Built for the Full Lifecycle of Healthcare Administration
THE BREAKDOWN
Core Administrative Services.
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Claims Processing (Medical, Supplementary)
- Claims intake and digitization
- Data entry and validation
- Claims adjudication support
- Payment processing and EOB (Explanation of Benefits) generation
- Claims auditing and reprocessing (Audit as a Service)
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Provider Services
- Provider Data Management
- Contracting and credentialing support
- Provider onboarding and directory management
- Provider termination
- Provider Contact Center Services
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Benefit Configuration
- Plan Setup: Configure deductibles, copays, coinsurance, limits.
- Product Build: Create plan designs (HMO, PPO, Medicare, etc.) and network tiers.
- Rule Configuration: Set accumulators, limits, prior auth, and COB rules.
- Compliance Setup: Ensure ACA, CMS, and state mandate alignment.
- Testing: Validate benefit rules via claims testing and UAT.
- Maintenance: Update plans for annual changes or regulatory needs.
- Audit & Optimization: Identify errors and improve configurations.
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Pricing Configuration
- Rate Setup: Configure premium rates (age, location, tier-based).
- Product Pricing: Set employer/member contributions and pricing tiers.
- Provider Pricing: Configure fee schedules and contract rates.
- Pricing Rules: Define allowed amounts and claim pricing logic.
- Actuarial Support: Assist with rate modeling and filings.
- Testing: Validate pricing accuracy using test claims.
- Maintenance: Update rates and fee schedules regularly.
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Enrollment & Eligibility Management
- Member enrollment processing (individual/group)
- Eligibility verification
- Open enrollment support
- Life event changes processing (marriage, job change, etc.)
- Data reconciliation with employer/government systems
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Payment Integrity
- Pre-Payment Controls: Claims edits, eligibility checks, duplicate detection, prior authorization validation.
- Post-Payment Review: Claims audits, overpayment recovery, COB and subrogation.
- Coding Accuracy: Review ICD/CPT coding, detect upcoding/unbundling, DRG validation.
- Fraud, Waste & Abuse (FWA): Analytics, anomaly detection, investigation support.
- Provider Payment Accuracy: Validate contracts, fee schedules, and reimbursement logic.
- Clinical Review: Medical necessity checks, high-cost claim review, LOS validation.
- Analytics & Reporting: Identify payment leakage and savings opportunities.
- Provider Engagement: Dispute handling, recovery follow-ups, provider education.
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Utilization Management (UM)
- Prior authorization intake and processing
- Medical necessity review support
- Concurrent and retrospective review
- Case routing to clinical staff
- UM documentation management
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Care Management Support
- Care coordination support
- Disease management program administration
- Outreach to members for care gaps
- Health risk assessments (HRA)
- Wellness program engagement
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Risk Adjustment & Coding
- Medical coding (ICD-10, CPT, HCC validation)
- Chart review and abstraction
- Risk score optimization
- Data submission to CMS or regulators
- Coding audits and compliance checks
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Quality & Compliance (Regulatory Reporting)
- HEDIS data collection and reporting
- STAR ratings support (Medicare Advantage)
- Regulatory filings (CMS, state mandates)
- Audit readiness and support
- Compliance monitoring
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Data Management & Analytics
- Data entry, cleansing, and validation
- Reporting and dashboards
- Predictive analytics (risk, utilization, cost)
- Population health insights
- Fraud, waste, and abuse detection analytics
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Appeals & Grievances Processing
- Intake and classification of appeals
- Case documentation and tracking
- Coordination with clinical reviewers
- Regulatory compliance timelines management
WHO WE SERVE
Built for Organizations & Corporations Across the Healthcare Ecosystem
Whether you’re launching, scaling, or optimizing, we support organizations across the healthcare landscape with solutions tailored to your model and growth stage.
We Manage Operations For:
- COMMERCIAL
- MEDICARE
- MEDICAID
- DUALS
- FEP
- SNP
- PROVIDER OWNED/IDN
- PACE
- TRI-CARE
- ACO
- DENTAL
- VALUE BASED
- EXCHANGES
- TPA
- TAFT-HARTLEY SELF-FUNDED
THE NETMARK LIFECYCLE
Technology-Driven. Experience-Focused.
We combine modern platforms, seamless integrations, and real-time data to create a connected experience—for members, providers, and plan administrators alike.
Powering Healthcare Through Smarter Systems
Our model is built on a technology-first foundation—integrating core systems, data, and workflows into one connected ecosystem. The result is faster operations, better visibility, and a more seamless experience across every touchpoint.
Built to Run the Core of Healthcare Administration
We deliver the essential services that keep health plans and TPAs running efficiently, compliantly, and at scale—across every function of the operation.
SOLUTIONS SUPPORT YOUR GROWTH
From optimizing a health plan's operations to launching a TPA platform, we deliver tailored solutions aligned to where you are—and where you're going.
HEALTH PLAN (BPO)
Optimize and Scale Health Plan Operations
Comprehensive administrative and clinical support across the full lifecycle—improving efficiency, compliance, and member outcomes.
- Member, Claims & Provider Operations
- Clinical & Care Management
- Finance, Billing & Compliance
- Technology & Analytics
- Enrollment & Eligibility
- Benefit & Pricing Configuration
- Quality, Risk & Regulatory
THIRD-PARTY ADMINISTRATOR (TPA)
Build, Launch, and Run Your TPA Operation
Whether implementing a new platform or optimizing a long-standing system, Netmark helps TPAs launch faster, reduce costs, and scale without operational bottlenecks.
- Core BPO/Operation
- Implementation
- Financial & Compliance
- Analytics & Planning
- Specialty & Value-Added
- Data Migration & Integrations
- Ongoing Managed Services