Medical Mutual Partners with Altegra Health for Risk Adjustment and Member Engagement Support

Medical Mutual is working with Altegra Health, a leading provider of technology-enabled, end-to-end payment solutions that improve healthcare organization performance, to deliver a number of services to enhance benefits for commercial members who purchased health insurance on and off the exchange.


Altegra Health® is a national provider of technology-enabled, end-to-end payment solutions that improve healthcare organization performance by aligning individual health status, member benefits, and accurate reimbursement.
Altegra Health’s Risk Adjustment solutions combine technology with ongoing analysis and expertise to optimize risk adjustment and encounter reporting through several proprietary services.

  • Risk Analytics & Reporting
  • Our advanced risk adjustment technology, combined with ongoing support, analysis, and score gap interventions help our partners improve revenue and the quality of care in a proactive and efficient manner. We support these services through an extensive team of experts and coding specialists who retrieve medical records, review those charts, and capture appropriate diagnoses and procedure codes.

  • Chart Retrieval & Coding
  • Our solutions – retrospective chart retrieval and review, risk adjustment data validation (RADV), certified professional coder (CPC) training, and ongoing physician and staff education – support the effort to capture missing risk adjusting diagnoses and ensure members are appropriately risk adjusted and, in turn, qualify for adjusted premiums.

  • Prospective Interventions
  • As a result of our dedication to improving the well-being of the individuals our partners serve, Altegra Health has become a single
    hub for gathering analytics that drives suspect targeting. Through our prospective intervention solutions, we assist health plans with extracting the necessary data for risk, retention, and care management services.

  • Encounter Reporting & Claims Data Management
  • We ensure complete, accurate, and timely reporting of ACA-Commercial, Medicare and Managed Medicaid data, including initial submission, reconciliation, adjustments, corrections, and resubmissions. Using our expertise and leading technology applications, called ENCOUNTER Complete and EDGE Complete, we enable health plans to report encounter, claims, and enrollment data in a cost effective and efficient manner.

    As a Web-based user interface, ENCOUNTER Complete and EDGE Complete are hosted and maintained by Altegra Health with virtually no burden on partner organizations’ IT departments. It is secure, flexible, and scalable, and can be accessed through any Internet portal.

  • Risk View
  • Altegra Health’s RISK View™ offers a flexible risk adjustment platform that lets healthcare organizations analyze risk scores for the Hierarchical Condition Categories (HCCs) defined by the Centers for Medicare and Medicaid Services (CMS) for Medicare and Commercial models and state-based Medicaid programs.

Altegra Health’s Quality Performance solutions provide continuous member engagement and quality measurement tools to ensure appropriate and satisfactory levels of care. Altegra Health partners with health plans in several unique ways to meet their HEDIS®*, Star Ratings and other quality reporting needs in order to better manage members’ overall care.

  • Member Outreach & Engagement
  • Altegra Health’s combined suite of member engagement services helps health plans enhance member satisfaction, lower long-term care costs, improve Quality Star Ratings, and secure optimal health outcomes. These solutions – SMART Connect, SMART Appointment Scheduling, and COMMUNITY Link – are supported by a powerful data analytics engine that optimizes identification of members who need provider care and prioritizes outreach to engage them with cost-savings and disease education programs – year round.

  • Clinical Care Visits
  • Through Altegra Health, healthcare organizations can support members with clinical care visits through providers. These visits allow members to obtain health assessments, medical tests, and follow-up care that increases their overall health and well-being.

  • SMART Connect
  • SMART Connect communications are multi-channel, allowing the member to choose whichever is most convenient. Members may choose to receive telephone calls, text messages, or use a smartphone app or a web-based dashboard.

  • Smart Appointment Scheduling
  • Altegra Health’s SMART Appointment Scheduling improves member satisfaction and retention while increasing quality of care and accuracy of risk adjustment by helping members make and keep appointments with their doctors.
Altegra Health’s Program Assistance solutions provide continuous monitoring of members’ social program eligibility and enrollment status to ensure they receive appropriate access to benefits. Advocates help health plan members apply for government and community assistance programs that improve member retention and enhance plan revenue.

  • Our COMMUNITY Link program provides healthcare consumers with social advocacy regarding public and private benefits for which they may qualify. These benefits can positively impact their overall health and well-being, as well as deliver financial assistance.

    Through COMMUNITY Link, we can help bring much- needed relief from some of the financial challenges facing a growing number of seniors and disabled individuals throughout the country. Altegra Health has developed an extensive database of more than 8,000 public and privately sponsored social programs in all 50 states. This social program database and our proprietary eligibility evaluation tool enables our advocates in a single interview to determine what programs for which a health plan member may qualify.

    From there, the appropriate applications are completed electronically for submission to the program sponsor. These programs may include: Adult Care; Assistive Technology, Child Care Services; Co-Payment Assistance; Educational Assistance; Home Repair; Legal Aid; Medicaid and Other State Related Programs; Nutrition; Respite; Telephone; Transportation; Veteran Assistance.

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