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Technology

 
Pool Administrators Inc. has extensive experience in developing customized systems for our client’s unique business needs, and our experienced internal IT staff partners with expert IT vendors on a regular basis. Both the internal staff and vendor partners have expertise in building, maintaining and implementing specialized systems used by PAI for its administrative needs. All systems are HIPAA compliant and built to be flexible and easily adaptable to our customer’s needs.

Reinsurance System

The reinsurance system is a web based system that supports the management of information required to administer small group and individual health reinsurance pools. This custom built system simplifies administration and supports the submission of information via a secure web interface or encrypted file transfer. System functionality can include automatic calculation of reinsurance premium due (if required), as well as the reimbursable amounts for submitted claims. In addition, the system has the ability to track deductibles, cost-sharing arrangements and coverage corridors. All information regarding policies, membership, reinsured individuals, claims and premiums is stored in a secure relational central database. Reports can be generated to facilitate a complete picture of the reinsured population and related financial transactions for reconciliation. The system can be easily configured to meet a variety of reinsurance requirements.

SPARCS Subsidy Administration System

SPARCS is a custom-designed web based subsidy payment administration, reporting and control system that has the ability to:

  • Determine eligibility based on complex business rules
  • Process and maintain member enrollment activity (including multiple lines of coverage)
  • Track subsidy payments
  • Generate outbound letters
  • Store and track scanned images of inbound correspondence  

The user-friendly web interface allows customer service staff to provide a comprehensive level of customer support.  The SQL based reporting capabilities offer limitless customized reporting options, such as:

  • Customer application and appeal process tracking
  • Outbound correspondence summaries
  • Customer call type/issue trend reports
  • Financial tracking, including payment history by member or by subsidized entity

SPARCS also offers the subsidized entities access to real time eligibility data via a web interface or through a secure batch file transfer.

Coverage Gap Subsidy Processing Tool

The Coverage Gap Subsidy Processing Tool is designed to capture, store and organize prescription drug event (PDE) data, as well as to process invoices for coverage gap subsidy (CGS) costs incurred by Medicare Part D providers. This data warehouse also serves as a financial recordkeeping system to validate, track and store invoices from PDPs. It also has the ability to verify that the per member annual benefit limits are not exceeded.

The Structured Query Language (SQL) based reporting capabilities offer limitless customized reporting options, such as:
  • Financial summaries by member or provider
  • Member claim submission history
  • Plan to plan benefit reconciliation.
In addition, The Coverage Gap Subsidy Processing Tool can be linked to other databases for eligibility verification.

Billing, Collection and Membership Management System

PAI’s Billing, Collection and Membership Management system is compatible with either individual or group business. Member profiles are created and stored within the secure database. Billing is calculated and generated, taking into account prior balances and applicable member subsidy information. The Billing, Collection, and Membership System has the ability to produce a variety of standardized reports that include cancellation and delinquency data, as well as the ability to produce ad hoc query reports.

Eligibility feeds are system generated and can be transferred externally in a secure manner. Banking feeds are accepted and allow for automatic application of payments to member records. The Billing, Collection, and Membership Management System is customizable, allowing a variety of data elements to be added to expand the information capabilities based on customer needs, including additional feed capabilities.

ACT Health Plan Administrative System (Group Insurance)

ACT is an eligibility, enrollment, premium billing and payment system that is used for group insurance administration.  This system provides detailed membership and financial reports to clients and members, as well as producing data extracts for use in accounting systems.  ACT securely stores and maintains member data, including member profiles, invoice payment and plan histories. 

The ACT website (www.ACT-Connecticut.com) compliments the ACT Administrative System by offering detailed plan information to employers, brokers, providers and insured employees in an easy to follow, consumer-friendly format.  Additionally, there is an Employer Portal, which allows employers to securely verify eligibility for participation in the plan and start the enrollment process by submitting applications online. 

The ACT Administrative System and online portal were designed to minimize administrative costs and be easy for employers to understand and use, and was made possible through a grant for Qualified State High Risk Pools. 

Connecticut Health Channel Website

The Connecticut Health Channel is an innovative, consumer-focused website that serves as the single source for Connecticut public and private health insurance information.  This website, administered by PAI and the Connecticut Health Reinsurance Association (HRA), aggregates information about health care insurance options available to consumers in a simple, easy to understand format to ensure that they have access to reliable, unbiased information that fits their individual needs.   The site development and maintenance is currently funded by a federal CMS grant legislated into Connecticut state law in 2010.  In accordance with the grant, the site is available to be used as a prototype by other states that would like to create an easy to understand, informative resource for their residents.  For more information, please visit: www.cthealthchannel.org.