eKlotho Nexus — User Manual

Logging In

• Navigate to your organization's eKlotho Nexus URL (e.g., nexus.yourorg.com) in a supported browser (Chrome, Firefox, Edge, Safari).
• Enter your assigned username (typically your organization email address) and temporary password, then click Sign In.
• If multi-factor authentication is enabled, enter the 6-digit code from your authenticator app or the SMS sent to your registered mobile number.
• On first login, you will be prompted to change your temporary password. Choose a strong password of at least 12 characters.
• Complete your profile by navigating to User Profile in the top-right avatar menu and verifying your contact information.

Navigating the Portal

• The dark sidebar on the left is your primary navigation. Click any section label to expand its sub-items.
• The hamburger icon (☰) in the top-left collapses or expands the sidebar to maximize screen space.
• Use the global search bar in the header to quickly find patients, claims, providers, or documents by name or ID.
• The breadcrumb trail below the header shows your current location in the portal.
• Click the ? (help) icon in the header on any page to open the Page Guide with context-specific tips.

KPI Cards (Pulse Strip)

• The Pulse Strip at the top displays your most critical metrics: active patients, open claims, pending authorizations, MLR, and more.
• Hover over any KPI card to see the 7-day sparkline trend and percentage change from the prior period.
• Use the date range chips (Today, Week, Month, Quarter) in the header to adjust the reporting window for all widgets.
• Cards with a colored left border indicate metrics requiring attention — red for critical, amber for warning.

Smart Alerts & AI Insights

• The Smart Alerts panel uses AI ranking to surface the most urgent items. Critical clinical alerts always appear first.
• Use the filter chips (All, Clinical, Claims, Compliance, System) to narrow alerts to your area of responsibility.
• Click the action button on any alert to navigate directly to the relevant record or workflow.
• AI Insights are generated automatically from pattern analysis of your organization's data — review and act on high-impact insights promptly.
• Click Dismiss on any insight you have already addressed; dismissed insights will not reappear for that session.

Searching for a Patient

• Navigate to Patient Management → Patient List from the sidebar.
• Use the search bar to find patients by name, date of birth, Member ID, or Social Security Number (last 4 digits).
• Apply filters for enrollment status, risk tier, care program, or primary condition using the filter panel on the left.
• Click on a patient row to open their full profile. The profile is organized into tabbed sections for easy navigation.

Creating a New Patient Record

• Click + New Patient in the top-right of the Patient List page, or use the Quick Actions button on the Dashboard.
• Enter required demographic fields: Legal name, date of birth, gender, address, and primary phone.
• Add insurance information including payer, plan, Member ID, group number, and effective dates.
• Assign the patient to a primary care provider from the Provider Directory and select applicable care programs.
• Click Save & Open Profile to complete registration and access the full patient record.

Patient Profile Sections

The patient profile contains the following tabbed sections:

Creating a Care Plan

• Open a patient's profile and navigate to the Care Plan tab, or go to Clinical → Care Plans and search for the patient.
• Click + New Care Plan and select a template from the library (e.g., "Diabetes Type 2 Management") or choose Blank Plan.
• Define goals with measurable targets (e.g., "HbA1c below 7.0% within 90 days") and assign responsible team members.
• Add interventions, action steps, and barriers. Set review frequency and next review date.
• Click Activate Plan to make it live. The patient's care team will receive a notification.

Conducting an Assessment

• Navigate to Clinical → Assessments and search for the patient or open it from the patient profile.
• Select the assessment type (PHQ-9 for depression, GAD-7 for anxiety, HRA for health risk, or custom organizational forms).
• Complete all required questions — the form validates completeness before allowing submission.
• Review the auto-calculated score and severity classification (e.g., PHQ-9: Mild, Moderate, Severe).
• Add clinical notes and recommended follow-up actions, then click Submit Assessment. Results are immediately visible in the patient's profile.

Setting Up RPM for a Patient

• Open the patient's profile, navigate to the Devices tab, and click + Assign Device.
• Select the device type (blood pressure monitor, glucometer, pulse oximeter, weight scale, etc.) and enter the device serial number.
• Set alert thresholds for each vital parameter (e.g., systolic BP alert above 160 mmHg).
• Confirm patient consent for RPM in the consent section — this is required for billing.
• The device will begin transmitting readings automatically. Monitor the Live Monitoring console for real-time status.

Reviewing Monthly RPM Summary

• Navigate to Vital Monitoring → Monthly RPM to view RPM billing summaries for all enrolled patients.
• Filter by month, care program, or provider to focus your review.
• Confirm that each patient has met the minimum 16 days of data transmission required for CPT 99454 billing.
• Review flagged readings where values exceeded alert thresholds, and document clinical response in the notes field.
• Click Generate Billing Summary to create the monthly RPM billing file ready for claim submission.

Reviewing Patient Medications

• Open a patient's profile and navigate to the Medications tab, or go to Medications → Overview for a population-level view.
• Review active prescriptions, dosage, frequency, prescriber, and dispense dates.
• Click Check Interactions to run a real-time drug interaction analysis against all active medications.
• Any flagged interactions are categorized by severity: Contraindicated, Major, Moderate, Minor. Review and document clinical decision.
• To add or discontinue a medication, click Edit Medications — changes require prescriber authorization and are logged in the audit trail.

Submitting a CMS 1500 Claim

• Navigate to Claims Processing → CMS 1500 and click + New Claim.
• Select the patient using the search field — insurance and demographic data auto-populate from the patient record.
• Enter the rendering provider, place of service, diagnosis codes (ICD-10), and procedure codes (CPT/HCPCS).
• Review the claim for completeness — the system highlights missing required fields in red.
• Click Validate & Submit to run pre-submission edits. Resolve any errors, then click Final Submit to transmit via EDI 837P.

Processing OCR Scanned Claims

• Navigate to Claims Processing → OCR Processing and click Upload Document.
• Upload a scanned PDF or image of the paper claim form. The AI OCR engine extracts all fields automatically.
• Review the extracted data in the side-by-side verification view — flagged fields with low confidence scores require manual confirmation.
• Correct any errors, assign the claim to the appropriate payer queue, and click Accept & Route.

Managing Denials and Disputes

• Navigate to Claims Processing → Disputes to view all denied or disputed claims.
• Filter by denial reason code (CO, PR, OA, PI) or denial category to identify systemic issues.
• Click Create Appeal on any denied claim to initiate the reconsideration workflow. Attach supporting clinical documentation as needed.
• Track appeal status (Pending, Submitted, Approved, Final Denial) through the dispute timeline view.
• Approved appeals automatically trigger claim reprocessing and update the payment ledger.

Verifying Patient Insurance Eligibility

• Navigate to Billing → Insurance Verification or open a patient profile and click Verify Eligibility on the Insurance tab.
• Select the payer and enter the date of service to run a real-time 270 eligibility inquiry.
• Review the 271 response: confirm active coverage, copay/coinsurance/deductible amounts, and plan limitations.
• Click Save Verification to record the result with a timestamp. The system alerts you if coverage is inactive or has changed since the last verification.

Submitting a Prior Authorization

• Navigate to Authorizations → Prior Auth and click + New Request.
• Search for the patient and select the requested service (procedure code, service type, or diagnosis-driven program).
• Complete the clinical justification section, referencing applicable criteria. Attach supporting records (office notes, lab results, imaging).
• Select the submission method (EDI 278, fax, or payer portal) and click Submit Request.
• Monitor status in the Prior Auth dashboard. The system sends alerts when SLA deadlines are approaching or decisions are received.

Searching the Provider Directory

• Navigate to Providers → Directory and search by provider name, NPI, specialty, or location.
• Apply filters for network status (In-Network, Out-of-Network, Preferred Tier), accepting new patients, telehealth availability, and language.
• Click a provider to view their full profile: credentials, contract terms, quality scores, and panel availability.
• Click Refer Patient from a provider's profile to initiate a referral directly linked to that provider.
• Use the Network Adequacy map to visualize provider distribution and identify access gaps by geography and specialty.

Processing an EDI 834 Enrollment File

• Navigate to Enrollment → EDI 834 and click Upload File to import an EDI 834 transaction set.
• The system validates the file structure, ISA/GS segments, and individual member records. Errors are highlighted with specific segment locations.
• Review the validation report: confirm add, change, and termination transactions before applying to the member database.
• Resolve any member matching errors (e.g., duplicate Member IDs, mismatched SSNs) using the reconciliation tool.
• Click Apply Transactions to commit changes. A 999 functional acknowledgment is generated automatically for the trading partner.

Opening a Care Coordination Case

• Navigate to Care Coordination → Cases and click + New Case.
• Search for the patient and select the case type (Complex Care Management, Chronic Disease, Transitions of Care, etc.).
• Assign the case to a care manager and set the intervention intensity level based on the patient's risk score.
• Document the initial assessment, goals, and planned interventions in the case workspace.
• Schedule follow-up touchpoints and set reminder alerts for the care manager. Cases auto-close after the inactivity threshold defined in system configuration.

Reviewing Risk Stratification

• Navigate to Population Health → Risk Stratification to view the full population segmented by risk tier.
• Filter by care program, condition, geographic region, or payer to narrow the analysis.
• Click any risk tier (High, Moderate, Low) to drill down to the individual member list with risk scores and contributing factors.
• Click Create Outreach to initiate a targeted intervention campaign for the selected member cohort.
• Monitor intervention effectiveness on the Interventions page, which tracks enrollment, engagement, and outcome metrics.

Managing HEDIS Measures

• Navigate to Population Health → HEDIS to view your organization's performance on all applicable HEDIS measures.
• Click any measure to see the numerator, denominator, current rate, benchmark, and gap count.
• Use the Member Gap List to identify specific members who need a service to close the gap (e.g., HbA1c test, mammogram).
• Generate an outreach list and assign members to care managers for gap closure outreach.

Running a Standard Report

• Navigate to Analytics & Reporting and select the relevant report category from the sidebar (Executive, Clinical, Finance, etc.).
• Set the date range, group filters, and any additional parameters using the filter panel.
• Click Run Report to generate results. Large reports may take up to 60 seconds to process.
• Use the export buttons to download results in CSV, Excel, or PDF format.
• Click Schedule to set up automatic delivery of this report via email on a recurring schedule.

Scheduling an Appointment

• Navigate to Scheduling → Calendar and select the provider and date.
• Click an available time slot on the calendar to open the appointment creation form.
• Search for the patient, select the visit type, and choose in-person or telehealth modality.
• Add any preparation instructions for the patient (e.g., fasting requirements, documents to bring).
• Click Confirm Appointment. The patient receives an automatic confirmation with visit details and a reminder sequence.

Creating an SMS Outreach Campaign

• Navigate to Alerts → SMS Campaigns and click + New Campaign.
• Define the target audience using filters (risk tier, condition, care gap, geography, etc.) — the estimated recipient count displays in real time.
• Select or create a message template. Personalization tokens (patient name, appointment date) are automatically resolved.
• Set the send schedule: immediate, scheduled date/time, or recurring (e.g., weekly medication reminders).
• Review the campaign summary and click Launch Campaign. Opt-out responses are automatically honored per TCPA compliance rules.

Uploading and Scanning a Document

• Navigate to Documents → AI Scanner and click Upload Document.
• Select the file (PDF, JPG, PNG, TIFF) from your computer or drag and drop it into the upload zone.
• Select the document type (Clinical Note, Lab Report, Imaging, Authorization, EOB, etc.) to guide the AI extraction model.
• Review the extracted data fields in the verification panel — fields with lower confidence are highlighted for manual review.
• Click Confirm & Link to associate the document with the identified patient and save to the Document Center.

Managing Premium Billing

• Navigate to Financial → Dashboard to view current premium collection status, outstanding balances, and aging receivables.
• Click Financial → Invoicing to generate monthly premium invoices for employer groups or individual members.
• Process incoming premium payments in Financial → Payments — payments are auto-applied to the oldest outstanding invoice.
• Members in grace periods appear in the Grace Periods queue with days remaining and termination risk status.
• Review MLR compliance in Financial → MLR, which calculates incurred claims vs. earned premiums with automatic ACA compliance flags.

Reviewing Plan Benefits

• Navigate to Plan Products → Product List to view all active and pending plan products.
• Click any plan to open the Benefit Design detail view showing covered categories, cost-sharing tiers, and coverage limits.
• Use the Plan Comparison view to compare up to four plans side-by-side on key benefit dimensions.
• Review Accumulators to see real-time deductible and out-of-pocket utilization for enrolled members.

Managing an Employer Group

• Navigate to Employer Groups → Setup to view or create employer group records.
• Click Census to upload or manage employee rosters — use the provided Excel template for bulk uploads.
• Configure open enrollment windows in Open Enrollment and set employee election deadlines.
• Review group billing statements in Group Billing — statements are generated monthly with line-item detail per enrolled employee.
• Manage COBRA notifications and continuation coverage in COBRA — qualifying event letters are generated automatically.

Reviewing Risk Pool Status

• Navigate to Risk Pools → Dashboard for a summary of all active risk pools and their current financial position.
• Click into any pool to view withhold balance, incurred claims, and variance from benchmark.
• Review Shared Savings to see projected year-end savings distributions by provider organization.
• Download settlement statements from Settlements for distribution to participating provider organizations.

Logging a Grievance

• Navigate to Grievances → Intake and click + New Grievance.
• Select the grievance type (Quality of Care, Access, Service, Billing), complainant (Member or Provider), and initial receipt method (phone, written, portal).
• Document the member's concern in the description field using objective, factual language.
• Assign the case to the appropriate department queue and set the acknowledgment letter generation (required within 5 days of receipt for CMS plans).
• Track resolution progress in Resolution Tracking. Final determination letters are generated from templates and logged with send dates.

Managing the Sliding Fee Scale

• Navigate to FQHC → Sliding Fee to view and configure the current sliding fee discount schedule.
• Update income brackets annually when the Federal Poverty Level guidelines are published (typically January).
• Assign patients to the appropriate sliding fee discount tier based on their documented household income and family size.
• Run the Patient Eligibility Review report to identify patients due for annual income re-verification.

Managing the Compliance Filing Calendar

• Navigate to Regulatory → Filing Calendar to view all upcoming regulatory deadlines in chronological order.
• Click any deadline to view filing details, responsible party, required data elements, and submission instructions.
• Assign filing ownership to staff members and set internal preparation deadlines to ensure timely completion.
• Mark filings as complete after submission and upload the confirmation receipt or acknowledgment document.
• The system sends automated email reminders to assigned owners at 30, 14, and 7 days before each deadline.

Updating Your Profile

• Click your avatar icon in the top-right header and select User Profile from the dropdown.
• Update your display name, title, phone number, and notification email address as needed.
• Click Change Password to update your login credentials — passwords expire based on your organization's policy (typically every 90 days).
• Configure Notification Preferences to enable or disable specific alert categories and choose your preferred delivery channel.
• Review Recent Login Activity at the bottom of your profile to verify no unauthorized access has occurred.