HEALTH PLAN SERVICES
HEALTH PLAN SERVICES
DRIVING GROWTH AND INNOVATION IN HEALTH PLAN SUPPORT SERVICES
Comprehensive Solutions for Health Plans
Fusion CX offers a complete suite of health plan services designed to streamline operations, optimize care delivery, and enhance both member and provider experiences. Our solutions cover the entire health plan lifecycle, from sales and quoting to core claims processing, medical management, customer service, and more. With decades of experience as a Medicare BPO, Fusion CX delivers tailored solutions to help health plans enhance operational efficiency, improve member satisfaction, and ensure compliance.
From member onboarding and provider credentialing to fraud detection and digital support, Fusion CX provides end-to-end solutions that reduce administrative burden, drive cost savings, and improve health plans, providers, and members’ outcomes.
TRANSFORMING HEALTH PLAN OPERATIONS THROUGH TAILORED SOLUTIONS
SALES, QUOTING, AND UNDERWRITING
Fusion CX helps health plans optimize the sales, quoting, and underwriting processes with comprehensive support:
Lead Generation Services
Identify and target potential members to expand your health plan’s market share.
Annual Enrollment Programs
Manage open and annual enrollment periods, reduce member attrition, and maximize retention with targeted outreach and education as a reputed Medicare call center.
Licensed Agent-Based Outreach & Enrollment
Provide expert outreach and compliance-based Medicare enrollment services to drive member acquisition.
Customized Quoting Solutions
Deliver accurate, efficient, and personalized quoting services to streamline plan selection for prospective members, ensuring they choose plans aligned with their needs.
MEMBER SERVICES
We enhance the member experience with a range of services designed to improve engagement, education, and satisfaction:
Account Setup, Enrollment, and Maintenance
Simplify member onboarding and ensure the accuracy of member data throughout the lifecycle.
Premium Billing and Reconciliation
Manage premium invoicing, payment collection, and reconciliation for financial accuracy.
Preventive Care Outreach & Support
Promote health and wellness through annual wellness visits and preventive care reminders.
Member Onboarding and Education
Offer personalized education to help members understand their benefits and health plan options during Annual Enrollment Period.
Benefit Management
Clarify and assist with benefit utilization to ensure members maximize their coverage.
Member Services Contact Center
Provide 24/7 support for members via multi-channel member support (phone, email, and chat).
PROVIDER SERVICES
Fusion CX’s provider services ensure smooth operations and strong provider relationships:
Provider Customer Service
Handle provider inquiries, claims issues, and network participation assistance.
Fraud, Waste, and Abuse (FWA) Detection
Identify and mitigate FWA risks to protect the integrity of the health plan’s network.
Support for Provider Claims and Billing
Address provider claims inquiries and assist with billing challenges to ensure timely reimbursements.
Provider Education and Training
Offer comprehensive education and training programs to keep providers informed about policy updates, compliance requirements, and best practices for interacting with the health plan.
Credentialing and Network Participation
Streamline the credentialing process, ensuring compliance with regulatory and network guidelines.
Provider/Facility Profiling
Maintain accurate and comprehensive profiles for healthcare providers and facilities.
Provider/Facility Data Management
Ensure accurate and up-to-date information for providers and facilities within the network.
Physician Credentialing
Ensure proper documentation and compliance for physician enrollment in the network.
MEDICAL MANAGEMENT
Fusion CX’s medical management services are designed to improve care quality and reduce costs:
Care Management
Handle provider inquiries, claims issues, and network participation assistance.
Utilization Management
Ensure appropriate use of healthcare services, improving care quality and reducing unnecessary costs.
Wellness Management
Deliver health promotion and disease prevention programs to improve long-term member health.
CORE CLAIMS PROCESSING
Fusion CX streamlines the claims processing lifecycle, ensuring accuracy and timely reimbursements:
Claims Adjudication
Ensure claims are reviewed, processed, and paid accurately according to plan guidelines.
Claims Adjustments
Facilitate adjustments to claims, ensuring accurate settlements for both members and providers.
Resolving Payment Disputes
Address payment discrepancies and disputes between health plans, members, and providers.
Claims Re-Pricing
Re-price claims based on provider agreements to ensure fair and timely reimbursements.
Payment Reconciliation
Reconcile payments to ensure consistency between claims, payments, and provider agreements, focusing on member and provider experience.
HCC Coding and Reporting Support
Provide HCC coding support to ensure accurate risk adjustment and compliance with healthcare reporting standards.
CUSTOMER SERVICES
Fusion CX provides customer service for both members and providers, ensuring seamless communication and satisfaction:
Customer Service for Members
Provide empathetic and responsive customer service for member inquiries, claims issues, and benefit clarifications.
Telehealth Support
Assist with telehealth inquiries, ensuring providers and members have seamless access to virtual care options.
Customer Service for Providers
Offer dedicated support for provider inquiries, claims processing, and network participation.
Digital Support
Provide assistance with health plan apps and portals, ensuring members and providers can easily navigate and utilize digital tools.
AI SOLUTIONS FOR HEALTH PLANS
Arya (Support Coach)
Provides real-time assistance to streamline provider credentialing, eligibility verification, and claims processing, ensuring accuracy and faster resolutions for providers and members.
Conversational AI
Enhances communication with AI-driven voice bots for eligibility verification, benefits inquiries, claims updates, and appointment scheduling, improving efficiency and satisfaction.
Marketing AI
Drives engagement and retention through targeted outreach campaigns and personalized communication strategies, improving satisfaction and service utilization.
AI QMS
Automates audits and compliance checks to maintain regulatory accuracy, HIPAA compliance, and high service quality standards for provider and member interactions.
MindSpeech
Enhances call clarity and professionalism with voice harmonization and real-time noise cancellation, optimizing provider and member support interactions.
THE FUSION CX-FACTOR
20K+
Skilled
Agents
PCI-DSS
Certified
25+
Language
Support
Ensured Business
Continuity
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WHY CHOOSE FUSION CX FOR HEALTH PLAN SERVICES?
End-to-End Health Plan Solutions
Fusion CX provides comprehensive services that cover the entire health plan lifecycle, from sales and quoting to claims processing and revenue cycle management.
AI-Driven Operational Excellence
Fusion CX utilizes AI and advanced technology to automate claims processing, optimize revenue cycle management, and predict healthcare trends to improve patient care.
Expertise in Member and Provider Services
We ensure smooth member onboarding, education, and ongoing support while also streamlining provider engagement and reimbursement processes.
24/7 Multilingual Support
Our healthcare call center provides round-the-clock, multilingual support to ensure accessibility and improve member and provider satisfaction.
FAQS
FAQS
What services does Fusion CX provide for health plans?
Fusion CX offers a wide range of services, including sales and quoting, member services, provider support, claims processing, and revenue cycle management.
How does Fusion CX ensure compliance for health plans?
We leverage advanced technology, expert licensed agents, and rigorous compliance checks to ensure that all services meet regulatory standards.
Can Fusion CX assist with claims processing?
Yes, we offer claims adjudication, claims re-pricing, payment reconciliation, and claims adjustments to ensure accurate and timely processing.
How does Fusion CX improve member engagement?
Fusion CX enhances member engagement through personalized education, preventive care outreach, and 24/7 multi-channel support.
Why should health plans choose Fusion CX?
Fusion CX combines over 35 years of expertise, AI-driven solutions, and a member-first approach to help health plans deliver exceptional service while optimizing operations.
