GPS Medicare Administration Support Tools
GPS Enrollment Administrator
Complete enrollment management tool
Key Features:
- Real time enrollment / disenrollment of members
- Loads batch enrollment files (frequency customized to client)
- Maintains enrollment history and complete audit trail of all data changes
- Generates eligibility files to support vendor needs (PBM, claims system, etc)
- Generates Part D enrollment submission files (RDS, BEQ, MARx and 4Rx)
- Imports CMS files (RDS response, TRR, COB, LIS) and updates enrollment information
- Part D enrollment reports customized for client to support eligibility administration
- Generates COBA submission files (medical and prescription)
- Imports COBA response files an update enrollment information
GPS Claim Auditor
Electronic prescription claim audit and reporting tool
Key Features:
- Verifies valid NDC codes
- Verifies proper AWP assignment (First Data Bank or Medispan)
- Verifies proper application of the contracted discounts, maximum allowable cost (MAC) arrangement and dispensing fees
- Verifies proper claim member cost sharing requirements
- Verifies proper claim adjudication in accordance with covered and excluded drugs
- Verifies proper claim adjudication in accordance with clinical protocols (i.e. refill too soon, quantity limits, prior authorizations and formulary compliance)
- Verifies claim payment made only for enrollees (Interfaces with GPS Enrollment Administrator)
GPS PDE Administrator
Creates, tracks and manages PDE submissions
Key Features:
- Creates PDE records using claim, enrollment and plan design data
- Tracks TrOOP based on claim experience (including P2P transactions)
- Pre-edits PDE based on DDPS error codes
- Generates PDE submission files
- Imports PDFS and DDPS response files
- Reports on rejected and accepted PDE for plan management
- Stores all PDE submission and response files
GPS Reconciliation Manager
Tracks actual plan expense versus CMS prospective payments and reports overpayment/underpayment amounts
Key Features:
- Using PDE, DIR and approved plan bid amounts, calculates plan expenses
- Using Monthly Member Detail reports and approved bid amounts, calculates prospective payments
- Using calculated plan expenses and prospective payments, reports on reconciled Low Income Cost Sharing (LICS), reconciled reinsurance , risk corridor and risk sharing amounts
GPS Medicare Advisory and Support Services
- Application filings and contract renewal support
- Communication generation
- Retroactive enrollment processing support
- CTM / customer service support
- Compliance program support
- HPMS reporting support
- Payment attestation support
