Eligibility

The patient visits the provider facility and presents their beneficiary card, which contains a magnetic stripe much like a credit card, or other identifier.

Provider Access Points

Conexia is able to engage providers through a variety of methods and platforms (access points). These access points strengthen the payer and provider partnership providing the maximum benefits of the real-time circuit.

In the model’s simplest form, a portal is accessed by providers via a secure web page. Integration with practice management systems and Electronic Medical Records (EMRs) is also possible. POS and IVR options are available for providers who lack internet access.

Eligibility is instantly confirmed because the payer and provider are electronically connected.

The provider is granted instant access to the patient’s record, which includes demographic data, diagnosed risk factors, current medications and results from recent tests or scans.

The provider enters a code for diagnosis and procedure. All other information that is commonly found on a pre-authorization or claim form has already been captured in the central database.

From Days to Seconds

Reduce Cost

Data Accuracy

Real-time Application of Business Rules

The medical treatment request is instantly processed via the interface, which uses business rules to adjudicate the transaction applying evidence-based medical guidelines and other relevant factors such as past patient utilization. This permits payers to positively and prospectively impact the care of the patient (as well as cost) by promoting adherence to medical standards at the point of care. Payers and providers are also able to communicate in real-time.

Approval & Alerts

90% of medical transactions can be adjudicated in real time using business rules.

10% Unusual transactions are routed to auditors at the payer for immediate review.

The provider is instantly notified of the action.

From Days to Seconds

Clinical Guidelines & Medical Audit

Providers have certainty of payment at the time of service. Importantly, patients can be made aware of their financial responsibility as well. Current fee schedules including alternative payment methodologies are automatically applied as part of this transaction, so that providers know precisely what their reimbursement will be for the service.
Additionally, the can be alerted at the point of care, or before, regarding the implications of their care decisions relative to quality metrics, peer performance, and evidence-based / customized clinical guidelines.

Simple Payment

The system automatically generates an electronic invoice for payment by the payer. Payment of invoices becomes prompt and simple.

Reduce Cost

From Days to Seconds

Reduce Cost

Key Metrics in Real-time

Indicators & Metrics

Conexia is monitoring the entire circuit to have quality metrics and payer has real-time access to the program performance.

Our impact today

20.000.000

PROVIDER SAT

20.000

AUTHORIZATION TAT

20.000

TRANSACTIONS PER MONTH

More about our Service Model

 

At Conexia we use our deep industry experience to optimize the balance between quality of service for patients, administrative cost and medical cost.
Know more about our Service Model for Healthcare

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Put the real-time adjudication solution to work for you

See why Conexia is the leading trusted software vendor in the global payer community.

A trusted leader in the global payer community