Health Plan Software Streamlined for Your Highest Business Outcomes

PLEXIS empowers medical, vision, dental, and Medicare Advantage health plans, enabling payers to grow and innovate across multiple business lines while reducing administrative costs. As new regulatory and technological drivers emerge for accountable care, claims processing modernization, payer-provider collaboration, and customer engagement, health plans are improving transparency and member services by leveraging PLEXIS’ trusted health plan software. Multiline health plans leverage the PLEXIS platform to enhance provider networks, simplify electronic workflows, coordinate care, lower utilization rates, predict costs, and more.

PLEXIS’ agile, scalable health plan software enables you to:

  • Enhance provider networks: The PLEXIS platform streamlines workflows for provider engagement. PLEXIS automates support for network management for multiple reimbursement arrangements allowing health plans to enhance collaboration with providers and members.
  • Model and predict costs: PLEXIS can integrate powerful business intelligence + business analytics (BI/BA) to deliver actionable insights. Predict outcomes and reduce risk as PLEXIS’ BI models the effects of different reimbursement configurations, CMS retroactive changes, HEDIS data, and more.
  • Lower utilization rates and close care gaps with coordinated care: PLEXIS can integrate care management, UM/UR, and disease management to enable powerful, preventative, outcome-based wellness. We include capabilities for medical management negotiations, data-driven utilization review, wellness services, and monitoring/management of high-dollar claims.
  • Configure complex benefit plans: PLEXIS created industry-leading configurability for flexible benefit plan administration (multiple products, multiple lines of business). Premium billing includes retroactive adjustments and multiple premium rate structures.
  • Simplify Medicare Prospective Pricing: Simplify APC and DRG pricing by embedding it within the adjudication process, delivering better accuracy with real-time results.
  • Manage your capitation contracts in addition to provider capitation arrangements.
  • Meet cost containment objectives: PLEXIS automates complex benefit calculations to drive high auto-adjudication rates and minimize the risk of paying claims incorrectly. Payers recover significant savings and reduce utilization costs by leveraging PLEXIS’ real-time alerts, automatic audits, responsive reporting, and more.
  • Create significant savings: PLEXIS enables effective medical cost reduction through advanced PPO repricing and Medicare Advantage repricing.
  • Simplify electronic workflows: PLEXIS’ powerful EDI hub delivers enterprise-wide efficiencies with end-to-end workflows for claims, encounter data (RAPS/EDPS), and more. Extensible functionality empowers payers to implement an enterprise data warehouse to track key performance metrics.
  • Connect and communicate: PLEXIS’ real-time portals connect you to members, providers, and all essential stakeholders. With PLEXIS’ self-service healthcare portal, members securely access eligibility, provider information, ID cards, claims history, and other configurable data fields – all from their computer, tablet, or smartphone.
  • Enhance automation and efficiencies: PLEXIS empowers efficient fraud, waste, and abuse (FWA) detection and automated claim editing.
  • Enhance transparency for evolving compliance requirements: Accelerate growth while minimizing risk through end-to-end transparency and centralized premium and claim data. PLEXIS provides holistic visibility for compliance requirements and helps reduce/eliminate duplication errors for an accelerated ROI.