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Technology Automation

Finding ways to optimize plan efficiency with a cutting-edge platform.

Ocular

Overview

Ocular Benefits reduces the cost of eye care delivery and enhances access to appropriate care through technology automation. Wonderbox Technologies, our sister company and developer of the software used by Ocular Benefits, is known as one of the leading technology companies in the healthcare benefit management industry. With this innovative platform we provide seamless benefit management, and accurate, timely claims management with minimal manual intervention. We can manage complex coordination of benefits, customized benefit plans as well as multiple reimbursement structures. Our tracking capabilities can also lead to more responsive programs and improved HEDIS scores.

Enterprise Business Intelligence

The Enterprise Business Intelligence System (eBIS) is to provide instant visibility into real-time data on comprehensive eye care programs for managers and executives. Working with eBIS, clients can generate reports customized to their business needs based on standard templates that include profile reports, comparative reports, and listing reports. Filters may be applied to any historical claims data held in the Enterprise System’s data warehouse. With eBIS’ easy-to-use web interface, clients have access to the information and insight they need to make informed decisions about their vision benefit program.

Executive Dashboard

Clients can monitor their eye care program on a 24/7/365 basis with the Enterprise System’s Executive Dashboard. The web-based dashboard features detailed statistics and comparisons in primary areas of benefit management, including volume and timeliness of claim payments, and performance metrics. Clients can also use it to monitor call center statistics and workflow efficiency, and identify trends over time. Featuring real-time data available anytime through the Client Portal, the Executive Dashboard gives clients the advantage of significant transparency into their vision program.

Vision-Specific Edits

Ocular Benefits utilizes a comprehensive set of predefined vision edits based on our extensive industry experience, industry best practices, and past client input. We also subscribe to regular updates for Medicare-specific edits, such as the National Correct Coding Initiative (NCCI) Edit. 

We offer clients a high degree of flexibility with vision edits during claims processing. Any edit can be turned on or off, corresponding exception messages can be customized, and client-defined edits and exception messages can be incorporated into claims processing steps without requiring a programming change.

Custom Web Portals

Our custom web portals decrease administrative cost and improve access to reliable, real-time information for clients, providers and members. Featuring review of claim status and call center inquiries, electronic submission of claims, and Find-a-Provider service, our portals are designed to make benefit programs straightforward and stress-free.  Our experience indicates that use of web portals can lead to faster turnaround times and lower administrative costs.  

Our Branded Client Web Portal is the gateway to powerful oversight and management tools: 

  • Manage claims and authorizations
  • Launch the Customer Service Module (CSM) to track inquiries
  • Launch the Authorization Determination Module (ADM) to determine authorizations and generate letters for providers and members
  • Launch the Enterprise Business Intelligence System (eBIS) to generate business reports
  • Launch the Executive Dashboard to monitor key business statistics

Our Branded Provider Web Portal is a powerful online tool that promotes improved member service and efficient claims processing through:

  • Claim management
  • Authorization management
  • Eligibility status inquiries
  • Benefit limitations
  • Data entry shortcuts
  • Report, document and file manipulation

Clinical Algorithms

Ocular Benefits uses a set of proprietary clinical criteria, or algorithms, to ensure fair and consistent determination of vision benefit coverage. We can modify any of these algorithms to meet each client’s requirements.

Ocular Benefits’ clinical algorithms were created and are maintained under the direction of our Chief Ocular Officer. They reflect numerous sources of industry-standard clinical criteria, including state Medicaid guidelines.  Use of these criteria in claims processing promotes consistent utilization for our clients and helps to detect and prevent potential fraud and abuse.

Flexible Authorization Requirements

With flexible authorization requirements and a simple submittal process, Ocular Benefits makes it easier to control benefit and administration costs. We offer the ability to automatically link claims to specific pre-authorized services, and consume prior authorizations and service items based on encounter data submitted by providers. Ocular Benefits tailors the rules for matching claims to pre-authorized services based on each client’s requirements. When our system cannot match a service that requires pre-authorization against an open authorization, an exception is recorded on the service. These exceptions can be reviewed and resolved before the claim is adjudicated.  This targeted, individualized approach reduces cost for our clients and their providers.

Authorization & Determination Logic

Our consistent, transparent approach to authorization determinations promotes clarity and reduces administrative cost. Ocular Benefits’ trained paraprofessionals and ocular consultants use clinical criteria to ensure a consistent approach for determining authorizations. Ocular Benefits clinical criteria is available via the Provider portal so optometrists and ophthalmologists can follow the decision matrix and understand the logic behind authorization decisions.

Customer Service

Ocular Benefits’ customer service representatives (CSRs) have all the tools needed to resolve members’ and providers’ questions during the initial communication with our contact center. CSRs have instant access to a host of service tools, including claim history, authorization history, eligibility history and office reference manuals. On the rare occasions when a second connection is required, CSRs can track and complete the follow up.

Ocular Benefits also provides complete, real-time transparency for clients into all CSR team member interactions with members and providers as well as historical tracking of each point of contact. We maintain a comprehensive history for every member and provider in our system, including audio transcripts of all communications.

Implementation

To ensure a smooth, timely transition for every client, Ocular Benefits prepares a comprehensive project plan to manage all transition-related activities. Our technical team has substantial experience with establishing secure electronic interfaces with a wide variety of vendors. We focus on customizing claims management and processes to our clients’ business requirements and state regulations. Ocular Benefits communicates extensively throughout the transition, so the go-live event becomes is a positive experience created by our close partnership, with no surprises.

Ocular Benefits, LLC

W140 N8981 Lilly Rd.
Menomonee Falls, WI 53051
info@skygenusa.com

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