Note: The descriptions below may be updated from time to time to reflect product and service changes. The Solutions available to Sponsor are subject to purchase.
THIRD PARTY ADMINISTRATION SERVICES SOLUTION DESCRIPTIONS
CORE ADMINISTRATION SERVICES
| Service | Description |
|---|---|
| Medical Claims Administration – Core Administration |
Core Administration is inclusive of: Medical/RBP claims administration, navigation and advocacy for Personify Health administered plans, and Core Wellbeing.
Medical/RBP claims administration:
|
| Member Services | Provides chat and toll-free member support after launch with Personal Health Advocates via chat and phone during normal business hours. The chats are handled within a secure environment within the Personify Health app. The toll-free number is listed on member ID card, website, and within the app. |
| Personalized Health Platform |
Our Personalized Health Platform equips members and client administrators with a centralized, easy-to-use solution for managing health benefits and improving engagement. Accessible via web and mobile app, the platform includes:
|
| Member Communications | Member and system-generated communications to engage members and align with client-specific needs. Using cost-effective, member-focused tools including flyers, posters, emails, app/portal messaging, secure texts, and phone calls to deliver tailored outreach in collaboration with the client. |
| Personify Health Informatics | Personify Health’s analytics platform leverages advanced predictive analytics to provide a comprehensive view of current and future health risks and costs for any population. It transforms complex healthcare data into actionable insights, enabling organizations to effectively manage health risks and optimize costs. The platform ingests and reports on data from various sources to offer insights into financial, eligibility, benefits usage, clinical, and demographics. |
| Core Wellbeing | Digital wellbeing included in TPA core and enhanced administration that includes: NCQA-certified health risk assessment, claims-validated gaps in care, Total Health content pack, daily cards, healthy habits, journeys, media library, personalized action lists, Personify Health IQ, stats, topics of interests, trophies, device integration. Does not include rewards or social features. |
| Cost Containment |
Subrogation: Personify Health pursues and pays for medical treatment, when another entity is primarily responsible for that payment. In such instances, Personify Health may seek reimbursement directly from the primarily responsible payer.
Dialysis management: This program identifies members with end-stage renal disease (ESRD) and coordinates Medicare enrollment and premium reimbursement. Once enrolled in Medicare, Personify Health pays dialysis claims at 125% of Medicare. Enhanced cost containment: Personify Health’s enhanced cost containment solutions help to identify and detect, prevent and correct improper activities and overpayments to ensure that resources are effectively utilized and minimize financial losses. Personify Health’s enhanced cost containment solution includes: payment integrity, out-of-network negotiations, bill audits, and claim editing. Payment integrity: employs an exhaustive set of processes, continuously updated library of fraud schemes, integrated technologies, deep expertise, and best-of-breed partnerships. Our processes include both automated and manual audits during every step in the life of a claim: during the adjudication of a claim, post-adjudication but before payment of the claim, and after payment of the claim via retrospective reviews. 100% of claims are checked multiple times and each scheme has multiple passes to be identified. Out-of-network negotiations: are bounced against multiple wrap networks (e.g., Zelis) and multiple datasets including Medicare, UC&R, No Surprise Act (NSA) for Qualifying Payment Amounts (QPAs), Personify Health’s historical negotiated rates, and outstanding payments and refunds. Historical data allows claims to be assessed based on their risk of grievances and appeals should a non-guaranteed pricing method be used. A machine learning model provides a scoring for likelihood of a grievance and appeal with an unsecured method – trained continuously using Personify Health’s data. Personify Health’s negotiations team makes a final determination on the optimum methodology to drive the greatest savings. Should a verbal negotiation be deemed most appropriate, the negotiator will call the provider, sharing any relevant information such as historical cases and rates honored in order to secure a rate with guarantees against any appeals or further billing. Bill audits: Bill audit processes include aggressive requests for additional documentation (e.g., longitudinal medical records, itemized bills, encounter notes, credentials, etc.), and span across both medical and pharmacy benefit and both in-network and out-of-network claims to ensure no spend area is under-focused. Our fraud technology enables rapid identification of schemes (e.g., through advanced analytics) and rapid implementation of prevention levers (e.g., automated workflows so that claims processors do not need to manually escalate claims from providers or members newly identified as high-risk). Claim editing: Personify Health reviews medical claims for compliance with policies and regulations, checking for errors, fraud, and ensuring services are medically necessary and correctly coded. |
| Case Management | Personify Health’s Case Management program delivers targeted support for members facing acute, complex, or catastrophic health conditions, as well as those at risk of high-cost claims. Personal Care Managers facilitate communication among patients, families, and providers to ensure coordinated care and adherence to individualized care plans. Services include: direct clinical support and whole-health care coordination; cost-saving triage and early intervention strategies; behavioral health case management; management of complex conditions including chronic disease, cancer, transplants, CKD/ESRD, and high-risk maternity; post-discharge follow-up and transitional care; large claim notification and redirection to Centers of Excellence when appropriate. |
| Utilization Management | Utilization review of medical necessity for members that allows for a discussion of progression of disease and alternative medical options. This program provides referrals to case management or chronic disease management for additional clinical support for members. Includes medical necessity, clinical & intake, precertification, post-service/claims, concurrent/prospective/retrospective review, coordination of appeals, discharge planning, and PPO channeling. |
| Personal Health Advocates | Provides primarily inbound support to members for technical and program-related inquiries, assistance with understanding plan benefits, and billing questions. When appropriate, facilitate warm handoffs to other teams to ensure seamless issue resolution. |
| Implementation | Personify Health’s implementation is inclusive of: Communications strategy and education campaign, continuation of care, Electronic Data Interchange (EDI) integrations, eligibility exchanges, ID card creation and delivery, Personalized Health Platform setup, plan review and plan building, Summary of Benefits and Coverage (SBC) review and creation (in English and Spanish when requested for no additional fee), Summary Plan Document (SPD) review and creation (in English and Spanish when requested for no additional fee), and system testing and training. |
| Plan Renewal |
Plan Renewal is inclusive of the following:
|
| PBM Integration | Personify Health supports Pharmacy Benefit Management (PBM) integration through client-selected contracts by transmitting eligibility and accumulator data to the client’s PBM to manage combined deductibles and out-of-pocket amounts. Data is securely loaded into Personify Health’s data warehouse to generate analytical reports and provide clinical teams with a comprehensive view of each member’s health journey. |
| Stop Loss and PBM Non-preferred Vendor Integration Fee | Personify Health charges an integration fee to cover the setup and support needed to connect non-preferred stop loss and pharmacy benefit manager vendors to our system. It includes everything required to ensure smooth operations and data sharing: claims, eligibility, and accumulator data, coordination with vendors and internal teams, contract reviews and negotiations, required filings and compliance. |
| Stop Loss Integration | Personify Health coordinates with client-selected contracts for stop loss carrier to file claims with them related to the health plan. |
| Stop Loss Marketing, Placement & Integration | Personify Health assists in securing stop loss coverage through our preferred partners to deliver an optimal combination of rates and service. We utilize A-rated carriers for timely claims reimbursement. Through our negotiation power, innovative, cost-saving medical management programs, and unique stop loss plan designs, we can deliver lower stop loss premiums. We can carve out and provide organ transplant and gene therapy programs through select partners. Personify Health stop loss/reinsurance plan management includes stop loss bid marketing, placement, contract management, and filing and managing reimbursements, along with comprehensive stop loss reporting. |
ENHANCED ADMINISTRATION SERVICES
| Service | Description |
|---|---|
| Medical Claims Administration – Enhanced Administration |
Enhanced administration is inclusive of: Medical/RBP claims administration, Complete Care Navigation, and Core Wellbeing
Medical/RBP claims administration:
Complete Care Navigation
|
| Member Services | Provides chat and toll-free member support after launch with Personal Health Advocates via chat and phone during normal business hours. The chats are handled within a secure environment within the Personify Health app. The toll-free number is listed on member ID card, website, and within the app. |
| Personalized Health Platform | Our Personalized Health Platform equips members and client administrators with a centralized, easy-to-use solution for managing health benefits and improving engagement. Accessible via web and mobile app, the platform includes comprehensive features for benefit management, claims tracking, provider search, and wellbeing resources. |
| Member Communications | Member and system-generated communications to engage members and align with client-specific needs. Using cost-effective, member-focused tools including flyers, posters, emails, app/portal messaging, secure texts, and phone calls to deliver tailored outreach in collaboration with the client. |
| Personify Health Informatics | Personify Health’s analytics platform leverages advanced predictive analytics to provide a comprehensive view of current and future health risks and costs for any population. It transforms complex healthcare data into actionable insights, enabling organizations to effectively manage health risks and optimize costs. The platform ingests and reports on data from various sources to offer insights into financial, eligibility, benefits usage, clinical, and demographics. |
| Core Wellbeing | Digital wellbeing included in TPA core and enhanced administration that includes: NCQA-certified health risk assessment, claims-validated gaps in care, Total Health content pack, daily cards, healthy habits, journeys, media library, personalized action lists, Personify Health IQ, stats, topics of interests, trophies, device integration. Does not include rewards or social features. |
| Cost Containment |
Subrogation: Personify Health pursues and pays for medical treatment, when another entity is primarily responsible for that payment. In such instances, Personify Health may seek reimbursement directly from the primarily responsible payer.
Dialysis management: This program identifies members with end-stage renal disease (ESRD) and coordinates Medicare enrollment and premium reimbursement. Once enrolled in Medicare, Personify Health pays dialysis claims at 125% of Medicare. Enhanced cost containment: Personify Health’s enhanced cost containment solutions help to identify and detect, prevent and correct improper activities and overpayments to ensure that resources are effectively utilized and minimize financial losses. Personify Health’s enhanced cost containment solution includes: payment integrity, out-of-network negotiations, bill audits, and claim editing. Payment integrity: employs an exhaustive set of processes, continuously updated library of fraud schemes, integrated technologies, deep expertise, and best-of-breed partnerships. Our processes include both automated and manual audits during every step in the life of a claim: during the adjudication of a claim, post-adjudication but before payment of the claim, and after payment of the claim via retrospective reviews. 100% of claims are checked multiple times and each scheme has multiple passes to be identified. Out-of-network negotiations: are bounced against multiple wrap networks (e.g., Zelis) and multiple datasets including Medicare, UC&R, No Surprise Act (NSA) for Qualifying Payment Amounts (QPAs), Personify Health’s historical negotiated rates, and outstanding payments and refunds. Historical data allows claims to be assessed based on their risk of grievances and appeals should a non-guaranteed pricing method be used. A machine learning model provides a scoring for likelihood of a grievance and appeal with an unsecured method – trained continuously using Personify Health’s data. Personify Health’s negotiations team makes a final determination on the optimum methodology to drive the greatest savings. Should a verbal negotiation be deemed most appropriate, the negotiator will call the provider, sharing any relevant information such as historical cases and rates honored in order to secure a rate with guarantees against any appeals or further billing. Bill audits: Bill audit processes include aggressive requests for additional documentation (e.g., longitudinal medical records, itemized bills, encounter notes, credentials, etc.), and span across both medical and pharmacy benefit and both in-network and out-of-network claims to ensure no spend area is under-focused. Our fraud technology enables rapid identification of schemes (e.g., through advanced analytics) and rapid implementation of prevention levers (e.g., automated workflows so that claims processors do not need to manually escalate claims from providers or members newly identified as high-risk). Claim editing: Personify Health reviews medical claims for compliance with policies and regulations, checking for errors, fraud, and ensuring services are medically necessary and correctly coded. |
| Case Management | Personify Health’s Case Management program delivers targeted support for members facing acute, complex, or catastrophic health conditions, as well as those at risk of high-cost claims. Personal Care Managers facilitate communication among patients, families, and providers to ensure coordinated care and adherence to individualized care plans. Services include: direct clinical support and whole-health care coordination; cost-saving triage and early intervention strategies; behavioral health case management; management of complex conditions including chronic disease, cancer, transplants, CKD/ESRD, and high-risk maternity; post-discharge follow-up and transitional care; large claim notification and redirection to Centers of Excellence when appropriate. |
| Chronic Disease Management | NCQA-certified chronic disease management program proactively addresses care gaps to help members manage chronic conditions, reduce hospitalizations, and improve quality of life. Through outbound outreach and coordinated clinical support, the program empowers members to take control of their health journey. Focus areas include asthma, metabolic and cardiac diseases, COPD, and mental health/substance abuse, with customization available to meet client-specific needs. |
| Utilization Management | Utilization review of medical necessity for members that allows for a discussion of progression of disease and alternative medical options. This program provides referrals to case management or chronic disease management for additional clinical support for members. Includes medical necessity, clinical & intake, precertification, post-service/claims, concurrent/prospective/retrospective review, coordination of appeals, discharge planning, and PPO channeling. |
| Personal Health Advocates | Provides empathetic, multi-channel support (app, email, phone) with direct access for high-need members. Services include comprehensive benefits guidance (medical, dental, vision, Rx), early clinical intervention, care coordination, provider referrals, and support for social determinants of health. The team offers both inbound and outbound concierge-style advocacy, warm handoffs to Case Management, and scheduling with coaches via asynchronous messaging. |
| Implementation | Personify Health’s implementation is inclusive of: Communications strategy and education campaign, continuation of care, Electronic Data Interchange (EDI) integrations, eligibility exchanges, ID card creation and delivery, Personalized Health Platform setup, plan review and plan building, Summary of Benefits and Coverage (SBC) review and creation (in English and Spanish when requested for no additional fee), Summary Plan Document (SPD) review and creation (in English and Spanish when requested for no additional fee), and system testing and training. |
| Plan Renewal |
Plan Renewal is inclusive of the following:
|
| PBM Integration | Personify Health supports Pharmacy Benefit Management (PBM) integration through client-selected contracts by transmitting eligibility and accumulator data to the client’s PBM to manage combined deductibles and out-of-pocket amounts. Data is securely loaded into Personify Health’s data warehouse to generate analytical reports and provide clinical teams with a comprehensive view of each member’s health journey. |
| Stop Loss and PBM Non-preferred Vendor Integration Fee | Personify Health charges an integration fee to cover the setup and support needed to connect non-preferred stop loss and pharmacy benefit manager vendors to our system. It includes everything required to ensure smooth operations and data sharing: claims, eligibility, and accumulator data, coordination with vendors and internal teams, contract reviews and negotiations, required filings and compliance. |
| Stop Loss Integration | Personify Health coordinates with client-selected contracts for stop loss carrier to file claims with them related to the health plan. |
| Stop Loss Marketing, Placement and Integration | Personify Health assists in securing stop loss coverage through our preferred partners to deliver an optimal combination of rates and service. We utilize A-rated carriers for timely claims reimbursement. Through our negotiation power, innovative, cost-saving medical management programs, and unique stop loss plan designs, we can deliver lower stop loss premiums. We can carve out and provide organ transplant and gene therapy programs through select partners. Personify Health stop loss/reinsurance plan management includes stop loss bid marketing, placement, contract management, and filing and managing reimbursements, along with comprehensive stop loss reporting. |
| Complete Care Navigation | Complete Care Navigation delivers an integrated member experience by combining digital tools for employer-sponsored plans with personalized support from an in-house care team that includes personal health advocates, personal health advocate specialists, personal care managers, clinicians, and social workers. Services include case management, chronic disease management, utilization review, clinical support, targeted activation campaigns (ER Solutions, Cancer Awareness), and maternity support through Nurturing Together. |
| ER Solutions | Personify Health’s ER Solutions program identifies members with recent emergency room visits and provides targeted outreach to promote high-value care alternatives, including telemedicine, urgent care, and primary care. Outreach includes phone calls, flyers, and through the Personalized Health Platform, supported by Personal Health Advocate Specialists. |
| Cancer Awareness | Personify Health’s Cancer Awareness program promotes early detection and intervention through targeted outreach and education. Members are identified for screenings based on age and gender, with quarterly campaigns focused on cervical, colorectal, prostate, breast, and skin cancers. Outreach is delivered via phone calls, flyers, and the Personalized Health Platform, supported by Personal Health Advocate Specialists. |
| Nurturing Together | Nurturing Together is Personify Health’s maternity care program that provides expectant mothers with services and educational materials designed to help give them and their babies a healthy start. Personify Health encourages an active partnership with the patient, providers, and prenatal nurses over the course of the pregnancy, increasing participation in all aspects of care. |
OPTIONAL SERVICES – AS APPLICABLE AND NOTED IN THE ASA
| Service | Description |
|---|---|
| ER Solutions | Personify Health’s ER Solutions program identifies members with recent emergency room visits and provides targeted outreach to promote high-value care alternatives, including telemedicine, urgent care, and primary care. Outreach includes phone calls, flyers, and through the Personalized Health Platform, supported by Personal Health Advocate Specialists. |
| Cancer Awareness | Personify Health’s Cancer Awareness program promotes early detection and intervention through targeted outreach and education. Members are identified for screenings based on age and gender, with quarterly campaigns focused on cervical, colorectal, prostate, breast, and skin cancers. Outreach is delivered via phone calls, flyers, and the Personalized Health Platform, supported by Personal Health Advocate Specialists. |
| Cleveland Clinic Centers of Excellence (COE) Program | The Cleveland Clinic COE Program, in partnership with Personify Health, offers specialized care for cardiac, bariatric, orthopedic, spine, and cancer conditions. It provides bundled pricing for cost predictability; clinical reviews to ensure appropriate treatment; travel support and care coordination for eligible patients; direct contracting with employers for simplified administration. The program focuses on improving outcomes while reducing unnecessary procedures and overall healthcare costs. |
| Nurturing Together | Nurturing Together is Personify Health’s maternity care program that provides expectant mothers with services and educational materials designed to help give them and their babies a healthy start. Personify Health encourages an active partnership with the patient, providers, and prenatal nurses over the course of the pregnancy, increasing participation in all aspects of care. |
| COBRA Administration | Personify Health provides comprehensive COBRA administration to support members and clients through streamlined continuation of health coverage. Services include: distribution of initial and qualifying event notices; courtesy billing statements or coupons; enrollment tracking and premium payment processing; remittance reporting to clients; notifications of rate changes and COBRA takeovers (upon request); ad hoc reporting and enrollment/termination updates to clients or vendors (upon request). |
| Dental Claims Administration | Personify Health administers dental claims for self-insured clients, managing the full process from initial report to coverage verification, claim evaluation, and payment ensuring accuracy and efficiency. Dental claims administration includes: dedicated client success team; claim fiduciary and processing; consolidated billing; data analytics and reporting; member communications and services; personalized health platform; and regulatory compliance. |
| Direct Vision Reimbursement Administration | Personify Health administers direct vision reimbursement for self-insured clients, allowing members to visit any provider without network restrictions. Reimbursements are issued to either the provider or member based on plan terms. Direct vision reimbursement administration includes: dedicated client success team; reimbursement processing; consolidated billing; data analytics and reporting; member communications and support; personalized health platform access; and regulatory compliance. |
| Flexible Benefits Administration (FSA, DCFSA, LPFSA, HRA, HSA) | Personify Health provides flexible spending account administration with options including Medical, Limited Purpose, Dependent Care, Commuter, Health Reimbursement Account (HRA) and Health Savings Account (HSA). Flexible benefits administration includes account management and support: provide standard enrollment materials, prepare weekly reimbursement checks for benefits, provide online access to participant accounts, participant communication, toll-free customer service number, facilitate direct deposit to participant’s account, facilitate automatic electronic transfers when Personify Health administers health plan, posting of annual health care spending account elections; and reporting and billing services. |
| Expanded Consolidated Billing | Billing for each additional set of 8 plan-to-vendor combinations outside of the initial eight included in the medical claims administration. Billing services consist of invoicing third-party vendors for member participation or eligibility based on client-vendor requirements (e.g., monthly member count and PMPM for a dental plan; short/long-term disability rates that include taking in eligibility and counts and applying calculations with various rates). |
| Positive Pay | Personify Health will send a positive pay file to client’s bank account detailing check number, payee name and check amount for each check produced for every check production cycle to validate and prevent fraud. |
| Banking Fee and Unclaimed Property | Banking fees for Personify Health-owned accounts plus reconciliation for any outstanding checks either by reissue or escheat. Employer must own their bank account and is responsible for the ‘at cost’ banking fees associated with the plan and benefit administration services. |
| Run-In Claims Administration | Handling of claims that were incurred under the old TPA but are processed and paid by Personify Health after the transition to ensure that there is no disruption in the management and payment of claims during the transition period, providing continuity and financial protection for the employer and members. We can only provide this service if the client is moving from a TPA that has access to a network that we also have access too. |
| Run-Out Claims Administration | Handling of claims that were incurred under the Plan year but are paid after the Plan year ends. This ensures that claims incurred before the transition are still managed and paid, providing continuity and financial protection for the employer and members. |
| Wellbeing Rewards | Digital wellbeing includes NCQA-certified HRA, claims validated gaps in care, Total Health content pack, daily cards, healthy habits, journeys, media library, personalized action lists, Personify Health IQ, stats, topics of interests, trophies. Wellbeing Rewards also includes: two preconfigured reward programs with on or off-platform redemption. |
| Wellbeing Success | Digital wellbeing includes NCQA-certified HRA, claims validated gaps in care, Total Health content pack, daily cards, healthy habits, journeys, media library, personalized action lists, Personify Health IQ, stats, topics of interests, trophies. Wellbeing Rewards also includes: two preconfigured reward programs with on or off-platform redemption. |
| Complete Wellbeing | Digital wellbeing that includes NCQA-certified HRA, claims validated or self-attest gaps in care, Total Health content pack, daily cards, healthy habits, journeys, media library, personalized action lists, Personify Health IQ, stats, topics of interests, trophies. Complete Wellbeing also includes: access to our engaging social features: up to 10 friends and family invites, social groups, shoutouts, and peer-to-peer challenges. Expanded client admin portal access enables admins to create custom content such as daily cards, healthy habits, and announcements, as well as access self-service reporting archive and standard reporting dashboards. Complete Wellbeing customers can select one of four comprehensive, best practice program and incentive designs, each built from decades of proven results, with additional custom reward earning opportunities and configurable program components. Expanded reward capabilities such as client-specific custom point earning opportunities and on platform rewards which includes Rewards Cash, gift card redemption, selection of items from the Personify Health store, and charitable donations. |