CMO provides a comprehensive offering of services to help manage medical and administrative costs and increase the effectiveness of healthcare benefits management. These services are available but not limited to health plans (insurance companies, HMOs, PPO's), self-insured organizations including unions, and federal and state agencies.

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Eligibility | Coordination of Benefits | Claims Processing & Billing | Electronic Claims Submission | Adjudication
Quality Assurance & Training | Appeals, Grievances and Resolution | Decision Support Services

Eligibility
Accurate claims processing begins with the ability to identify and verify eligibility as well as manage the authorization process for services. CMO has the technology and resources to maintain an accurate and current database of members and their eligibility to administer benefits under a client contract. Using CareLink, an integrated web application, participating providers can verify member eligibility, determine primary care capitation, submit referrals for consultations and office visits to participating providers, obtain authorizations for elective hospital admissions, and view the status of referral and authorization requests previously made. Membership information is continually updated for new and terminated members to ensure accurate eligibility and proper claims processing.
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Coordination of Benefits
The role of Coordination of Benefits (COB) is to coordinate the payment for services when a member has insurance coverage from more than one source. Through electronic enrollment transactions from contracted health plans and other data collection activities, COB captures coordination of benefits data to determine payment liability when other insurance coverage exists, including Medicare, other health plans, Worker's Compensation and No Fault. The goal is to prevent inappropriate, excessive or duplicate payment of a claim.
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Claims Processing & Billing
CMO delivers a full complement of lifecycle claims management services. Through end-to-end best-practice business processes, our experienced staff and state-of-the-art technology, CMO provides accurate and timely processing of claims. Our years of experience have resulted in excellent first pass rates and timely adjudication for our clients. Our familiarity with many different benefit plans and payers gives us the flexibility to customize how we receive and adjudicate claims based on the specific requirements of a plan. CMO's claims processing system uses proven technology to ensure accuracy, maximize efficiency and shorten the bill-to-pay cycle. Bill review services are also available to provide an additional level of security.
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Electronic Claims Submission
CMO has initiated an Electronic Claims Submission Program (ECSP) that allows providers to electronically submit claims to CMO. Our ECSP offers the following benefits:

• More timely and efficient claims payment
• Automated responses to providers
• Greater reliability than paper submissions
• Reduced paperwork for office staff

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Adjudication
CMO manages adjudication of all claims based on our expertise in the development of business rules and our extensive knowledge of industry practices. All our services adhere to HIPAA mandates and standard code sets.
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Quality Assurance & Training
CMO's quality assurance services conduct statistically valid claims audits to determine both financial and non-financial processing accuracy. In addition, we conduct individual quality audits on all claim processing staff to identify error trends and develop or enhance our policies and procedures, training sessions and system functionality as part of our commitment to continuous business process improvement.
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Appeals, Grievances and Resolution
CMO Customer Service oversees the complaint process including acknowledgment, investigation and timely response on all member issues. Any issue that comes into the Customer Service Department via telephone, in person or in writing is categorized as one of the following types: Appeal, Complaint, Concern, Grievance, or Inquiry. The issue type determines the resolution procedure used and ensures compliance with all state and federal laws and regulations, NCQA guidelines and contractual obligations. In addition, CMO will actively seek feedback from members on behalf of their clients through follow-up and satisfaction surveys and use this valuable information to continuously enhance the care and services it provides.
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Decision Support Services
CMO has the technology and expertise to offer a full range of Decision Support Services to enhance medical, quality, financial and marketing decision-making. Our team is comprised of highly qualified healthcare support staff. We have at our disposal the latest data mining, data warehousing and reporting tools to provide critical healthcare business intelligence. Our organization is dedicated to providing clients with practical, powerful and effective information to improve the quality, process and outcome of patient care while managing costs.

We can provide standard, customized and ad hoc utilization reports as well as:
Financial and Cost Analysis

• HEDIS
• Clinical Outcomes Analysis
• Population Profiling
• Satisfaction Survey Reports

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