Smarter Operations for High-Performing Health Plans

From member services to claims, compliance, and care management, we deliver the operational expertise and infrastructure needed to improve performance at every level.

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WHAT WE PROVIDE

Comprehensive Capabilities. Delivered with Precision.

With over two decades of experience, Netmark guides clients through data-driven strategies, precise implementation, and continuous support, ensuring each step aligns with their operational needs for sustainable, long term growth.

Netmark supports all lines of business for health plan operations and technology including commercial, Medicare/SNP, and Medicaid. Our engagements are customized to meet the needs of the health plan. This can include professional services, technology support or BPO as needed. We meet our customers where they are and develop a joint agreement on the services needed and the delivery mechanism.

Netmark is well-positioned to leverage and integrate Generative AI and Agentic AI across core healthcare administrative platforms — driving automation, intelligent decision-making, and operational efficiency while enhancing scalability, streamlining workflows, and enabling intelligent, autonomous operations.

Core System Services

  • Medical, dental, and pharmacy claims adjudication
  • Claims editing and auditing
  • Coordination of benefits (COB)
  • Fraud, waste, and abuse (FWA) detection

Provider Data Management

  • Provider credentialing and contracting support
  • Network management and directory maintenance
  • Provider dispute resolution
  • Fee schedule management

Member Services

  • Enrollment and eligibility management
  • Member onboarding and ID card issuance
  • Benefits explanation and customer support
  • Grievances and appeals processing

Clinical & Care Management

Proactive care programs that improve outcomes, manage risk, and support members across every stage of their health journey.

  • Utilization management (prior authorizations, referrals)
  • Case and disease management support
  • Care coordination for high-risk members
  • HEDIS/quality measure data collection and reporting

Finance & Billing

Accurate, streamlined financial operations — from billing and collections to reconciliation and risk adjustment — ensuring stability and visibility.

  • Premium billing and collections
  • COBRA administration
  • Employer group billing reconciliation
  • Risk adjustment data submission (RADV)
  • Capitation and encounter data processing
  • Pay cycle management

Regulatory & Compliance

End-to-end compliance support that keeps your plan audit-ready and aligned with evolving CMS, state, and federal requirements.

  • CMS reporting (STAR ratings, EDGE server submissions)
  • State regulatory filings support
  • HIPAA compliance and privacy operations
  • Audit support (internal and external)
  • ACA compliance (MLR reporting, 1095-B/C filing)

Specialty Services

Advanced capabilities for complex programs, including government plans, PBM support, recovery services, and vendor management.

  • Medicare/Medicaid administration — specialized compliance, dual-eligible coordination
  • Pharmacy benefit management (PBM) support — formulary management, prior auth
  • Dental/vision/behavioral health carve-out administration
  • Subrogation and recovery services
  • Vendor management — coordinating third-party vendors on behalf of the health plan

Technology & Analytics

Scalable platforms, seamless integrations, and real-time insights that power smarter decisions and operational efficiency.

  • Health plan platform hosting and administration (e.g., HRP, FACETS, QNXT)
  • Data warehousing and reporting
  • Population health analytics
  • Member and provider portal management
  • EDI transaction processing (837, 835, 270/271, etc.)
  • Agentic & Generative AI, RPA
  • API Solution Development
  • Core Systems Selections, RFP Support and Implementation
  • Business Analysis, Configuration and Testing Services
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WHO WE SERVE

Who We Serve

We partner with health plans and organizations across the healthcare ecosystem—delivering tailored support aligned to your structure, goals, and stage of growth.

CONTACT SALES

Medicare & Medicaid Administration

Deep expertise across Medicare Advantage, Part D, Medicaid managed care, and Special Needs Plans—delivering compliant, high-performing operations in highly regulated environments.

  • CMS bid preparation and submission support
  • Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) production
  • Low Income Subsidy (LIS) / Extra Help administration
  • STAR ratings program management (improving HEDIS, CAHPS, HOS measures)
  • RAPS and EDPS risk adjustment data submission
  • RADV audit preparation and defense
  • Medicare Secondary Payer (MSP) compliance
  • Part D reconciliation (DIR fees, TrOOP tracking, catastrophic coverage)
  • State-specific contract compliance and reporting
  • LTSS (Long-Term Services and Supports) administration
  • CHIP program administration
  • Encounter data submission and validation
  • MLTSS (Managed Long-Term Services and Supports) care coordination support
  • Waiver program administration (1115, 1915(b)/(c))
  • Integrated care coordination between Medicare and Medicaid
  • Model of Care (MOC) development and oversight
  • Individualized Care Plan (ICP) management
  • State Medicaid agency coordination
Medicare & Medicaid Administration

Subrogation & Recovery Services

Maximizing Recovery. Protecting Your Bottom Line.

Identify, recover, and maximize reimbursement across subrogation, COB, workers' compensation, and Medicaid estate recovery—reducing costs and improving financial performance.

  • Identification of third-party liability (TPL) claims
  • Lien filing and pursuit against at-fault parties
  • Settlement negotiation with plaintiff attorneys
  • Coordination with auto, workers' comp, and liability insurers
  • ERISA plan subrogation enforcement
  • Primary vs. secondary payer determination
  • Overpayment recovery from other carriers
  • Medicare as Secondary Payer (MSP) recovery
  • Birth order rules and COB dispute resolution
  • Post-death Medicaid claim recovery from member estates
  • State Medicaid agency reporting and filing
  • Hardship waiver processing
Subrogation & Recovery Services

Dental, Vision & Behavioral Health Carve-Out Administration

Comprehensive administration across dental, vision, and behavioral health—ensuring seamless coordination, compliance, and a better experience for members and providers.

  • CDT code-based claims adjudication
  • Dental network credentialing and contracting
  • Orthodontic claims management (installment tracking, lifetime maximums)
  • Dental prior authorization
  • Missing tooth clause and waiting period enforcement
  • VSP/EyeMed-style benefit administration
  • Frame allowance and lens benefit management
  • Vision network provider directory management
  • Routine vs. medical eye care benefit coordination
Dental, Vision & Behavioral Health Carve-Out Administration

Pharmacy Benefit Management (PBM) Support

Comprehensive support across formulary management, prior authorization, network contracting, and PBM oversight—driving cost control, compliance, and clinical effectiveness.

  • Formulary design, tiering, and maintenance
  • Drug utilization review (DUR) — prospective, concurrent, retrospective
  • Step therapy and quantity limit program management
  • Specialty drug prior authorization workflows
  • Formulary exception and appeals processing
  • PA intake, review, and determination workflows
  • Peer-to-peer review coordination
  • Real-time PA processing via NCPDP SCRIPT standards
  • Gold carding program administration (exempting high-performing providers)
  • Retail, mail-order, and specialty pharmacy network management
  • Pharmacy credentialing
  • MAC (Maximum Allowable Cost) list management
  • 340B program compliance support
  • PBM contract performance monitoring
  • Rebate reconciliation and validation
  • DIR (Direct and Indirect Remuneration) fee analysis
  • Spread pricing audits
Pharmacy Benefit Management (PBM) Support

Vendor Management

End-to-end oversight, delegation, and consolidation of third-party vendors—keeping your ecosystem accountable, compliant, and aligned to plan strategy.

  • Vendor contracting and SLA development
  • Ongoing performance monitoring and score carding
  • Corrective action plan (CAP) management
  • Regulatory delegation oversight (CMS, state agencies require health plans to oversee delegated entities)
  • Credentialing delegation audits
  • UM delegation oversight
  • QM/QI delegation compliance
  • Delegated entity reporting and attestation
  • PBMs
  • Behavioral health organizations (BHOs)
  • Dental/vision carve-out vendors
  • Disease management vendors
  • Transportation (NEMT) and supplemental benefit vendors
  • Print/mail fulfillment vendors
  • IT and data vendors
  • Helping health plans rationalize their vendor ecosystem
  • RFP development and vendor selection support
  • Transition management when switching vendors including BPO support for legacy platform
  • Business Analysis, Configuration and Testing Services
Vendor Management

Testimonial

Netmark quickly became an extension of our team. Their deep understanding of health plan operations, claims administration, and system optimization helped us streamline workflows, improve turnaround times, and identify opportunities we hadnx27t previously considered. The combination of strategic insight and hands-on execution has delivered measurable value across our organization.

Darrin Mitchell Chief Operating Officer, Regional Medicare Advantage Health Plan

COMMON QUESTIONS

Health Plan FAQs

Yes — we have an AI-driven tool that helps a plan pre-assess their ratings mid-year and make course corrections.

We use AI in testing, provide AI-driven bots to plans to reduce provider abrasion, and in provider clean-up.

We use a variety of internally developed tools that translate domain expertise and large data models.

Netmark's offshore center is located in Chennai, India.