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VBA Included in 2016 Gartner Market Guide for Healthcare Payers Core Administrative Processing Systems

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Inside your Gartner Market Guide for Healthcare Payers’ Core Administrative Processing Systems you will find recommendations and market information regarding the Healthcare Administration Software industry. This guide will help your team as you decide on a benfits administration system.

Disclaimer for Report:
Gartner, Inc., Market Guide for Healthcare Payers’ Core Administrative Processing Systems, Constance Sjoquist, 18 June 2016.
Gartner does not endorse any vendor, product or service depicted in its research publications, and does not advise technology users to select only those vendors with the highest ratings or other designation. Gartner research publications consist of the opinions of Gartner’s research organization and should not be construed as statements of fact. Gartner disclaims all warranties, expressed or implied, with respect to this research, including any warranties of merchantability or fitness for a particular purpose.

VBA Gateway Web Portal February 2015 Release Notes

MEMBER TERMINAL
  • No changes
  • PROVIDER TERMINAL
  • No changes
  • EMPLOYER TERMINAL
  • The Employer Online Enrollment menu has been activated. Users can now make the following requests in the Employer Terminal:
    • Change Address
      • Select an insured, or member of their family, and update their address information.
    • Add Member
      • Select an insured and add a new member to that subscriber.
    • Disenroll Member
      • Select an insured and either Disenroll the entire family or select an individual member of that family to be disenrolled.
    • Add Coverage
      • Select an insured add a new coverage with an associated coverage level (tier) to indicate which members of the family are covered by this change.
    • Terminate Coverage
      • Select the insured and remove coverage for the family or select an individual member and remove coverage from that specific member.
    • Request New ID Card
      • Select the member you wish to request ID Card be generated using the administrator ID Card process.
    VBAGateway Global (All Terminals)
  • No changes
  • VBA January 2014 Release Notes

    ACCOUNTING SERVICES Process Void will now assign a batch claim number to re-entry claims. Disability claims were created without receiving the next available batch claim number and would create claims with an already existing batch claim number.
    BENEFIT SERVICES
    • Added the ability to assign effective dates to benefits attached to plans. In some instances this will make the process simpler when a plan change is needed. It is still recommended the enrollment process be used to facilitate plan changes, but these new effective dates offer an alternative approach. (Image 4) (Image 5)
    • Modified the Benefit Level of “Modifier” to allow the definition of multiple required modifiers on a particular line to match this benefit. Each Modifier line acts as an “OR” while modifiers on the same entry are treated as “AND”. This allows for a more finite definition of modifier based benefit levels. (Image 6)
    • Added options when defining Plan Modifiers. (Image 7)
    • This option tells pricing to apply the defined modifier Fee % when the claim is determined to be Out of Network.
    • This option tells pricing to apply the defined modifier Fee % when the service line applies a Usual & Customary rate.
    • Service area, an error would occur when processing an Add or Copy.
    • Added the ability to assign a benefit to multiple plans at once from the Benefit update screen. The Add to Plan button on the Benefit update screen will open the Add to Plan screen. This screen allows the user to select Covered, Excluded, or Rider for all plans that do not have the benefit. The Add to Plan button on this screen will update plans with the selected flags and remove those plans from this screen. Those plans are now visible on the On Plan screen. (Image 8)
    • Added the ability to define a maximum by “Birth Date Year”. This maximum is an annual only maximum and is based on the member’s birth date. This means that, annually, from the member’s birth date, the defined maximum is allowed. (Image 12)
    • Added an option for defining modifier information as part of a plan procedure age restriction. When defining a plan procedure age restriction, you can enter a list of modifier rules that must be satisfied as part of that procedure. Selecting “No Modifier” will enforce the age restriction only when no modifiers are entered on the service line. When “No Modifier” is not selected, a series of 1 to 4 modifiers can be entered as matching criteria. Multiple entries can be added under a single procedure allowing for multiple modifier rules to be defined. (Image 9)
    • Made a cosmetic change to the Benefit Levels screen to make it easier to identify the required fields for each type of benefit level. This will make benefit levels easier to maintain and read.
    BILLING SERVICES
    • Added the ability to filter Self-Admin Invoices on the Generate Invoices Wizard. This functionality currently exists for Group/Division Invoices and Individual Invoices.
    • Improved performance of the initial query of the Existing Payments screen when adding a payment to an invoice. Users should no longer receive a “Not Responding” message in the title bar.
    CALL TRACKING SERVICES
    • Added an option for filing a grievance directly from the selected Member within Enrollment Services. (Image 15)
    • Added a reference to grievances filed directly from the Call Tracking module for purposes of navigation. (Image 16)
    CARE MANAGEMENT SERVICES CLAIM SERVICES
    • The Disability Payment Creator will now create claims with a Group ID assigned from the enrollment of the patient entered. This will allow users with access to those groups to see the claims before they are adjudicated.
    • Modified the claim error screen to display all matching criteria without the need to scroll to the right. Also added visual cues to the missing criteria by marking the check box “red” when that criteria is missing. When a benefit has effective dates defined, those dates will appear along with a visual cue if the service date is outside the defined range. (Image 13)
    ENROLLMENT SERVICES
    • Added an option for filing a grievance directly from the selected Member within Enrollment Services. (Image 2)
    • Added a location to view existing grievances filed by the selected member. You can also navigate directly to any filed Grievance from the enrollment screen similar to Claims and Auths.
    (Image 3) FEE SCHEDULE SERVICES
    • Added the ability to identify a third pricing method under each fee schedule entry. Each fee schedule entry allows for a flat rate, percent of billed and now a custom pricing percentage. This custom pricing percentage allows for a zip code based pricing method that is used when there is no flat rate or billed percentage entered for that fee schedule. This provides for highly configurable fee schedules based on a number of additional options beyond those already defined.
    • GRIEVANCE SERVICES
    • Added an option to Procedure Codes for defining Age Settings. This allows the age information on the procedure to be defined by years, months or days as well as defining the age as of the member birth date or the end of the month of the member birth date. (Image 10)
    • Added an option to Diagnosis Codes for defining Age Settings. This allows the age information on the diagnosis to be defined by years, months or days as well as defining the age as of the member birth date or the end of the month of the member birth date. (Image 11)
    • Changed the mask for ID Codes (custom fields) identified as number. This field will no longer include commas.
    GRIEVANCE SERVICES
    • Added additional fields to the grievance tracking module. The grievance tracking information now includes:
    • Grievance # – This is the tracking number assigned to this grievance.
    • Status (required) – This is the current status of this Grievance.
    • Category (required) – This is the user-defined category to which this Grievance is assigned.
    • Type (required) – This is the user-defined type to which this Grievance is assigned.
    • Received (required) – This is the date the Grievance was received. When filed from a Call Tracking entry, the Call Date is the Received Date. When filed from an enrollment or provider record, the current date is the Received Date.
    • Filed – This is the date the Grievance was filed. When filed from a Call Tracking entry, the Call Date is the Filed Date. When filed from an enrollment or provider record, the current date is the Filed Date.
    • Resolved – This is the date the Grievance was resolved.
    •  Grievance Source:
    • Member – This will hold the member information if the source of this Grievance is a member. Initiating a Grievance from the Enrollment module will populate the source value.
    • Provider – This will hold the provider information if the source of this Grievance is a provider. Initiating a Grievance from the Provider module will populate the source value.
    • Call # – If this grievance is initiated from the Call Tracking screen, the Call # will be held for navigation along with provider information or member information depending on the path initiated by the user.
    • Issue – This will indicate the actual issue related to the Grievance.
    • Issue Type – This is the Type of Issue being reported. Having a defined list allows for more robust and accurate reporting.
    • Issue Date – The date the Issue information was entered on the Grievance. o Resolution – This will indicate the resolution of the Grievance.
      • Resolution Type – This is the Type of Resolution being reported. Having a defined list allows for more robust and accurate reporting.
      • Resolution Date – The date the Resolution information was entered on the Grievance.
    • Administrative Change – This will indicate if there was an administrative change or procedural change made as a result of this Grievance.
    • Admin. Change Type – This is the Type of Administrative Change being reported. Having a defined list allows for more robust and accurate reporting.
    • Admin. Change Date – The date the Administrative Change information was entered on the Grievance.
    Related Items:
    • Related Claims – This will list any claims related to this Grievance. This list can also be maintained under ID Codes as the list is based on a specific custom value.
    • Related Auths – This will list any authorizations related to this Grievance. This list can also be maintained under ID Codes as the list is based on a specific custom value.
    • Adding a Grievance will pre-populate the default status as defined by the Grievance Status Configuration similar to Grievance Category and Grievance Type.
    • Changed the drop down list for Category and Type to only display the description. Including the Code Value was confusing and unnecessary.
    • Added a new configuration area for defining Issue Types.
    • Added a new configuration area for defining Resolution Types.
    • Added a new configuration area for defining Administrative Change Types.
    • Added Advanced Search to Grievance Search.
    PROVIDER SERVICES
    • Added an option for filing a grievance directly from the selected Provider within Provider Services. (Image 1)
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