ALIVI

Business process outsourcing for health plans and healthcare businesses, namely, the management and administration of healthcare and managed-care contracts with healthcare organizations, arranging service contracts between healthcare organizations, physicians, providers and members, providing healthcare benefit administration, namely, cost management for the health care benefit plans of others, membership administration, namely, administering loyalty programs and discount medical service programs, namely, negotiating contracts with providers of medical services, to enable participant members to obtain discounts, co-payments, and rewards on the purchase of medical products and services through the use of vouchers, digital memberships, discount membership cards, and coupons, provider network administration in the nature of healthcare management service organization (MSO) services, namely, providing practice organization, management and administrative support services to individual physicians or small group practices and business administrative functions and services for healthcare organizations; provider network administrative services, namely, business management of medical and non-medical networks of providers rendering healthcare and healthcare related services to healthcare organizations, employment recruiting, negotiating of reimbursement rates, provider contracting and credentialing of providers, namely, verifying the skills and knowledge of licensed professionals on behalf of others, maintaining provider network adequacies in the nature of professional staffing and health care employment staffing services in accordance to local, federal, and client requirements; providing awareness of the provider network, namely, providing medical billing support services in accordance with the network's internal billing guidelines and upstream contractual obligations with clients; health plan member engagement and access services in the nature of patient enrollment services, managing member enrollments and disenrollments, managing enrollment retroactivity, enrollment reconciliations, capitation rate reconciliations, coordination between primary and secondary insurance policies in the nature of administration, billing and reconciliation of accounts on behalf of others, member premium billing, primary care physician assignments, managing in-network and out-of-network benefits, namely, cost management for the health care benefit plans of others; back office outsourcing services for companies in the health plan administration and the health care provider industries, namely, outsource service provider in the fields of healthcare business and health plan administration in the nature of medical billing support services, management in the nature of database management of Electronic Data Interfaces (EDI), management of proprietary and standard (HIPAA X12) data files and feeds to include enrollment status, eligibility verification, benefit availability, claims and encounter status requests and responses, management, namely, business management of standard and internally developed healthcare claim billing and payment integrity protocols, tracking and monitoring insurance compliance for business purposes regarding compliance with local, federal and client requirements, maintaining compliance with Claims Editing Software (CES), Correct Coding Initiatives (NCCI), Local Coverage Determinations (LCD), National Coverage Determinations (NCD), financial management, namely, financial records management and reconciliation in the nature of administration, billing and reconciliation of accounts on behalf of others in the field of risk bearing capitated (PMPM) and fee-for-service (FFS) upstream and downstream service contracts, establishing business relationships with clearinghouses; managed health care network services, namely, independent medical management services for health plans and their health care providers, medical cost management services, and utilization review of healthcare services for health plans and health systems; business administrative services, namely, healthcare benefit administration services, namely, managing in the nature of cost management of healthcare benefits, benefit limits and frequencies, exhausting of benefits, accumulators, exclusions, deductibles, cost shares, copays, coordination of benefits, coinsurance, and maximum out of pocket costs

Medical claims and utilization management services for health care organizations, health care plans and healthcare providers, namely, professional and institutional medical claim payment processing, processing of paper and electronic claims, claim adjudication in the nature of assessing insurance claims and distribution of funds to providers, insurance claims processing services utilizing complex reimbursement methodologies, issuing insurance claim denials, assessments of insurance claim appeals and claim reconsiderations, and reviewing claims for compliance with payments integrity protocols, insurance claims processing services, namely, generating of claim letters, explanation of benefits (EOB) letters and explanations of payments (EOP) letters, insurance claims processing services featuring compliance with local and federal claims processing regulations and guidelines; utilization management services for healthcare organizations and healthcare providers, namely, medical insurance case reviews and utilization review of services rendered, insurance claims management of referrals and authorizations ensuring the proper use of industry accepted and internally defined clinical criteria, medical insurance eligibility review of cases for level of appropriateness and medical necessity, insurance risk and cost management services, providing insurance claims assessments utilizing medical loss ratios, outlier reporting, peer to peer reviews in the nature of insurance claims reviews, insurance claims review and insurance claims adjustment services for health care plans and providers, claim payments and distribution of funds to providers by generating Explanation of Payment letters (EOPs) with direct deposit or paper checks

Non-emergency medical transportation services

Providing education, namely, training of the provider network in the field of compliance with the network's internal billing guidelines and upstream contractual obligations with clients

Software as a service (SAAS) services featuring software for business process outsourcing for health plans and healthcare businesses; information technology (IT) and software development; providing temporary use of non-downloadable software for scheduling, dispatching, invoicing, fleet management, and routing and mapping of non-emergency medical transportation

Health care services offered through a network of health care providers in all health care fields