Optimized for Health Plans With Multiple Lines of Business

As new regulatory and technological drivers emerge, multi-line health plans are improving transparency, cost containment, and member services by incorporating PLEXIS’ proven core administration and claims management platform. The PLEXIS platform empowers health plans in 37 states (doing business in all 50) to streamline efficiencies for a combination of medical, dental, vision, and Medicare Advantage. Multi-line health plans leverage the PLEXIS platform to simplify electronic workflows, coordinate care, lower utilization rates, predict costs, and more.

PLEXIS’ agile, scalable solution for multi-line health plans 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 you to enhance collaboration with providers and members.
  • 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.
  • Model and predict costs: PLEXIS can integrate 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.
  • 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.
  • Create significant savings: PLEXIS enables effective medical cost reduction through advanced PPO repricing, Medicare Advantage repricing, and maximum network discounts (primary, wrap, and supplemental).
  • 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.
  • 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.