Puerto Rico
MMM Healthcare (Medicare y Mucho Más) is a Medicare Advantage health plan in Puerto Rico with over 100,000 senior lives. In addition, they have a network of over 4,000 providers. With their main corporate office in Hato Rey, Puerto Rico and several regional offices around the island, they needed applications that were accessible by all staff members in all offices.

• Developed a custom Disease Management program to manage high risk patients with Diabetes, Congestive Heart Failure and COPD.
• Patient Profiles, Health Assessments and Disease Specific surveys trigger automatic interventions. The interventions become tasks for the Case Manager to complete on a daily basis, all driven help manage the patient


• Developed an Inpatient or Concurrent Review application (both web and Tablet PC based) that provides the ability to:
• Approve or deny bed days. MMM’s Claims department is automatically notified of denied bed days
• Create a Discharge Plan
• Complete Pre Auths for SNF’s, Home Care, DME, etc. The Pre Auths are automatically written to MMM’s EZ-CAP database
• Refer a patient to Disease Management. The patient is automatically entered into the DM tool mentioned above
• Report Quality issues
• Print letters, Pre Auth approvals, etc. in the hospital for the patient or patient record


• Developed a web-based Pre Auth system to allow Providers to log in and do Pre Auth requests. Automatic approval occurs when certain CPT codes and conditions are met


• Developed an Appeals & Grievances application
• Documents every step in the Appeals or Grievance process
• Scanning and pdf storage of incoming correspondence from members and providers
• Tracks each step with due dates to ensure timely processing of each case
• Creates an Appeals Committee file and if necessary, a CHDR file


• Developed a web-based Customer Service application which:
• Reduced customer service calls from 60,000/mo to 40,000/mo because it gave the Customer Service Reps all the information they needed in one application
• Integrates information from their Membership software (Oracle bases Market Prominence) and their auth/claims software (SQL Server based EZ-CAP)
• Logs all calls and issues into a database for reporting purposes later


• Developed web-based reporting system to that allows all staff members to drill down or distribute data
• The Daily Census of which patients are currently in the hospital is created as a pdf and distributed daily
• Turn Around Time (TAT) reports are used to monitor how long it takes to process auths, appeals & grievances
• Emergency Room visits – patients can be referred to the Disease Management tool from here
• HRDMA report allows data mining of the claims data to refer high cost patients to Disease Management


• Developed a Tablet PC based Provider Relations application which allows Provider Reps to:
• Sign up providers with a PC based application and captures the provider’s signature
• Documents follow up visits