Health Alliance Medical Plans
Urbana, IL (healthalliance.org)

Health Alliance is the largest Health Maintenance Organizations in downstate and central Illinois.  With over 230,000 members enrolled in its commercial and Medicare programs, HAMP consistently takes top ranking as one of the best HMO's in America in U.S. News and World Reports annual survey.  Health Alliance is also an NCQA accredited HMO.

Among the numerous MC400 projects completed over the past several years is an electronic claims system that takes in professional (HCFA 1500) and institutional (UB92) claims directly from providers and clearing houses.  This batch oriented system processes over 25,000 claims an hour and has a clean adjudication rate of nearly 98%.

Another major accomplishment was the integration of HBOC's Code Review®  product with HAMP's claims system, batch and on-line.  HBOC once remarked that this interface was the tightest and most seamless integration between a claims system and Code Review that they have ever seen.

Several years ago PPMSI saw a need to allow physicians to enter authorization requests directly from their office via their personal computer. Michael Gordon was asked to create a system that would read the request and automatically determine whether the authorization would be approved, denied or pended.  He built a system using a protocol table that enabled PPMSI's medical staff to create different case classes based upon dozens of clinical criteria such as ranges of ICD-9 and CPT-4 codes as well as Place of Service, provider specialty and health care carrier, to name but a few.  Approved and denied authorizations were immediately sent back to the provider while pended records were place on a worklist queue to be reviewed by nurses and the Medical Director.