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A Fast and Easy Solution for Pharmacy Benefit Managers

MedHOK integrates the enterprise, optimizes Risk, Care, and Quality, and ensures government compliance

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Pharmacy Benefit Managers

As managers of pharmacy benefits for millions of members, the PBM is responsible for ensuring compliance with state and federal regulations and meeting service level agreements (SLAs) with payers.

MedHOK’s solutions for PBM include

  • Prior Authorizations- Rx: MedHOK’s pharmacy prior authorization solution is a fully CMS compliant for processing Coverage Determinations (prior Authorization), Redeterminations (Rx Appeals), Direct Member Reimbursements, and IRE for Medicare Part D plans (External Pharmacy Appeals). The out-of-the-box functionality supports Medicaid and commercial books of business. The module includes multiple intake channels including electronic prior authorization through our 360EPA® functionality, auto-population of eligibility data, the captures of all key data elements needed for the processing of each case and structured workflow with individual user roles and responsibilities/functions that define which task can be completed by the specific user.
  • Complaints Tracking Module: MedHOK’s CTM is a CMS compliant workflow solution for processing and tracking CMS Medicare member and Part D complaints. The module has integration capabilities with CMS for bi-directional loading of case files. The system offers a structured workflow based on individual user roles with responsibilities/functions that define which task can be completed by the specific user. The system-defined workflow ensures that cases are processed consistently and correspondence is triggered automatically and attached to the original case. The dashboard allows for real-time monitoring of activity by management and promotes a proactive approach to case load and compliance deadlines.
  • Grievances: MedHOK’s grievance module is a CMS compliant workflow solution for managing all grievances across the organization. The system-defined workflow ensures that cases are processed consistently and correspondence is triggered automatically and attached to the original case. A dashboard allows for real-time monitoring of activity by management and promotes a proactive approach to administering case load and meeting compliance deadlines.
  • 360Star®: MedHOK has designed a Part D Star performance product that helps plans identify deficiencies and opportunities for improvement on a year-round basis and push for 4 and 5 Stars. MedHOK’s comprehensive 360Star® monitoring dashboard reports on current Star scores (by state, contract number, product, etc.) and measures against targets. Status of each measure and progress toward goals are displayed, along with mitigation activities performed using the comprehensive workflow solution.
  • MTM: MedHOK’s Medication Therapy Management (MTM) software offers a structured workflow solution for the processing and tracking of medication reviews, interventions and therapy changes performed on eligible beneficiaries of the MTM program. The software identifies beneficiaries at least quarterly for program enrollment based on established MTM program parameters submitted to CMS by Part D plans. The system measures and reports on the number of comprehensive medication reviews, number of targeted medication reviews, number of prescriber interventions, and changes in therapy directly resulting from performed interventions.
  • Rx Specialty Management: MedHOK’s Rx Specialty Management solution offers plans, PBMS, and other entities the ability to operate patient-specific clinical programs that center on medication management to improve patient drug adherence and clinical outcomes. The solution utilizes an intelligent workflow system that optimizes the resources used to manage and perform drug and manufacturer assessments for patients. The business configurable software solution allows for the creation, processing, and tracking of patient /drug assessment programs to be performed in a structured workflow that automates the calendaring of assessments and the triggering of evaluations and interventions based on individual needs and program parameters.

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