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TruCare Utilization Management

Intuitive, dynamic, and affordable digital utilization management tools align health plans and providers to work effectively together to reduce over-utilization, erroneous requests, and back-and-forth, all while improving the timeliness and appropriateness of care

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How we help

Utilization Management supports the authorization life cycle from entry to determination

Seamless Process Management

Our business rules engine allows users to create bulk or individual tasks, send tasks to queues, develop messages, generate correspondence, and open cases based on configured rules.

Automated Authorization Processing

Enables automated and digital processing of authorizations for pre-certified claims submitted through multiple channels, such as 278 transactions, fax, or ETL, supporting multiple types of authorizations, including inpatient, ambulatory, services & procedures, and pharmacy.

System-guided Workflows

TruCare ensures consistent, efficient, and proper utilization - saving the client’s time, resources and money. Users can create population-specific utilization management rules by line of business, geography, contact, and more.

Transform your care model with next-gen population health

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TruCare®Standard

Prebuilt processes and a powerful, configurable rules engine that automates authorization request workflows and auto-approvals. Users are guided step-by-step through authorizations, reviews, medical-necessity criteria, determinations, appeals and grievances, and notifications via automatic letter generation.

TruCare®ProAuth™ Version

In addition to the features offered through the Standard version, enables an interactive digital authorization management tool designed to make the authorization process easy for providers and display real-time updates regarding prior authorization decisions from the plan.

Key Value-based Features

What makes TruCare a truly unique and integrated population healthcare solution is our all-in-one platform and the wrap-around features that support every aspect of the tool

Use our TruCare ®Pre-Screener to configure guided workflows for authorization rule sets and next steps for clinical review, secondary review, determination, and notification processes. 

Configure intake rules, turnaround times, and approvals for request type by provider, diagnosis, procedure/services code, and thresholds using our intuitive business rules engine.

Handle all prospective, concurrent, and retrospective review processes with our pre-built templates for clinical review notes and determinations, integrated with third-party clinical guidelines.

Use our structured note templates to capture required data and quickly pass it into our auto-generated template-driven Microsoft Word-based letters or integrate it with your correspondence management system through our Connected Health suite of products.

TruCare provides native application program interface (“API”) integration with Change Healthcare's InterQual® Connect and MCG's CareWebQI® to allow clinical guidelines and determination details to be automatically populated in the authorization.

Manage the authorization appeals process with pre-built workflows to create, review, and provide outcomes to revise /uphold the authorization determination.

TruCare includes comprehensive authorization reporting with real-time dashboards across all data in the system.

With the TruCare®ProAuth™ add-one, TruCare® Utilization Management is seamlessly embeddable into a third-party provider portal giving 24x7x365 access to submit prior authorizations and receive real-time responses.

Return on Investment

Claims Savings

 A Midwest health plan achieved $1.2 million in annual claims savings attributed to readmission rates dropping from 13% to less than 10% since going live with the TruCare Platform.

Increased Automation

A major health plan experienced a 34% increase in the automation of outpatient authorization determination and a 22% increase in the automation of inpatient authorization determinations via the TruCare Platform.

Resource Savings

An East Coast health plan was able to re-focus an entire team of information technology resources due to process automation achieved with the TruCare Platform.

Reduced Errors

A national payer saw a 60% reduction in erroneous claims payments across their 19 health plans using the TruCare Platform.

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