommendation is made by the system for review and
approval. Once a batch has been created, a file is
generated to be sent to a GL/AP system for checks
production and payment processing. Explanations of
Benefits (EOBs) are also generated to accompany the
payment to the provider.
Reports
- Claims processing inquiry
- Claim appeal inquiry
- Authorization inquiry
- Concurrent review inquiry
- Provider-authorized dollars
- Provider IBNR claims
- Claims paid by provider
- MSO average cost per service per member
- MSO average cost per member per month
- Case manager authorized dollars
- Generate hard copy
authorizations
- Provider appealed authorizations
- Current authorizations
by provider
- Generate GL/AP report
- Claims paid within 30 days
Maintenance
Through the maintenance functions, the user has
the ability to setup contract requirements, plan
definitions, service codes, fee schedules and
provider credentialing. Other functions include,
loading of eligibility files, employee registration,
member merge and Pend/ Denial Rules definitions.
Contact us today for additional product information. |
