Benefit Query provides a comprehensive and searchable view of Plans, associated benefits, and historical data. Benefit Query solves a costly and persistent operations problem: delivering precise, accurate, current and detailed benefit information to an array of users (e.g. Members, Providers, and Custom Service).
Rapidly search and display the benefits related to any Plan. Benefit details can be presented specific to Plans, products, programs, insured party or Groups. Outputs can be customized and range from detailed scripts for Call Centers to benefit summaries, coding , contracts, and certificates of coverage.
Key Features
Search and Display Plan
- Search for Plan by Plan Id, Group Number and Sub-group
- Support for two-dimensional access: Date-of-Service or As-of-Date
- Support for viewing terminated plans
- Display of plan history
Display Benefits
- Presentation of configured plan options and benefits to the user
- Support for benefit scripts, that attach customer service wording around plan components
- Supports Provider/Network inquires, with exact terms of coverage
- Glossary with on-line display
- Benefit summary information is supplemented with secondary product information such as:
- Applicable mandates and medical policy
- Administrative instructions, for example, how to add dependents to the plan, coordination of benefits, general plan exclusions
- Exclusions
Search for Benefit
- Top-down approach, allowing a user to drill-down into the benefit structure
- Support for filtering: for example, show institutional, outpatient services only
- Bottom-up approach is supported through keyword search
- Benefits can be further restricted by place of service
Benefit Resolution
- In case a service or procedure is covered by multiple plans, the system resolves the conflict (e.g. dental services may be covered by the medical, as well as the dental plan)
Audit Control
- Plan information is shown based on the Date of Service and As of Date
- Information shown to the user is logged for audit-purposes
Output
- EDI (e.g. for Providers: detailed conditions of coverage, etc.)
- Benefit Summaries or highlights for marketing and sales
- Coding documents
- Detailed scripts for Member Services
- PDF or MS Word document
Integration
- Benefit Query can be launched stand-alone or as part of a portal (member or provider portal)
- API: Open Interfaces
