Utilization Management

Utilization management is a cutting-edge, customizable utilization and prior authorization management system for health plans.

Why our Utilization Management Solution is preferred by Health Plans

Optimized

Optimized for case and disease management

Flexible architecture

Flexible architecture to meet specific requirements

Real-time updates

Real-time updates and notifications

Identification of Patients

Identification of Patients who need your services at the health plan level

User-friendly interface

Reduced turnaround time

Why our Utilization Management is preferred by Health Plans

Optimized

Optimized for case and disease management

Flexible architecture

Flexible architecture to meet specific requirements

Real-time updates

Real-time updates and notifications

Identification of Patients

Identification of Patients who need your services at the health plan level

User-friendly interface

Reduced turnaround time

Features at a glance

Calypso Lite which is a PCP portal for eligibility verification and authorization submission with real time authorization status updates

Calypso which has approval/denials for part a and part b services, reporting, efficient and streamlined letter batching & letter fulfilment for both members/ providers

Quick AUTH creation while meeting cms/ncqa standards. UM service groups can create commonly used codes for providers with a single mouse click

AUTH Summary which allows end users to complete a quality check

USER QUEUE’S with each queue having a summary tab with specific information to ensure timeliness

SMART ASSIGN which helps intake coordinators identify the work volume in each referral coordinator, nurse, or md queue

In accordance with CMS/NCQA standards, members receive approval/denial letters via USPS. Fax notification is also provided on all requests

○Part B: Approval, Denial, Pending, Rescind, QIO NMNC, Global CMS Audit reports: Expedited Organization Determination (EOD) and Standard Organization Determination (SOD) Universe, EOD and SOD Universe Internal, CMS, Timelines, Timelines, Internal.

○PART A WORKFLOW: Intake queue, Nurse review queue, MD review queue, MD peer to peer queue, Facility queue, Prior auth coordinator queue, Discharge planning queue, QC approval (letter batching), QC denial (letter batching)

* Intake approval has restrictions for specific services to ensure medical necessity review by a licensed clinician.

BACKEND SERVICES:

○API’S to receive information from Provider Villa, Member House, MDM.

○278 EDI transactions

○API’S to provide information to the following system’s:

○Claims adjudication

○Customer service management

○Provider Portal

REPORTING:

○Standard reports:

○Part A: Approval, Denial, Pending, Rescind, QIO NMNC, Global, Overdue, Inpatient census, Key metrics, Discharge

○Part B: Approval, Denial, Pending, Rescind, QIO NMNC, Global

CMS Audit reports: EOD Universe, SOD Universe, EOD Universe Internal, SOD Universe Internal, CMS, Timeliness, Timeliness, Internal

DASHBOARDS:

○Part A: To measure productivity and member LOS at a glance.

○Part B: shows TAT to ensure CMS timeliness standards/ internal timelines are being met. Also shows how the requests were received and how many standard vs expedited requests.

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Why choose MIRRA's® Utilization Management?

We understand that Members and Providers require a solution that solves the time crunch and work seamlessly with their existing system to get the authorization requests processed on time.

Ideal for managed care, our Utilization Management modules can easily integrate with your organization’s management system and fix the bottlenecks in no time. Calypso, our range of software, is streamlined to take only 2 minutes to enter an authorization request into the portal.

Reviews & Testimonials

DJ OLIVERExecutive Director of Liberty Medicare Advantage

"In the process of looking for a Third Party Administrator, we identified Mirra as a candidate. After meeting with the team and understanding their experience, systems, and processes, we knew we had a great partnership opportunity. Mirra was able to transition our data quickly and effectively. Our teams work very closely to ensure successful operations of the health plan."

NANCY GAREAUCEO of Ultimate Health Plans

"In 2021, Ultimate Health Plans (UHP) partnered with Mirra Health Care (Mirra) to develop a software platform to support processing Claims, Customer Service, Eligibility, Enrollment, Premium Billing, Encounter Processing and a Provider Portal for our Medicare Advantage Plans. Mirra collaborated well with our operations and compliance teams to successfully design and implement a system that was innovative, efficient, and compliant with all Medicare and Florida Medicaid guidelines and requirements all within the scope of our required timeline. We greatly benefitted from the Mirra Project Management Team’s regular communication with Stakeholders through monthly meetings and recurring weekly breakout-focused calls, which were geared towards troubleshooting and goal alignment. Mirra was able to quickly maneuver and adapt their systems to our needs, resulting in successful implementation and go-live. Mirra continues to support our compliant operation and growth in the ever-changing healthcare industry rapidly and effectively updating their systems with new Medicare and Florida Medicaid rates and guidelines to ensure seamless compliance and efficiency. I have absolutely no reservation in recommending their systems to any Payer searching for improvement in their operational efficiency."

DJ OLIVERExecutive Director of Liberty Medicare Advantage

NANCY GAREAUCEO of Ultimate Health Plans

DJ OLIVERExecutive Director of Liberty Medicare Advantage

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