SHMS Payer Platform

Cohesive approach to healthcare operations

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What is SHMS Payer Platform

A cohesive approach to all core business processes of a healthcare payer organization using an established, secure, and high-performance framework. The SHMS Payer Platform is extensible and scalable to adapt to virtually any organizational need.

  • Allows plans to delegate risk by supporting multiple capitated arrangements with providers or external MSOs.
  • Claims processing, which can be labor-intensive, is largely automated; claims are auto-adjudicated and repriced based on customizable rules and industry best practices
  • Beneficiary history, including all claims (Part A, Part B, and Part D), lab results, encounters, CMS transactions and payments, and utilization information, is centrally available providing a more complete view of the beneficiary which enables plans to better manage clinical and disease management outcomes.
  • Provider relations and network management is simplified with complete contracting, claim status and payments, and line-item EOB/EOP generation.
Extensive reporting and ad-hoc reporting tools simplify the auditing, management, and monitoring of the operational status of any functional area of the system.
Consistent approach and flexibility of the system results in improved beneficiary relations and health care outcomes.
An integrated approach to all core business processes of a healthcare payer organization provides in-depth visibility into key business performance indicators
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INTEGRATED APPROACH

All core business processes are included which provides in-depth visibility into key business performance indicators

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CLAIMS AUTOMATION

Claims processing is largely automated. Typically, 80% or more of FFS claims can be adjudicated, repriced, and paid with no human intervention required. 

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PROVIDER NETWORKS

Elaborate contracting scenarios, beneficiary network management, and automated EOB/EOP generation are fully-supported in the SHMS Payer Platform. 

More Information

From a technical perspective, the SHMS Payer Platform is a full-stack Microsoft .NET application and backend. Leveraging Microsoft SQL Server for data storage, analysis, and disaster recovery provides industry-best performance, reliability, and enterprise support.