Paramount Health Care Administrative Services Only (ASO)

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1 Paramount Health Care Administrative Services Only (ASO) The majority of Paramount large group clients self-fund their healthcare programs. Paramount maintains the staff and resources it takes to deal with the complexities of administrating a health plan so you don t have to. Our Administrative Services Only (ASO) product option offers a wide range of solutions for controlling costs, managing risks, strategically responding to critical trends and ACA loopholes, particularly in a time of significant changes and reforms in health care. KNOWLEDGE AND SERVICES Scope and Flexibility Paramount provides a multitude of tools to help manage risk easily and effectively while potentially generating tremendous savings. As your partner, Paramount will work with you in every way possible to make sure you get the right fit and risk parameters needed. Paramount s ASO products include a wide variety of services that are available as a bundled turnkey package option or as individual services based on your specific administrative needs. ADMINISTRATIVE LINES OF SERVICES Member Enrollment Paramount s system receives membership data in a secure environment weekly, biweekly or monthly based on the client s specific needs. Membership enrollment types include: HIPAA 834 Transactions Clearinghouse Transfers FTP File Transfer Paper Enrollment Excel Enrollment Center for Medicare/Medicaid Services (CMS) Voyager Eligibility Interface Paramount maintains the staff and resources it takes to deal with the complexities of administrating a health plan. 1

2 Electronic Data Interfaces (EDI) Paramount receives and transmits HIPAA secure data downloads to and from outside vendors. Outbound Data Transfers Include: Eligibility Data to Carved-Out Vendors COBRA Vendors Pharmacy Benefit Managers Utilization Management/Case Management/ Disease Management Vendors Behavioral Health Services Vendors Wellness and Condition Management Vendors Government and Compliance Entities (CMS, MSP and ERRP) Financial HRA, HSA Vendors (banks) Benefit Encounter Data (deductible and maximum out-of-pocket MOP) Medical Management and Case Notes upon Group Termination Group Utilization/Experience Reports Reinsurance Activity Reports Designated Audit Forms Claims Run-Out Inbound Data Uptake Services Include: Membership Data Benefit Encounter Data (deductible credits from previous carrier/tpa) Human Resource Information System (HRIS) and Payroll Captured Data Financial Account Data (HRA/HSA balances) Disease Management and Condition Management Participant Data Utilization and Case Management Notes Reinsurance Encounter Data and Accruals PBM Data (MTM/accruals) Behavioral Health Services Data Banking Data Enrollment Services Paramount offers a line of enrollment services to assist you during the implementation process, from creating and distributing member enrollment materials to training and benefit education. Enrollment Services Include: Create and Distribute Benefit Summary Forms Create and Distribute Member Enrollment Materials Create and Distribute Summary Plan Descriptions (SPDs) and/or Member Handbooks Create and Distribute Member ID Cards Train the Trainer HR Services Schedule and Lead Onsite Enrollment and Benefit Education Meetings HIPAA Certificates of Creditable Coverage Spousal and Dependents Validation Process and Maintain Eligibility Create and Hand-Off Electronic Enrollment Images (PDFs) of Benefit Materials and Communications for Client Intranet or Website(s) Manage All Electronic Enrollment Interfaces Supporting Clients Web-Enabled Enrollment Needs (links) 2

3 Financial Administration Services As a full-service third-party administrator, we offer peace of mind in knowing that all facets of financial administration are covered components of our ASO offering. These components meet all bank and HIPAA transaction requirements. Financial Administration Services Include: Monthly Administrative Services Billing Biweekly PBM Check Registers Monthly Reinsurance Reporting at 50% of Specific Deductible Monthly Reinsurance Premium Billing and Remitting Weekly Medical Claim Check Registers ACH Wire Transfers IRS Form 5500s Annually SSAE16 Compliance Collecting and Remitting All Service Fees (single source billing and remitting) Accounting and Financial Account Management Services Subrogation and COB Recoveries oofraud Waste and Abuse Services Actuarial Services Paramount s actuarial services provide you with financial tools to help manage claims expenses. Paramount s Actuarial Services Include: COBRA Equivalency Rating Services IBNR Reserve Estimation Administrative Fee (new and renewal) Generation Claims Run-Out Service Fees State or Federal Benefit Rate Formula Filings Financial Modeling Services Financial Risk Assessment Services Reinsurance Evaluation, Pricing and Purchasable Policies Claims Administration Paramount has strong trading partner relationships whereby you can feel confident your inbound data is exchanged in a HIPAA secure environment. Claims Administration Services Include: Timely Claims Processing and Payment Accurate Claims Processing and Payment Application of and Adherence to Prompt Pay Legislation (when obligated) Creation and Distribution of Explanation of Benefits (EOBs) to Members Creation and Distribution of Explanation of Payments (EOPs) to Providers Application of Subrogation, Coordination of Benefits (COB) and/or Maintenance of Benefits (MOB) Application of Claims Processed Against Your SPD and Allowable Benefits Fraud Waste and Abuse Oversight Claim Bundling and Unbundling Services Application of Eligibility Standards to Your Business Rules MSP (Medicare Secondary Payer) Compliance Claims Run-Out Services Claims Pricing and Repricing Activities We offer peace of mind in knowing that all facets of financial administration are covered. 3

4 Ongoing Account Administration As your business partner, Paramount understands that ongoing account administration is critical. Account Consulting and Acquisition Services Creation of Needed Account Infrastructure (group numbers, divisions, locations, segments) Creation of Client-Specific Benefit Levels and Packages Claims and Product Configuration to Stated and Agreed Upon Level of Benefits in Summary Plan Description (SPD) Creation of Enrollment Materials and Summary of Benefits (SOB) Creation and Management of Project Go Live Task List (timelines) Active Participation in and Management of Enrollment Activities (enrollment meetings) Control Agreement Creation and Contract Execution Administrative Service Agreement (ASA) and Business Associate Agreement (BAA) Train the Trainer HR Administration and Compliance Performance Guarantee Contracting Compliance Governance and Compliance Services for PPACA, DOL, ODI, and HIPAA Benefit Administration (medical, PBM, vision, etc.) Medical Management Financial Administration Group Utilization Reporting Carved-Out Vendor Interfaces Integrated COBRA Administration Services Packaged or A la Carte Purchasable Services Reinsurance Policies and Compliance Network Management Recruitment Paramount as your TPA and Managed Care Network has over 25 years of network management experience. Managed Care Network Creation and Maintenance Network Recruiting and Access to Care Optimization Provider Contracting Services Provider Fee Schedule Compliance/ Management and Maintenance to the Specified Contract Provider Credentialing and Policy Compliance Provider Electronic Interface to Your Group Employee Benefit Levels Provider Training and Education Dedicated Provider Inquiry Unit Provider Payment and Reimbursement to Set Fee Schedule Aligned Network Creation, Contracting and Management (supporting customer needs) Center of Excellence Contracting and Compliance Provider Satisfaction Surveys Physician Profiling Service As your business partner, Paramount understands that ongoing account administration is critical. 4

5 Medical/Clinical Management Our medical/clinical management approach allows Paramount to deliver cutting-edge care management programs, assuring our clients the highest quality in the most cost-effective setting. Loading of Your Benefit-Covered Services, Eligibility and Exclusions into Our System Medical and Clinical Compliance to Your Stated Benefit Levels Clinical Appropriateness of Care Measures Against InterQual Clinical Standards Active Management of Treatment Plan Compliance Case Management and Utilization Review Care Coordination and Guidance Services Steps2Health Medical Home Services and Care Coordination (Care Navigator) Organ Transplant and Shock Loss (high dollar) Encounter Management and Compliance Focus on Medical Outcome (ACO) Metrics Imaging Services Management Medical Director Reviews Prior Authorizations Assuring our clients the highest quality in the most cost effective setting. Condition Management Paramount has designed a formal program, Steps2Health Condition Management, targeting prevalent chronic conditions associated with decreased productivity, high morbidity and high cost. Chronic Condition Management Asthma COPD (Chronic Obstructive Pulmonary Disease) Diabetes ESRD (End-Stage Renal Disease) CVD (Acute Cardiovascular Disease) Depression CKD (Chronic Kidney Disease) Migraine Management Steps2Health Medical Home Services and Compliance (includes reporting) Outbound Disease Management Coaching and Tracking Group-Specific Metric Disease Management Reporting and Tracking Emmi Participation Physician Advisors Clinical Treatment and Drug Regimen Compliance Management Patient-Specific and Condition-Specific Action Plans Member, Age and Gender-Specific Wellness and Prevention Notices NCQA Compliance HEDIS Reporting 5

6 Preventive/Wellness Programs Paramount will partner with you to achieve common goals through a wide range of preventive and wellness programs that are designed to improve the quality of life for your employees, reduce healthcare costs, increase awareness of disease risk and treatment options, increase productivity, and reduce absenteeism. HRA (Health Risk Assessment) Employee Onsite Health Events (T-DAP, flu shot) Administration and Client-Specific Reporting Integrated Wellness Compliance, Incentives Biometric Health Screenings and Rewards Health Fair Participation and Scheduling Purchasable Wellness Services Targeted Member Health Communications Steps2Health Services End User Enabled Wellness Portal and Partnership Agreements Web Materials Inducement/Incentive Metrics Patient-Specific Wellness Home Page Active Participation and Patient Ownership Interactive Online Wellness Programs of Personal Health Health Action Plans Member Services Paramount s Member Services options will provide you with exceptional customer service and assist in your health and wellness needs. 24/7 Member Call Center 24/7 Nurse Line 24/7 Online Member Direct Portal Claims Appeal/Grievance Process Local and Toll-Free Lines Web-Enabled Member Tools Including: ooeobs oobenefit Counter Accruals oobenefit Summary Data oochange Providers ooorder Additional ID Cards Member Customer Service Center Customer Satisfaction Surveys Paramount Perks Program 6