| Management Information Systems |
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| La Cruz Azul decided to acquire the Power Managed Healthcare System (POWERMHS) product in response to the need of a new information system that could integrate all the functions realized by claims, enrollment, servicing, and finance areas. Also that could serve as support to other department's functions as providers and Governmental programs. |
- Count with an information system totally integrated.
- Create a file that maintains the history of our insured's contracts.
- Adjudicate claims
- Obtain precise information in utilization areas, providers and physician costs.
- Transmit information under HIPAA law regulation (universal standards)
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| La Cruz Azul decided to acquire the Power Managed Healthcare System (POWERMHS) product in response to the need of a new information system that could integrate all the functions realized by claims, enrollment, servicing, and finance areas. Also that could serve as support to other department's functions as providers and Governmental programs. |
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| Computer Assisted Credentials Tracking & Update System was designed to facilitate the process of qualifying providers. It tells us if providers are up-to-date, qualified and certified. It helps us to adhere to the standards of the NCQA and the URAC. Keeps us involved in the Medicare Advantage and Reforma markets. CACTUS also offers a wide network of pharmacies and companies outside of Puerto Rico to choose from. One of the most significant advantages is the easy access to details such as: personal or professional locations, initial approval dates, certification, re-certification information, cancellation & expiration of documents, education, licenses and policies of medical knowledge. |
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| VIPS/STAR Sentinel is an electronic services tracking, analysis & reporting system. It was created to minimize the instances of fraud, abuse and misuse of services offered by La Cruz Azul de Puerto Rico, Inc. This program is a tool for the analysis of information directed to the detection of fraud, investigation, documentation & coordination of health services. It facilitates the functions of analysts and investigators by looking into: use trends, invoicing patterns, and deviation from statistical relations caused by fraud and abuse; it also focuses on the medical practices, uses & profiles of providers. |
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| La Cruz Azul de Puerto Rico, Inc, has incorporated this totally automatic system that verifies the coding of claims submitted by providers. This system adheres to the standards and protocols of the CPT manual, coding guides of CMS, HCPCS Level III and other references specializing in the medical field. With this system we assure ourselves to be paying correctly for services rendered and complying with HIPPA requirements. Along with Claim Check ® we offer Clear, Claim, Connection (C3). This new tool is for use by providers via the Internet. It gives providers access to: check policies & rules related to claim submission, explanations and relations of codes used via Claim Check ®, and the resources used to determine them.
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