MCOs — Managed Care Organizations
A health plan that manages the delivery and financing of healthcare services through a defined provider network, utilization management, and quality improvement programs. MCOs include HMOs, PPOs, POS plans, and EPOs. They accept premium payments, assume insurance risk, and ensure access to covered services.
22
Primary Modules
7
Key API Integrations
11
Regulatory Requirements
Primary Portal Modules
Products Enrollment Claims Providers Auth Financial Risk Pools Analytics Care Coordination Population Health Grievances Compliance Regulatory Billing Patient Communication Clinical Medications Employer Groups Alerts Documents Tenants
Organizational Relationships
▲ Vertical — Reports To (Upward)
- State DOI/DMHC
- CMS (for MA and Medicaid managed care)
- NCQA/URAC (accreditation)
- DOL (employer plans)
▼ Vertical — Oversees (Downward)
- Delegated entities (IPAs, PHOs, MSOs)
- Contracted providers
- Subcontracted vendors (PBMs, behavioral health)
- TPAs (if subcontracted)
▶ Horizontal — Collaborates With (Peer)
- Hospitals and health systems
- Physician groups/IPAs
- ACOs (value-based contracts)
- FQHCs (safety-net access)
- Employers (group coverage)
- Brokers/agents
- PBMs
- Reinsurance carriers
- HIEs
Key API Integrations
CMS MA APIs (HPMS, MARx, Stars, Risk Adjustment)State Medicaid InterfacesFull X12 EDI SuiteFHIR Interoperability (Patient Access, Provider Directory, Payer-to-Payer)NCPDP PharmacyHEDIS/CAHPS/StarsPrice Transparency APIs
Regulatory Requirements
- State insurance licensure and RBC
- CMS MA/Part D regulations
- Medicaid managed care (42 CFR Part 438)
- NCQA/URAC accreditation
- MLR requirements (80/85%)
- Network adequacy
- HEDIS/CAHPS/Stars
- Grievance and appeal timelines
- CMS Interoperability Rule
- No Surprises Act
- Mental Health Parity