SHMS Payer Platform
Cohesive approach to healthcare operations
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.
All core business processes are included which provides in-depth visibility into key business performance indicators
Claims processing is largely automated. Typically, 80% or more of FFS claims can be adjudicated, repriced, and paid with no human intervention required.
Elaborate contracting scenarios, beneficiary network management, and automated EOB/EOP generation are fully-supported in the SHMS Payer Platform.
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.