Healthcare IVR Solutions for: Health Plans, HMOs , PPOs , MCOs , TPAs , Healthcare Payors

Interactive Voice Response (IVR) Applications for
Managed Care Organizations (MCOs)

FlexVP IVR Platform

FlexVP allows callers to automatically access healthcare and member information using a touch-tone telephone. Applications include verification of member eligibility, obtaining member benefits information, accessing status of claims information, and authorizations / referral entry and review.

This information is obtained through an interface to the managed care organization's claim system. ISG has integrated the FlexVP interactive voice response (IVR) system with healthcare claims systems offered by: DST Health Solutions, Perot Systems, Erisco Facets, and OAO Healthcare.

FlexVP applications requiring on-line information can connect to an external database running on a mini or mainframe computer using 5250, 3270 or VT100 terminal emulation. In addition, FlexVP can access network or LAN databases (dBase, Access, SQL, etc.) through ODBC.

FlexVP offers the following benefits to managed care organizations (MCO, HMO, IPA, etc):

· Information available 24 hours a day, 7 days a week

· Faster service to providers and members

· Decreased wait times and abandonment rates

· Increase incoming call capacity without adding service reps

· Customer defined levels of login and password security

· On-line, real-time system status checks and reporting

FlexVP Managed Care Applications

ISG has created a series of IVR applications that can be selectively integrated to provide custom call handling solutions for health care organizations, including:

Member Eligibility Application

The eligibility application allows physician or specialist providers to use a touch-tone telephone to confirm coverage status based on a member ID number. Membership eligibility information is determined through a real-time data link between the FlexVP system and the MCO’s membership database. This on-line data link assures that information provided to the caller is current.

Other information that can be given to the caller includes:

- Benefit plan coverage data

- Member name

- Primary care physician name and telephone number

- Plan and group codes

- Plan and group expiration dates

Eligibility Sample Report (Generated by ISG's on-line reporting system)

Claims Application

This application allows members and providers to retrieve basic claim information over the phone without tying up your staff. The claims application uses a data interface to access real-time claims information residing on the MCO's central computer system.

Using data entered in by the caller (provider ID, member ID, the date of service or a claim number) claims are retrieved from the MCO's database. The caller can then review each individual matching claim over the phone, or have a summary of each claim faxed to them.

The claims application can provide information on the following frequently asked claim questions:

· When was the claim processed?

· How much was paid?

· When was the paid date?

· Is the claim still pending?

Referral Application

The referral application gives providers an automated method of referring a member to a specialist and a convenient way to review previously entered referrals. FlexVP accesses referral information through a data interface and this on-line data link assures that information provided to the caller is current. FlexVP then provides the caller with all matching referral information.

The referral application can be configured to include the following:

· Referrals can be immediately entered into the MCO referral database

· Referral codes such as ICD-9 and CPT can be included

· Automatically generate referral case number or authorization number

In general, the referral application requests that the caller enter the following information: ID number of the referring physician, ID of specialist, diagnosis code, and the number of visits requested. Invalid referrals or diagnosis codes can be flagged and explained to the caller. When necessary, the caller can be transferred to a service representative to handle non-standard or problem referrals.

FlexFax Server

The FlexFax server allows for two faxes to be simultaneously sent from the voice response unit. FlexFax also allows for multiple entries during one telephone call and will combine the results into a single fax. Individual FlexFax templates are available for the eligibility, claims, and referral applications.

Depending on data availability, the fax sheet can include detailed membership, claims and referral information, as well as: name, social security number, health plan ID, sex, birthday, PCP name, PCP phone number, plan termination date and benefit summary/limitations.