Third Party Administrators Services for Healthcare Insurance Providers

SERVICES FOR THIRD PARTY ADMINISTRATORS

Sun Knowledge 41 Madison Avenue, 25th Floor, New York, NY 10010

WHO WE ARE

Key Facts Awards, Affiliations & Certifications

2Sun Knowledge © 2015-16 Private & Confidential

‘Onshore /Offshore’ KPO & BPO Services Serving US healthcare industry since 2007 Robust & scalable infrastructure State-of-the-art technology and systems Highly skilled and trained staff with good

communication skills and in-depth knowledge of process

Structured training, feedback and coaching HIPAA-HITECH compliant State-of-the-art office inbuilt with all redundancies –

power, infrastructure and others

ISO 27001:2013 and ISO 9001:2008 certified CMMi-SVC implementation in progress under KPMG

guidance Member of NASSCOM, the Governing Industry body for

IT/ITES in India Awarded ‘Best Emerging BPO Company of the year 2010’

by The Economic Times, India Recognized as one of the foremost 'Emerging companies in

Eastern India' by NASSCOM in 2011 Awarded Asia-wide ‘Healthcare BPO Provider of the Year’

at the Asia BPO Excellence Awards ceremony hosted by Asia BPO Summit on 14th February 2013 in Mumbai, India

Awarded the prestigious ‘Outsourcing Service Provider of the Year’ award in the Asian Outsourcing Excellence Awards ceremony hosted by CMO Asia on 1st August 2013 in Singapore

Awarded ‘Highest New Job Creator (IT/ITES)’ by STPI (Software Technology Parks of India) on 3rd December 2015

41 Madison Avenue, 25th Floor, New York, NY 10010, USA

Office at 41 Madison Avenue, 25th Floor, New York, NY 10010

WHAT WE DO

Provider SupportMember SupportMember Retention ProgramClinical Help Desk

Contact Center

Utilization ManagementMedication Therapy ManagementHospital Re-admission

ManagementTherapeutic InterchangeFormulary Management

Clinical Services

Medical Coding & BillingClaims AdministrationEnrollment Processing &

MemberFulfillmentCredentialing Premium billing and collections

Administrative Services

Analytics

Telemedicine ServicesRemote Patient MonitoringApplication Development & SupportTechnical SupportTechnical Documentation

IT Services

Claims /Drug Utilization AnalysisPDE AnalysisRAF AnalysisPayment Reconciliation

3Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA

We provide services toPROVIDERS – Physicians, Hospitals, DME, P&O, Home Health Care and Pharmacies

PAYERS – Commercial Plans, MA Plans, Medicaid HMOs, MAPD/PDPs, IPAs, MSOs, TPAs, PBMs and RBMs

SERVING THIRD PARTY ADMINISTRATORS


Third Party Administrator (TPA) is an organization that processes insurance claims on behalf of an Insurance Company.

TPA’s play an important role in the Health Insurance sector by ensuring better services to Policy Holders.

Since 2009, we have been continuously serving some of the major TPA’s of the US, including Heritage Provider Network, California and HealthCare Partners, IPA of New York in claim adjudication, vendor credentialing and customer care.

QUICK DEFINITION

KNOW OUR CLIENTS


Today, Heritage Provider Network is comprised of 2,100 primary care physicians, over 30,000 specialists and numerous affiliated hospitals. It is one of the most competitive and cutting-edge network providers in the nation and one of the largest in California.

It currently serves over 700,000 individuals in California, making it one of the largest IPA’s in the United States.

The New York operation currently serves over 70,000 individuals, including over 35,000 Medicare Advantage beneficiaries.

Founded by Richard Merkin, M.D. in 1979 to provide affordable, quality healthcare to its members through innovative programs and services designed specifically for the managed care environment.

KNOW OUR CLIENTS


Since 1996, HealthCare Partners, IPA has been a leading physician-owned organization located in New York that manages and administers healthcare products for contracted health plans.

HealthCare Partners is the name behind a number of programs for their members that are aimed at promoting health and wellness, identifying member risk factors and applying the principles of proactive, preventive health care.

They provide services in the following areas:

NETWORK OPERATIONS• Credentialing• Provider Services• Contracts

CLINICAL SERVICES• Case Managers• Utilization Management

CUSTOMER SERVICE• Claims Operations• Member Inquiries

OUR HIPAA COMPLIANCE SUMMARY


SL. COMPLIANCE ASPECT HIGHLIGHTS

1 Physical Access Authorized access only | Bio-metric access | Proximity card system | Photo ID cards | Access log review

2 General Security 24 hour security personnel | Logging of visitor details | Physical register retained for 10 years

3 Monitoring CCTV monitoring (with recording) of production area | Daily review of recording

4 Vendor Access Signing confidentiality agreement before accessing sensitive areas | Accompanied by security personnel/employee during all times

5 Mobile Phones All employees (except managers) are required to deposit mobile phones in the locker box before entering facility

6 Personal Baggage No backpacks or other bags allowed | All baggage to be deposited in locker box before entering facility

7 Network & Application Usage

Unique user IDs created using Microsoft Active Directory | Access to storage devices, shared drives, USB/mass storage devices, printers – controlled by Domain Group Policy | No wireless access points

8 Firewall Unified Threat Management System | Internet traffic regulation using multiple filters | Network Address Translation (NAT) | Intrusion Prevention Systems (IPS) | Port-mapping for traffic between Virtual LANs | Default setting to deny all traffic

9 VPN (Virtual Private Network)

Site-to-site IPSec VPN tunnels | Authorized access via client-to-site VPN connections | Access authorization controlled by Active Directory's authentication service

10 Redundancy Management

Fully redundant network stack | Two ISP links configured in active-active mode | Power backup supplied by 130 KVA UPS and 750 KVA generator | 22 KVA UPS backup for server and network systems

11 Virus & Malware Protection

Central anti-malware system | Automatic updates | Extra protection by gateway firewall | Centralized OS patch management system (using Microsoft's WSUS server)

12 Other Measures Fire extinguishers at key areas | Half-yearly fire drills

SUMMARY OF SERVICES


PRACTICE MANAGEMENT

Scheduling

Eligibility & Authorization Verification

Prior Authorization

Customer Care

MAIN SERVICES FOR THIRD PARTY ADMINISTRATORS


CLAIMS PROCESSING (PROFESSIONAL)

CLAIMS PROCESSING (FACILITY)

CUSTOMER CARE – MEMBER & PROVIDER

SERVICE

ADDITIONAL SERVICES


Processing of enrollment application/files received from beneficiary/CMS/SPAP/EGWP on the same day of receipt of the file Real-time eligibility verification during enrollment process Auto generation of enrollment transaction file through scheduled job and transmission to CMS Consistently achieved 100% LIS match rate Retroactive enrollment and disenrollment processing and sending transactions to CMS Generation of exception reports at every stages of enrollment processing which in turn reduces errors and triggers corrective

action Reconciliation of beneficiary records with CMS data Strict adherence to CMS compliance requirements and timeliness Consistently achieved 100% LIS match rate

Delivery of all printing materials within the timelines specified by CMS and thereby increasing member satisfaction Generation of enrollment specific letters and enrollment kit after receiving acceptance of enrollment transaction from CMS Generation of disenrollment letters after receiving intimation from CMS or acceptance of disenrollment transaction from

CMS Preparation of datasheet for letter generation by the printer Coordination with the printing and mailing company to send members their welcome kits, ID cards and other letters or

statements on time Tracking and managing, printing and mailing work to comply with CMS specified timelines

Member Fulfillment

Enrollment Service

ADDITIONAL SERVICES


Generation of invoices based on plan premium, CMS subsidy on premium, payment mode (SSA/Direct) and effective date of enrollment & disenrollment

Verification of premium invoice with monthly member files from CMS (MONMEMD and FEFD) Timely generation and mailing of invoices to the members as per invoicing schedule Generation and mailing of SPAP Invoice Timely and correct posting of payment received Payment reconciliation and generation of periodic outstanding payment report Payment reconciliation using MONMEMD file and member eligibility data Premium payment reconciliation and reporting

Forecasting of CMS payments – LIS Premium, Risk Adjusted Direct Subsidy, Reinsurance Subsidy and Low Income Cost Sharing Subsidy

Monthly reporting of region wise cash flow Reconciliation of Low Income Cost Sharing Subsidy Reconciliation of reinsurance subsidy Reconciliation of direct subsidy Computation of risk sharing/ risk corridor cost Computation of period-wise P2P payables & receivables and reconciliation

Payment Reconciliation

Premium Billing & Collection

ADDITIONAL SERVICES


Dedicated clinical services team comprising of physicians and pharmacists Final decision making process involves qualified physicians at US Reduces the standard procedure turnover time from 72 hours mandated by CMS to 48 hours. Expedited procedure to determine authorization within 24 hours Standardized process and effective application of pharmacoeconomics before rendering any decision Sun Knowledge is equipped with specialized clinical customer support help desk working 24x7

Proprietary MTM software conducts automated screening of claims data and flags Drug-Drug Interaction, Drug-Disease interaction, Drug Adverse effects, Drug Duplications, etc. to improve overall quality of care.

Identifies MTM eligible members, data mining on Claims data to identify drug complications, conflicts and interactions Ensures that correct medication, dose and dosing regimen is prescribed Qualified pharmacist and healthcare professionals conduct quarterly & annual review and recommends treatments for

improvement Improve outcomes while controlling medical costs & member education program

Medication Therapy Management

Utilization Management

ADDITIONAL SERVICES


Claims forms entry – HICF1500 & UB04 Online and offline authorization/referral request entry Maintained 24 hours TAT consistently Consistently achieving 98% accuracy

Online and offline provider data entry Service address, phone & fax Billing address, phone & fax NPI, TIN, License no. etc Credentialing related information

Creation of professional & provider IDs in claims system Attaching fee schedules/contracts to professional /provider Preparation of report for credentialing committee meeting Preparation of client specific reports as per schedule Real time audits: 5 – 8 % entries audited

Consistently achieving more than 99.5% accuracy

Credentialing & Provider Data Maintenance

Data Entry – Claims & Utilization Management Fax

ADDITIONAL SERVICES


Brand vs. Generic utilization Protected and non-protected class Average beneficiary utilization, number of Rx, TDC, etc Utilizing member Pharmacy chain (in-network or out-of-network) Formulary and non-formulary Fraud, waste and abuse detection and control Reject claims analysis

Consistently maintained better than industry PDE Acceptance Rate (>99.5%) Identification and classification of PDE errors reported by CMS based on eligibility and non-eligibility issues PDE error resolution based on PDE reports Follow up with PBM for reprocessing / regenerating the corrected PDE records for both eligibility and non-eligibility issues Reconciliation of new PDE records with the rejected records to identify missing records Submission of new PDE file to CMS

PDE Analysis & Reconciliation

Drug Utilization Analysis

CLIENTSPEAK

15Sun Knowledge © 2015-16 Private & Confidential

“I was always against the idea of outsourcing our back end claims processing work but I was wrong. Sun Knowledge provided extraordinary deliverables on a timely basis which led to cost cutting considerably for us.”

CEO of a leading MA-PD Plan

Ronnie Hastings(646) 661-7853Email: [email protected]

Sun Knowledge41 Madison Ave., Suite 2511, 25th Floor

New York, NY 11001, USA

For Additional Information, Please Contact…

41 Madison Avenue, 25th Floor, New York, NY 10010, USA

Third Party Administrators Services for Healthcare Insurance Providers

Healthcare

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