QCconnect – PLEXIS Quantum Choice User Group – 8/14/2024

 

Throughout 2024, PLEXIS is organizing and moderating a quarterly user group forum in which all users of the Quantum Choice (QC) core administration and claims processing platform can gather to share experiences, tips, and tricks for the benefit of other QC users around the world.

Links to all resources available for each quarterly meeting are posted below:

3rd Quarter QCconnect – PLEXIS User Group Meeting – Wednesday, August 14th

CLICK THE BUTTON TO VIEW A RECORDING OF THE MEETING

Various topics including a new client portal, QA processes, beta testing, AI and automation in claims processing, and company information sharing among attendees.

  • Introduction and Meeting Start: The meeting started with Dennis Hubbard announcing it was live, followed by greetings among attendees, including Sean Garrett, Marcia Larsen, and Sandy Windom.
  • Client Portal Overview: Sean Garrett introduced Deborah Greaves, who provided an overview of the new client portal for submitting and tracking tickets, emphasizing features like self-service, ticket tracking, and knowledge base articles.
  • Security Concerns: Sean highlighted the importance of not submitting PHI (Protected Health Information) through the portal and discussed automated processes for securing sensitive data.
  • QA Processes and Beta Testing: Discussions included the QA processes for releases, the possibility of beta testing with clients, and the need for regression testing to ensure backward compatibility of claim adjudications.
  • Company Information Sharing: Attendees shared information about their companies, including Alliance Coal Health Plan and Sandy Windom’s unique secondary insurance product, highlighting the need for better system compatibility and integration.
  • AI and Automation in Claims Processing: Sean discussed the potential of AI in automating claims configuration and processing, emphasizing the benefits of reduced manual effort and increased efficiency.
  • File Transformation Automation: Sean introduced the idea of using tools like Pilot Fish for easier file transformation and mapping, which could benefit organizations dealing with multiple file formats for eligibility and other data exchanges.
  • Next Meeting and Housekeeping: The next meeting was scheduled for November 13th, with a call for agenda items to be submitted in advance. Dennis Hubbard emphasized the importance of early submissions for better organization.

Here are the key points and the times they occurred during the meeting:

  1. Client Portal Overview:
    • 0:18 – Sean Garrett introduced Deborah Greaves.
    • 4:39 – Deborah Greaves provided an overview of the new PLEXIS client portal.
  2. Security Concerns:
    • 8:03 – Sean Garrett discussed the importance of not submitting PHI through the portal.
  3. QA Processes and Beta Testing:
    • 16:50 – Sean Garrett and Marcia Larsen discussed QA processes and the possibility of beta testing with clients.
  4. Company Information Sharing:
    • 12:32 – Dennis Hubbard shared information about Tokio Marine HCC– Supplemental Health and Alliance Coal Health Plan
  5. AI and Automation in Claims Processing:
    • 8:20 – Sean Garrett discussed the potential of AI in automating claims configuration and processing.
  6. File Transformation Automation:
    • 8:34 – Sean Garrett introduced the idea of using tools like Pilot Fish for easier file transformation and mapping.
  7. Next Meeting and Housekeeping:
    • 12:16 – Dennis Hubbard scheduled the next meeting for November 13th.

 

Responding to a request to provide information about the companies represented by the attendees, Marcia Larsen and Sandy Windom provided information about their companies.

Alliance Coal Health Plan – Marcia Larsen

  • An employer-sponsored health plan regulated by ERISA.
  • Membership is approximately 11,000. Members do notpay premiums. Members are employees and their families.
  • The annual number of claims is approximately 130,000 for medical, dental and vision.
  • Plexis’ QDS system is used to import 837I, 837P and 837D files.
  • Plexis’ AIS is used to create/import members, enrollments, eligibility, authorizations, and providers.
  • Currently using QC v 21.2 and planning to upgrade to QC v 23.1.2
  • Claims pricing is calculated via an API with Zelis/Visium.
  • Payment processing is processed via Echo Health using the Echo400 format.
  • The clearinghouse that receives claims and eligibility requests (X12 270) is SDS (Smart Data Solutions).

Tokio Marine HCC– Supplemental Health – Sandy Windom

“Our company’s product is a secondary GAP group health plan. The MedPlus plan is secondary to each group’s health insurance plan( BCBS, UHC, Cigna, Aetna, etc.). MedPlus is not a voluntary plan. All claims require the primary plans COB information from the X-12 file or an EOB from the primary plan. All plans and eligibility are built in the QC system with Other Insurance.

We have been able to configure the members and benefit plans in QC to accomplish these requirements. We utilized result codes to identify what amounts from the primary plan’s deductible, coinsurance, and copay go to the repriced amount on the claims.”

We Will Send an Invitation to Register Approximately Two Weeks Before Every Meeting Followed by a “Call for Discussion Items” a Week Before Every Meeting

 

Contact Marketing@plexishealth.com for any questions