MCO Pro - Claims

The claims system is a built in component to the MCO Pro product. The claims system was designed to handle the most complex reimbursement methodologies. The system is user friendly, comprehensive, accurate, fast and designed according to the HIPAA X-12 health care EDI transaction code sets (834, 837, 997, 999).


The software is Windows based and is supported by a Relational Database Management System (RDBMS) utilizing SQL Server. These individual software modules, linked together act as the skeleton and musculature providing the software with it’s flexibility, adaptability, capability, accuracy, ease of operation and speed.

Reimbursement Capabilities

The software has the capability to accommodate any number of networks, hundreds of thousands of providers and millions of rates and reimbursement records, including:

  • DRGs
  • Per-Diems
  • Global Rates
  • Fee For Service
  • Percentage Discounts
  • Minimum Maximum Charges
  • Minimum Maximum Discounts
  • Ambulatory Surgical Groupings
  • Modifier Rules (Medicare Guidelines or Fee Specific)
  • Anesthesiology, Physical Status and Qualifying Circumstances

The MCO Pro software also provides many automatic services as well as the ability to apply rates and fees based on a specific product or network:

  • Automatically Identify Duplicate Services
  • Apply Rates Based on Product and/or Network
  • Assign Carve Out Rates and Fees to a Single Provider
  • Automatically apply the Appropriate Rate or Fee to any claim
  • Assign Multiple Rates and Fee Schedules to a Single Provider over time

Claim Identification

Pre-load Eligibility or build on 'the fly'. Members can be identified by:

  • Payer Name
  • Patient Name
  • Policy Number
  • Employee Name
  • Employer Name
  • Social Security Number
  • Group/Plan Name/Number
  • Receipt of previous claim(s)

These identification functions were written in order to allow the user the ability to easily identify a member. This capability greatly reduces:

  • Rejected Claims
  • Claim Handling Costs
  • Unidentifiable Claims
  • Complaints from Providers and Members
  • Claim Inquiries from Employees and Providers

Eligibility Management

The MCO Pro eligibility subsystem delivers tools to manage your network membership. While the MCO Pro system is NOT eligibility driven, storing member data allows for higher auto-price percentages and gives you the tools to compare member counts with payments from your payers, carriers and self-administered clients.

In addition the eligibility subsystem accepts ANSI 834 eligibility files and for those payer’s unable to create an 834, a standard format for importing member information. Additional features include:

  • Viewing claim history
  • Viewing change history
  • Tying a member to different networks
  • Tying a member to different employers over time
  • Tying a member to different claims payer’s over time
  • Storing member level effective and termination dates
  • Storing BOTH an SSN and a policy number for a member
  • Commenting a single member OR commenting all membership with a particular employer, claims payer or broker for special handling instructions

Customer Service (CSR)

The MCO Pro system delivers tools that allow CSR’s to handle a variety of typical customer service functions including:

Claim Inquiries

Calls in regards to claims from providers, billing agents, payers, and patients. Complete transaction history, claim image and remittance advice (repricing cover sheet) can be researched and reproduced. Processors can research claims by searching on:

  • Claim Number
  • EDI Claim Number
  • Tax ID and date(s) of service
  • Patient SSN and date(s) of service
  • Patient Name and date(s) of service
  • Patient Policy Number and date(s) of service

Provider Participation Inquiries

The system allows CSR’s to handle calls in regards to provider participation and calls for a particular medical specialty in a given area. Search capabilities include:

  • Facility Name
  • Provider Name
  • Tax Identification Number
  • One or more medical specialties in a given zip code or city
  • Providers affiliated with a network hospital (hospital affiliation) and their privileges at the hospital
  • One or more medical specialties within a given distance (10, 15, 20...) of a zip code (i.e.: Internists within 25 miles of the callers home zip code)

Provider Directories

CSR’s can also produce provider directories which can be printed, emailed or extracted as raw data. Directories come with a customizable cover sheet, table of contents and index. Directory creation capabilities include:

  • City
  • State
  • Zip Code
  • 3 Digit Zip Code
  • One or more counties
  • Within a mileage radius of a zip code
  • Metropolitan Service Area (MSA)
Electronic Data Interchange (EDI)

The MCO Pro system delivers rich EDI capability and can bring your organization into HIPAA claim transaction compliance immediately. The system delivers an automated solution to pick up EDI files from clearinghouses and directly connected providers and payers. The built in EDI capabilities include:

  • ANSI834 (Eligibility)
  • Clearinghouse Connections
  • 999 (Claim Acknowledgments)
  • ANSI837 5010 (Claims)
  • Optical Character Recognition (OCR)
  • Point to Point (Direct) Connections

Fee Schedule Reimbursment Methodologies

The MCO Pro system currently supports the following fee schedule reimbursement methodologies and scenarios:


  • Per Diems
  • NDC code billing
  • Percentage Discounts
  • Revenue Code specific pricing
  • ICD9/ICD10 specific reimbursements
  • Flat or Global Rates (i.e.: Transplants)
  • Rates negotiated on a percentage of invoice cost (i.e.: 110% of hospitals invoice cost)
  • Modifier pricing: EITHER Medicare guidelines or specific to a fee schedule and negotiation
  • Negotiated Fee For Service (Physician Fee Schedule) on either an allowance for CPT/HCPC billing or a percentage of billed charges
  • Diagnostic Related Groups (DRG) based upon a base dollar amount to be multiplied by Relative Weights or upon specifically negotiated rates for some or all DRG’s
  • Ambulatory Surgical Groups (ASG/ASC) with provisions for 2nd, 3rd, 4th, 5th and subsequent procedures. Also handles bilateral procedures for ambulatory surgery.
  • Anesthesiology, Physical Status, Qualifying circumstances with negotiated rates and minute calculations stored at EITHER the provider level or the fee schedule level.


The MCO Pro system also accommodates a number of limiting factors and scenarios that our network partner’s have experienced including:

  • First and Second dollar stop loss
  • Minimum Maximum Charges: also with the qualifiers denoted above if desired
  • Allowing Repriced amount to exceed billed charges on a fee schedule by fee schedule basis
  • Specific procedure stop loss: Stop loss for Transplants follows a different set of rules than overall stop loss
  • Per Diem changes: Surgical days 1-5 are reimbursed at $1,500 each subsequent day is reimbursed at $1,200
  • Combination billing qualifiers: If provider bills ICD9 XX.XX and CPT/HCPC code combination reimburse at $1,500 other wise reimburse following FEE A
  • Carve Outs: A provider is primarily under the network’s primary fee schedule EXCEPT for X number of CPT codes which have been specifically negotiated
  • Fee schedule changes based on place of service: Reimburse utilizing FEE A unless procedure is performed at a hospital (either inpatient or outpatient). Then reimburse at FEE D.
  • Multiple Tier stop loss provisions: Facility is reimbursed 70% of billed charges for claims over $20,000 and not exceeding $35,000 while claims in excess of $35,000 are reimbursed at 65% of billed charges.
  • Minimum/Maximum Discounts: The facility allows for a minimum discount of 10% and a maximum discount of 40%. These minimum Maximum’s can be qualified as well with:
    • Minimum or maximum allowance
    • Minimum or maximum dollars billed
    • Minimum or maximum length of stay


The MCO Pro system comes standard with more than 120 reports. These reports can be broadly categorized as: Broker, Internal, Network Wide, Payer/Carrier, Employer Group and Miscellaneous Reports. A brief description of these report categorizations follows:

Network Wide Reports

These reports encompass reports across the organization and include:

  • Broker reports
  • Internal reports
  • Network Wide reports
  • Payer/Carrier reports
  • Miscellaneous reports
  • Employer Group reports

Payer/Carrier, Broker and Employer Group Reports

These reports encompass reports showing these entities:

  • Savings
  • Run in/out claims volume
  • Utilization reports as outlined above
  • Claims turnaround and lag analysis reports
  • And many more!

Internal Reports

These reports encompass reports dealing with the system and users:

  • User productivity
  • User error reports
  • Claim error reports
  • Auto-reprice statistics
  • Management report outlining claims processed, average claims/processor, client counts, revenue over the past 3 years
  • And many more!

Miscellaneous Reports

These reports encompass a variety of additional reports including:

  • Non Par Analysis
  • Claims history for a given patient
  • Claims processed along product lines
  • Average claims per employer group/insured over time
  • And many more!

Custom Reporting

In addition, the ClaimEDIx team of programmers can create specific ad hoc reports with a simple phone call. Additional reports desired to be made part of the permanent system are reviewed and if warranted made part of future program patches/releases.

Provider Demographic Data

MCO Pro allows for capture and maintenance of extensive provider credentialing and demographic information. The systems give the user the flexibility to capture as little or as much information as desired in regards to provider data.

Data Captured

In addition to baseline provider information (Addresses, Medical Specialty, Tax ID’s) the system allows for the capture of:

  • References
  • Attestation
  • Citizenship
  • Work history
  • Provider level contacts
  • Practice level contacts
  • Office Hours at each location
  • Product/Network Participation
  • Hospital Affiliation including privileges
  • Fee Schedule/Reimbursement information over time
  • Legal proceeding history (both civil and criminal)
  • Languages spoken either natively or via an interpreter
  • Certification through Medical Boards including history
  • Licensure of all types (State license, Medicare Medicaid, UPIN, NPI)
  • “Opt out” information from participation with a client, payer, broker, etc
  • Practice limitations at each location (i.e.: Patient’s over 12 years of age)
  • Provider participation as a single practitioner or as part of one or more groups
  • Malpractice insurance including carrier, Policy type, number, limit and aggregate amounts
  • Education: Undergraduate, medical, residency, fellowship, continuing, resident alien testing


The provider subsystem also has built in processes for provider application and provider contracting via any number of contracts your organization may utilize.

File Cabinet

A provider file cabinet is provided to maintain and record all correspondence from any Window’s based software program utilized by your organization by and between you and the provider. Make part of your permanent provider file system:

  • Audio Files
  • Video Files
  • Photographs
  • Correspondence in any format you currently utilize
  • Scanned documents (Signed Contracts, notes from an on site visit, etc…)


Finally, the provider subsystem comes with a powerful provider extract routine built to support your payer community’s data needs. This extract allows for a single flat file or a relational set of files to be distributed to your client’s via FTP. This process is automated, eliminating the need to create disk media or emails to distribute the data. The system also allows for fee schedule extracts specific to each payer in instances in which you may allow the payer client to reprice claims on behalf of your provider community.


ClaimEDIx takes the business of security seriously!

The MCO Pro system allows system administrators/managers to assign logins and passwords for each processor. In addition permissions to various portions of the application can be granted or denied on a login by login basis. This built in security keeps access to sensitive parts of your business to users with duly authorized access. As your users responsibilities change, so too can their access to the system.

If you opt to utilize the ClaimEDIx compute utility strategic partner, your organizations data will reside on servers lying behind two firewalls with 24/7 electronic and physical intrusion monitoring. Our strategic partner undergoes self-imposed annual HIPAA compliance audits and their personnel have authored, co-authored or contributed on several HIPAA compliance implementation guides, white-papers and other publications. Our partner welcomes onsite visits and inspections whether they are announced or unannounced.

All EDI claim transmissions were built utilizing the PGP SDK (software development kit) as an encryption mechanism. This encryption technology is readily accepted within the industry. In addition the ClaimEDIx FTP site includes security measures to ensure data is not intercepted or inadvertently retrieved. The ClaimEDIx FTP site is hosted by our strategic partner as mentioned above.

9229 Ward Parkway, Suite 300
Kansas City, Missouri 64114

Phone: 800-870-6252