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Nexus - Health Risk Management System

Nexus - Core Functions

  • Managed care
  • Claims Processing
  • Nexus on Call (NOC)
  • Member Administration
  • Contribution Management
  • Security & Access Control
  • Self-Service & Web Access
  • Automated Communications
  • Financial Adviser Admin
  • Imaging 3rd Party Integration
  • Finance
  • Reports
  • Nexus is a comprehensive health risk management and administration system that incorporates the vast Helios knowledge and understanding of the healthcare industry.

    Nexus also houses the ability to seamlessly connect and integrate with other 3rd party administrative, switching and risk management systems.

    Find out more about our other products, AFA and UMS.

    Managed care


    The Nexus Managed Care modules apply a rules- based clinical protocol process within the system. This allows users to better manage members' benefits based on clinically appropriate protocols. The modules are designed in such a way that they are able to receive and adjudicate member claims internally within Nexus or external claims (interfacing with third party systems).

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    Claims Processing


    The concept of "engines" is integral to the design of the Nexus claims system. Varied specialised engines are the driving forces that pick up claims and direct them through the various sets of rules for the particular transaction type, or to meet the criteria of a specific contract. The engines may be used in either real-time or batch submission mode.

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    Nexus on Call (NOC)


    A product is only as good as the service it provides and Nexus has gone to great lengths to ensure that the Nexus On Call (NOC) module is a comprehensive, user-friendly contact centre solution which minimises conversation time and maximises first-time query resolution. NOC is used to log, track and finalise queries from members, beneficiaries, healthcare providers, financial advisers and employer group representatives. Nexus On Call's unique beneficiary call logging ability allows contact centre agents to capture incoming queries on beneficiary level. This feature ensures comprehensive reporting, providing funds with specific information.

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    Member Administration


    The vision to provide a customer- centric solution for the full spectrum of customers served by the system lies at the heart of Nexus. The Nexus member administration module supports this by managing members, beneficiaries and company details while simultaneously calculating and raising contributions. User privileges to access functions, allowing updates such as backdated changes to benefit options, are strictly controlled by the client's defined security policy. In addition, the system keeps a full audit trail of all data changes made (including user name and processed date as well as old and new values). Late joiner penalties are automatically computed and an automatic review of the eligibility of beneficiaries may be undertaken subject to the parameters provided by the client.

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    Contribution Management


    This fully integrated module manages the collection, credit control and reconciliation of group and individual contributions. Group debtors are tracked and reconciled at member level while the outstanding balances (including savings portions, core contributions and late joiner fees) are accounted for at individual product level.

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    Security & Access Control


    With the increasing availability of tools with which databases can be accessed, as well as the increasing sophistication and skills of users, the matter of data protection is of high priority. International audit standards are becoming stricter while data and users proliferate. The balance of restricting access to data while not restricting a user's ability to perform their job efficiently and effectively, is a delicate one. Nexus addresses both aspects by having a multi-tiered security access control system with a wide reaching audit system where access, once allowed, is recorded as outlined below.

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    Self-Service & Web Access


    A primary feature of the Nexus system is its user- friendly, self-help functionality which allows users 24- hour interface with the system. Accessed via a secure username and password, this web-based facility allows users to view real-time information, update details and monitor transactions within a custom branded environment.

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    Automated Communications


    Integral to Nexus is a comprehensive, integrated rules- based, real-time communication system which can be branded to the unique requirements of a client. The client decides how, when, how often, what and with whom communication will take place. This optimises the flow of information to members, healthcare providers, employer groups and financial advisers. Different communication items are set up to be sent in different ways and includes SMS, email, post and fax. Messages can be set up for different recipients eg. members, providers, trustees, healthcare providers, financial advisers etc. Nexus' communication module includes over 80 types of automated communication triggers, generating messages for members, healthcare providers and financial advisers.

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    Financial Adviser Administration


    Nexus includes a comprehensive financial adviser module which facilitates the management and automation of key functions. This includes the automatic calculation of commission and claw-backs as determined by client fund rules and/or legislation. Transactions are generated on a real-time basis, allowing financial advisers to obtain a provisional statement at any given time of the month.

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    Imaging 3rd Party Integration


    For most corporate companies striving to achieve a paperless environment, and particularly for healthcare fund and insurance administrators who are in the business of processing large volumes of paper, scanning, interfacing and imaging plays a vital role. Nexus allows for decentralized scanning functionality, automatic uploading, indexing, statistical data on quality and quantity of scanned images as well as electronic document functionality.

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    Finance


    Possibly most important of all, members and healthcare providers are concerned about the accurate and timely payment of claims submitted for services rendered. The Nexus financial claims payment system is a real- time, integrated, transactional system that manages the accounts and payments of members and healthcare providers. The system functionality caters for creating remittances and statements for members and vendors.

    Nexus allows for integrated Accounts Payable (AP) and Accounts receivable (AR) functionality that allows real-time interaction based on a client�s rules. Nexus manages the member�s savings account based on the client�s rules and is able to handle the full range of functions including pro- ration, the allocation of advances and the calculation of interest on positive or negative balances. The Nexus general ledger is populated with information from other financial and savings modules within Nexus. Clearing accounts are created to allow balancing. Workflow is used to approve transactions that have a financial impact.

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    Reports


    In a world where data mining and access to information is key to making informed business management decisions and to manage performance, costs and risks, Nexus boasts a host of standard reports available to users at their fingertips. Nexus gives the option to allow reports to be run on a real-time basis or to be scheduled to be run at specific times. Reports can be viewed graphically or exported to a variety of formats including exports into Adobe's PDF, Rich text formats, CSV files and Microsoft Excel. Reports are parameterised, giving the user the freedom to extract very specific information.

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