UPMC Benefit Management Services

Business Process Outsourcing

BMS offers third party administrator (TPA) services across the commercial, individual, managed Medicaid, and managed Medicare lines of business. BMS offers not only a core set of essential services, but also additional layers of potential functionalities. The core services are:

1. Customer service – member and provider services (superior contact center, secure online portals)
2. Operations – enrollment, claims adjudication, plan management (COB), and data & reporting
3. Technology – IT infrastructure/ support, member and provider portals, and provider data management
4. Finance – claims payable, premium billing, payment processing, and banking arrangements

BMS delivers superior service to health plans, members, and providers through seamless integration of services in user-friendly platforms. MC400 is the core transactional system that handles all benefit, pricing, provider, member, claims, member accumulation, financial, and customer & provider services. It is a nimble, highly user-configurable system that fully integrates the modules for all offered services. It leverages today’s technology against the everyday processing needs of health plans. In addition to its core services, BMS offers a wide range of additional functions, some of which collaborate with UPMC portfolio companies to create a comprehensive suite of TPA services. These additional services are:

• Workflow automation including appeals & grievances
• DRG grouping and pricing
• Encounter processing for Medicaid, Medicare, and Individual Exchange
• Pharmacy
• Wellness
• Utilization management
• Mobile applications
• Marketing
• Analytics, HEDIS, risk assessment
• Risk adjustment and regulatory filings (with Health Fidelity)
• Sales portal (with Cavulus)
• Care management, population health management and health coaching (with HealthPlaNET)
• Employer benefits and work productivity (with Work Partners)

Eric Stock
Director, TPA Implementation and Operations
W: 412-454-7729
U.S. Steel Tower, 600 Grant Street
Pittsburgh, PA 15219