Cost and competitive pressures are continually driving the need to improve business process automation, provider and member services, and the implementation of regulatory requirements; all in addition to processing claims more efficiently. As a healthcare payer, you need a solution that’s flexible enough to address your changing needs quickly, efficiently, and cost-effectively.
Wipro presents QCare — a powerful, automated claims-processing system designed to be an integral part of your day-to-day health plan business processes. As one of the market’s first rules-based solutions, QCare can be easily customized to specific requirements. Its inherent flexibility makes it valuable to a wide variety of healthcare payers, including managed care organizations, HMOs, and PPOs. It enables support for Medicare Advantage Plans, Medicaid Managed Care Plans, and indemnity plans, as well as dental, pharmacy, and vision services.
QCare offers an integrated HIPAA and multipartner electronic data interchange (EDI) solution that supports HIPAA-mandated transactions, security, and privacy (including a tool for tracking protected health information [PHI]). Role-based security is defined down to field-level access, and QCare also offers software maintenance services and software customization. The solution is available under two types of contracts: a customized ASP model or a perpetual license agreement.
The Benefits of QCare
With the advantages of 99.99% availability, data security, and 24/7/365 operations, QCare provides continuous support and system-monitoring capabilities. Our account manager will work with you to create a customized solution that fits your business and will scale as your business grows. QCare offers the following key benefits:
QCore can enable the comprehensive management of everything from benefits coordination to the entry of preexisting conditions to Medicaid/Medicare information. It enables automatic assignments of primary care and ancillary providers, and “flags” members to alert claims or preauthorization, as well as pending or holding claim payments.
Claims Adjudication and Encounters
The solution offers real-time adjudication capabilities or online data entry with batch adjudication, as well as the routing of pended claims. It calculates “would pay” amounts for capitated services, allows facility claims processing with a tiered pricing structure, and automatically applies the coordination of benefits pricing during adjudication.
Organizations can adopt QCore for the online setup and management of provider demographics with unlimited comments and field-level auditing. It enables the flexible definition of contract and payment terms, the creation of provider directories and individual provider rosters, and provider participation in an unlimited number of product offerings.
Payers can track responsiveness to inquiries, problems, and grievances for employer groups, providers, members, and special documents. QCore allows unlimited comments and online audit trails, as well as automatic letter generation in multiple languages. It can also consolidate data for easy access to member- and employer group-specific coverage.
Employer Group Coverage
QCore identifies employer groups and their unique coverage options, such as network access, benefit coverage, and other payment calculations. The solution can enable the tailoring of multiple products, including those from Medicaid MCOs, commercial organizations, and TPAs, and allows employer groups to control product portfolios.
QCare has the ability to interface with a variety of third-party software. The architecture of the system makes it easy to share data with other systems, departments, agencies, or insurers.
The system’s rules-based architecture keeps custom coding to a minimum and provides maximum flexibility in developing business processes. It offers an extensive library of migration tools that minimizes the migration effort and ensures the quality of the data being loaded to a new system.
And much more, including:
- Plan benefit coverage
- Member eligibility management
- Provider administration/Pre-authorization and referrals
- Case management
- Capitation capabilities
- Premium billing
- Financial and premium billing
- Intelligent reporting