Softheon offers a comprehensive suite of cloud-based, HIPAA-enabled and MITA-aligned solutions to assist states in developing robust healthcare IT infrastructures for their Medicaid operations. These solutions eliminate duplicate and administrative inefficiencies, promote collaboration with key stakeholders, ensure mechanisms of enhanced transparency, and provide visibility into insurance transactions and member activities. The innovative solutions we employ with our clients include:
Health benefit shopping & account management
Softheon's plan benefits & product management platform, Clarity, presents a quote-to-card shopping experience for members, employers & brokers. Clarity empowers members to manage their own accounts, including the ability to update personal information, view current benefits, and request new ID cards.
With Clarity, your members get the tools they need to control and understand their healthcare benefits. Features include: a robust rating engine, the ability to support a wide variety of health and ancillary products, regulatory and compliance requirements, in-depth plan comparison functionality, comprehensive account management capabilities, and a configurable interface for employees and employers.
The ability to support a wide variety of health and ancillary products
Regulatory and compliance requirements for the membership served
In-depth plan comparison functionality
Comprehensive account management capabilities
Seamless enrollment processes
Configurable interface/accessibility for employees and employers
Softheon's rules-based EDI payload management platform, Gateway, exchanges enrollment information (834s) to handle the enrollment, effectuation & reconciliation of your members. Gateway was designed to eliminate the risks and issues associated with importing bad data. Our solution provides a secure and efficient integration and file transfer platform that allows you to connect to new channels with ease, while ensuring all access points remain secure
By leveraging a secure and adaptable integration center with an industry-standard file transfer and validation process, Gateway serves as a powerful solution that protects your system from bad data.
Requires that all files passed through, meet the necessary structural checks before proceeding downstream
Generate and process:
Enrollment and Eligibility Data (EDI 834)
Financial Remittance Data (EDI 820)
Medical and Pharmacy Claim Files (EDI 837)
Acknowledgement Files (999s / TA1s)
Eligibility Benefit Inquiry and Response Files (EDI 270 / EDI 271)
Financial and Medical data files for ETL (Extract, Transform, and Load)
Reconciliation Files (RCNI, RCNO, Pre-Audit, ISUIPA, and more)
Softheon's enrollment & underwriting engine, Remedy, allows you to easily enroll & effectuate members and manage ongoing member services, including processing cancellations, terminations, delinquencies, and more in real time. Remedy’s comprehensive rules engine allows you to customize your members’ enrollment processing to suit different needs. Our solution also uses role-based user access, so you can ensure each user only has access to the data they need.
Remedy serves as the foundation of our end-to-end solution suite, processing the incoming files that supplies our e-payment and data analytics solutions. This data also generates invoices, EDGE server extracts, and more.
Over 150 Enrollment Business Rules to process records
Integrated UI that provides an ease of access to view data from multiple sources
Configurable settings for simplified management and control of your system
Comprehensive audit tracking and reporting to maintain regulatory compliance
Cutting-edge matching processes to ensure enrollment and financial data consistency
Softheon's premium billing & payment aggregation tool, Equity, offers an integrated online & banking solution that provides a customer-friendly billing experience while allowing you to manage financial transactions, premium payments & financial reconciliation. As an accessible PCI DSS 3.1 Electronic Payment platform, Equity serves individuals and brokers with multi-channel options, and offers the back-end processes needed to continually manage and track their payment statuses. To assist with higher membership retention, we support all payment types including credit cards, ACH & e-Check, and lockbox processing.
As a designated Payment Facilitator, we can also conveniently and quickly process payments without any third-party involvement. This prevents payments from building up and means we’re able to deliver outstanding service with unmatched reliability.
Electronic bill presentment
Multiple payment accepted
Credit & debit cards, including: Visa, MasterCard, American Express, and Discover
ACH & e-Check: Withdraw payments directly from a customer’s bank account without interchange fees
Lockbox processing: Collect and apply paper checks to the appropriate member account with regionally based lockbox processing hubs
Third-party payment detection with configurable processing procedures, helping to prevent against authorized sponsors from illegally obtaining higher reimbursement rates
Softheon's data analytics and reporting platform, Foundry, captures and tracks every member touchpoint, analyzing both their interactions and behaviors. Foundry’s reporting capabilities provide you with all the tools necessary to access and parse data from a high-level population overview down to an individual member. This platform is also capable of generating and exporting standard reports, including the Payment Discrepancy Report, RCNI – Baseline Reconciliation file, Cost Sharing Reduction (CSR) Reconciliation report, EDGE Server processing reports, and more.
Foundry BI, the solution’s business intelligence component, features configurable, state-of-the-art tools for non-technical users. Providing the ability to “slice and dice” data in near real-time, the reporting and business intelligence suite offers comprehensive analysis of transaction trends and key performance indicators (KPIs), including member demographics, geography, financial data points, and cost comparisons.
Generation of de-identified risk adjustment and reinsurance data sets
Extract, Transform & Load (ETL) from multiple data sources to create HHS-defined claims & enrollment files
Comprehensive reporting for risk adjustments, cost sharing reduction, and profit/loss ratios
Compliance with HHS data submission and HIPAA requirements
Recovery: Back-up, restore, version, and recover capabilities
Softheon’s Asset Verification System platform, Verify, brings robust data verification and a simple workflow to complex, varied eligibility and asset verification data. Streamlining eligibility determinations for Medicaid and now, Human Service beneficiaries, Verify funnels all pertinent results into a single portal where a comprehensive business rules engine determines an overall risk score. All data is then stored, offering customized tracking, complete auditing capabilities, and extensive reporting.
Verify goes far beyond simple credit bureau data to minimize fraud, offering an industry-leading approach designed to help states develop, improve, and refine processes that achieve significant savings. A model that includes the most data sources with the largest number of identities is the only viable approach to achieve a gold-standard. By performing effective pre-enrollment asset and eligibility verification, you’ll have a proven mechanism to deter fraud, save valuable funds, and bring your state’s Medicaid program into compliance with Social Security Act §1940.
Medicaid and SNAP verification with future deliveries of TANK, cash allowance, and Long Term Care (LTC)
A comprehensive network of Financial Institutions (FIs)
Web-based Asset Verification System (AVS) portal with secure access to the world’s largest database of public records
The ability to assign asset and eligibility risk scores at the applicant and beneficiary level
Mike Sasko is a specialist in health care IT and Health Insurance Exchanges. Mike leads all strategic government partnerships. He joined Softheon in 2017, after working as a project lead, client lead, and business architect lead for several major State, Federal, and Medicaid healthcare projects. Throughout his career, he has also served various leadership roles within Accenture, Pfizer, and early stage IPO organizations. He can be reached by phone at (916) 802-0638 or email firstname.lastname@example.org
At Softheon, we strive to create simple solutions to complex problems. For over 15 years, our
innovative, easy-to-use products have revolutionized the way people control their healthcare
needs. Our agile approach, including a 90-day implementation, empowers our partners to create
the ultimate member experience. We are trusted by 60 healthcare payers participating on public
exchanges, managing 37% of the overall ACA membership.