eKlotho Nexus is the operating platform for Independent Practice Associations (IPAs), MSOs, PHOs and ACOs that take delegated responsibility from health plans. Utilization management, credentialing, claims, population health, risk pools and regulatory reporting run on one entity-aware record — the same record the clinics chart in.
An Independent Practice Association (IPA) is a network of independent physicians that contracts with health plans under capitation or shared-risk arrangements. The plan delegates operational functions — utilization management (UM), credentialing, claims processing and quality reporting — and the IPA runs them day to day for hundreds of physicians, answering to each plan under delegation oversight. That position, downstream of plans and managed care organizations (MCOs) and upstream of contracted providers, is the one eKlotho Nexus was designed around. IPA COOs and Medical Directors are its primary users, and the platform is organized the way their week is: what each plan has delegated, what is due back, and whether the organization can answer a delegation audit from the system.
Nexus is not multi-tenant software with one tenant per IPA. It models the payer–provider relationship graph: regulators, health plans, MCOs, IPAs, ACOs, PHOs, MSOs, TPAs, FQHCs and individual providers, joined by first-class relationships — DELEGATION, VALUE_BASED_CONTRACT, CONTRACTED_PROVIDER, SERVICE_CONTRACT, EMPLOYMENT and CREDENTIALING. A delegation carries its scopes (UM, credentialing, claims, quality) and effective dates, and every user's session is scoped by those relationships. A plan sees the slice it delegated, an MSO sees its client IPAs, a provider sees its own panel, and the IPA sees all of it — with no permission lists to maintain.
On that graph sit the modules an IPA runs: the prior-authorization workstation, credentialing and provider network, a claims workstation, enrollment and eligibility records, population health with care gaps and RAF/HCC (Risk Adjustment Factor / Hierarchical Condition Category) intelligence, care coordination, risk pools and capitation, grievances and appeals, regulatory filings, communications, documents and administration. Because the eKlotho EMR charts on the same patient record, a signed encounter in a clinic is already visible to UM, quality and claims, and a referral placed in the chart opens a review in the IPA's own authorization queue — no interface engine, no nightly sync, no re-keying.
Needs · One place to see what each health plan has delegated, what is due to them, and whether the organization can answer a delegation audit this week.
Gets · Delegation records scoped by function with reporting calendars, an attestation tracker, organization pages showing provider composition and adequacy counts, and executive dashboards that read from the same rows the teams work in.
Needs · Reviews that need a physician's decision in one prioritized list, committee decisions recorded defensibly, and quality and risk figures that match what the plan will see.
Gets · The Medical Director UM queue with criteria and a recorded determination, PDF determination letters, committee decisions with rationale, HEDIS measure tracking, the Stars dashboard and the RAF score dashboard.
Needs · A prior-authorization queue with criteria at hand, low-risk services cleared automatically, and a clean hand-off for anything outside the rules.
Gets · An authorization queue with SUBMITTED, IN_REVIEW and PENDED states, a clinical criteria library, auto-approval rules with a test endpoint, an EDI 278 log and UM dashboard KPIs.
Needs · To move applications through verification and committee without chasing expirations in a spreadsheet.
Gets · An application timeline with live NPI checks, a PSV event ledger, a recredentialing queue, an expiration alert scanner, bulk import and CAQH-format roster export.
Needs · Each claim beside the contract's fee schedule and benefit design, with denials, disputes and appeals tracked instead of re-keyed.
Gets · An adjudication queue with controlled status transitions, fee-schedule and accumulator lookups, COB and crossover, denial and dispute workstations, remittance posting with line reconciliation and CSV export.
Needs · Open gaps and high-risk members surfaced from current data, outreach that can be tracked, and transitions of care that do not depend on memory.
Gets · Care-gap registries, the patients-by-RAF roster, risk stratification tiers, outreach campaigns, a caseload dashboard with transitions due, and care alerts with resolve and suppress actions.
| Area | Today | With IPA Solution |
|---|---|---|
| Delegation audit | Evidence is reconstructed from email threads, vendor exports and a shared drive the week before the plan visits. | Delegation scopes, attestations, committee decisions, PSV events and UM determinations are records with timestamps; the audit is answered from the system. |
| Prior authorization | Requests arrive by fax and phone; low-risk services wait in the same pile as complex ones, and the referral and the auth live in different systems. | Requests land in one queue — including referrals from the EMR — auto-approval rules clear the listed services, and the rest route to nurse review or the Medical Director with a generated letter. |
| Credentialing expirations | License, DEA and insurance dates live in a spreadsheet someone remembers to check before the 36-month cycle comes due. | An expiration scanner produces an alert queue from the credentialing records themselves, and the recredentialing queue sorts by due date. |
| Claims status | A claim's status is whatever the last person typed; nobody can say who moved it or why. | Every status change goes through a state machine that rejects invalid moves and writes an audit row with the user and notes. |
| Quality and risk adjustment | HEDIS gaps are worked from a plan-supplied list that is months old, and RAF is whatever the plan reports back after the year closes. | Gaps sit on the shared record and close when a qualifying lab is signed; RAF is recomputed from signed encounters and shown by patient and tier. |
| Plan and provider access | Each plan gets a separate export; providers call to ask about their own panel; the MSO keeps a spreadsheet of who may see what. | Access is computed from the contract graph: a plan sees its delegated slice, an MSO sees its client IPAs, a provider sees its panel, the IPA sees everything. |
11 modules, each describing what is built today.
Delegation agreements recorded per health plan with the functions delegated, effective dates, reporting calendars and attestation tracking — the relationship that drives access everywhere else.
The delegated-UM workstation: intake by web form, EDI 278 transaction log or referral, clinical criteria at hand, auto-approval rules for low-risk services and a Medical Director queue for the rest.
Initial applications, primary-source verification (PSV), committee review and recredentialing on one timeline, feeding a provider directory with tiered and specialty networks.
Professional, institutional and dental claims entered directly, submitted through the API or scanned from paper, then validated, de-duplicated and worked through an adjudication queue with denials, disputes and remittance posting.
Member enrollment and coverage records: EDI 834 intake, enrollment periods, plan benefits, accumulators, carve-outs, crossover for dual-eligible members and retroactive changes.
Care-gap registries, HEDIS measure tracking, Stars dashboards, risk stratification and RAF/HCC intelligence on the shared patient record, with outreach campaigns to close what is open.
Delegated case management and disease management: cases assigned to care managers, longitudinal care plans, transitions of care after discharge, chronic-condition tracking and clinical alerts.
The money behind delegated risk: capitation batches against enrolled member-months, PMPM rate records, risk pools with withholds and settlements, invoices, payment posting, AR aging and MLR reporting.
Member grievance and appeal cases with server-computed SLA deadlines and generated correspondence, alongside the regulatory filing calendar, agency directory and compliance views the delegation requires.
Outbound member and provider communications, the platform-wide notification backbone, and an entity-scoped document repository with versions and signed-URL access.
Employer groups and FQHC programs for IPAs that run them, analytics dashboards and a query builder, and the administrative console: users, roles, fee schedules, integrations and the audit log.
In managed care, authority flows down a hierarchy: regulators oversee health plans and managed care organizations (MCOs), plans delegate to IPAs, ACOs (Accountable Care Organizations) and PHOs (Physician-Hospital Organizations), and those networks contract individual providers and community health centers. Most software flattens this into isolated tenants. Nexus stores each organization as an entity and each agreement between them as a first-class relationship — DELEGATION, VALUE_BASED_CONTRACT, CONTRACTED_PROVIDER, SERVICE_CONTRACT, EMPLOYMENT and CREDENTIALING — each carrying its scope and effective dates.
Access is then computed from that graph rather than administered by hand. Every user's signed session carries their organization, role, the scopes their delegations grant, and the list of organizations reachable from theirs — computed at sign-in from the relationships. Every backend query scopes to that list. A health plan sees exactly the slice it delegated; an MSO (Management Services Organization) sees its client IPAs; a physician sees their own panel; the IPA sees all of it.
Because the relationships are the permissions, a change to the contract is a change to access: end a delegation and the plan's visibility ends with it, with nothing to remember to revoke. Users who serve more than one organization — a Medical Director who also sits with a plan — switch entities and receive a fresh session scoped to the other side, never a widened one.
Claims arrive three ways: entered directly as professional, institutional or dental claims, submitted through the REST API, or scanned from paper with vision-model field extraction that a person then verifies. Each claim is validated and de-duplicated on entry, so the queue holds workable claims rather than noise. EDI 837 submission batches are tracked by file and status; parsing of X12 837/835 file contents is on the roadmap.
Adjudication is a worked queue under status control, not an auto-pricing engine. The examiner opens the claim with the contract's fee schedule, benefit design and accumulators beside it — plus a Medicare fee-schedule reference by locality — and records the determination. Every status change goes through a transition table: an invalid move is rejected, and every valid one writes an audit row with the user and notes.
Downstream, coordination of benefits (COB) and crossover handle members with more than one coverage; denials carry reason codes and route to their own workstation, as do provider disputes and appeals; remittance posting reconciles payment lines against the claim. History search, reports and CSV export support the audit trail, and fraud-review flags are recorded for a human reviewer — automated anomaly detection is on the roadmap.
RAF (Risk Adjustment Factor) is the number CMS uses to measure how sick a Medicare Advantage patient is expected to be — and it adjusts what the plan, and downstream the IPA, is paid for that member. The score is not assigned by the doctor: it is computed from the chronic conditions documented as ICD-10 diagnosis codes on encounters. A condition that is real but undocumented contributes nothing, which makes documentation an operational discipline rather than a coding afterthought.
Nexus implements the current CMS-HCC V28 model: a demographic baseline, plus a weight for each documented HCC (Hierarchical Condition Category), plus interaction factors when specific conditions co-exist — such as diabetes with heart failure — divided by a normalization factor. Within each disease family only the highest-weighted category counts, so duplicate coding adds nothing; the calculator shows those duplicates plainly.
The pipeline is event-driven. Signing an encounter in the eKlotho EMR maps its diagnoses through the ICD-10-to-HCC crosswalk and recomputes the patient's HCC summary. Scores surface on the RAF dashboard, the patients-by-RAF roster for care-program targeting, and an interactive calculator where a clinician can simulate re-capturing a dropped condition before the visit — for conditions that are clinically supported, never as a coding exercise.
Under delegated risk the IPA is paid per member per month, not per service, so the first discipline is knowing what the enrollment actually supports. Capitation batches are computed against enrolled member-months for each delegation and period, with PMPM (per-member-per-month) rate records kept by delegation and period — and the variance between enrolled and capitated membership is surfaced rather than buried in a reconciliation spreadsheet.
Risk pools are tracked per contract across the performance period: withhold balances, surplus or deficit, and medical expense recorded against the pool as the year runs rather than reconstructed at the end of it. Interim and final settlement runs are computed with their history preserved, alongside a shared-savings summary — so the year-end conversation with the plan starts from numbers both sides can trace to source records.
Around the pools sits the financial close: invoices, ACH and wire payment posting with adjustments, accounts-receivable aging buckets, general-ledger journal entries and month-end close views, with medical-loss-ratio (MLR) reporting by period showing how much of the capitation went to medical care. The money side of the delegation is answered from the same records the operational teams work in every day — not from a parallel finance spreadsheet.
A delegation survives on evidence: the plan's oversight program — typically aligned to NCQA delegation standards — expects the IPA to show that credentialing, UM turnaround and quality reporting meet the agreement. Nexus keeps the obligations visible: a regulatory filing calendar and agency directory covering CMS, state Department of Insurance and NCQA deadlines, preparation pages with filing status, and statistics packets assembled for plan and agency reporting.
Member grievances and appeals run on the same discipline. The SLA (service-level agreement) deadline for each case is computed on the server from its priority — never taken from the request, so a mis-keyed date cannot loosen a regulatory clock — and the case carries its timeline, reviewer assignment and template-generated correspondence. Cases are archived, never deleted, so the reporting the delegation requires reads from the record itself.
Attestations for delegated functions are tracked and invalidated with a reason rather than removed, and an immutable audit log records user actions across modules. When the plan audits, the answer is the system: scopes, PSV events, committee decisions, determinations and SLA clocks with timestamps. Automated OIG/SAM exclusion screening is on the roadmap; today that evidence is recorded as attachments and attestations.
Quality work starts with knowing who is open. Care gaps are tracked per member with evidence status and linkage to the HEDIS (Healthcare Effectiveness Data and Information Set) measure they belong to, and measures are tracked per delegation and measurement year — the same way the plan will score them. Risk stratification tiers, disease registries, pharmacy-adherence views and social-determinants data define the cohorts worth acting on first.
Closure is event-driven where the data supports it: when a qualifying lab result is signed in the eKlotho EMR, its LOINC code maps to the measure and the numerator is marked met for that patient and year — the gap closes because care happened, not because someone reconciled a plan file months later. A nightly batch engine for the full measure set is on the roadmap.
What stays open drives outreach. Campaigns go to cohorts — the open-gap list, a chronic-condition registry — through the communications module, interventions are logged against the member, and the Stars dashboard shows measure-level performance with an improvement what-if. The same gaps appear in the clinician's chart, so the person who can close a gap sees it at the point of care.
Create the IPA, its health-plan relationships and the scopes each plan delegated (UM, credentialing, claims, quality) with effective dates. Upload the agreement and reporting calendar. Access for every user now follows the contract.
Applications arrive by intake form, self-submission or bulk import. NPI is verified live against NPPES and logged as a PSV event; the committee records its decision; approved providers become contracted-provider relationships and receive access. The recredentialing queue and expiration alerts keep the multi-year cycle on schedule instead of in a spreadsheet.
Authorization requests land in one queue — including referrals placed in the EMR, which the delegation contract routes to auto-approval, nurse review or the plan — with turnaround visible on the UM dashboard. Claims are validated, worked through the adjudication queue and posted against remittance.
Care gaps, HEDIS measures and RAF/HCC capture sit on the shared record; signed labs close measures, outreach campaigns go to cohorts, and care managers work cases and transitions of care.
Capitation, risk pools, withholds and settlements are calculated from enrolled member-months, with MLR reported by period; filings, grievance SLAs and delegation attestations are answered from the same records the teams work in.
Every promise on this page maps to something the software actually enforces.
No. Nexus models the relationships between regulators, plans, IPAs, practices and providers and computes access from them. A health plan can be delegated to several IPAs and see each slice; an MSO can administer several client IPAs; a provider can belong to more than one network.
Utilization management, credentialing, claims, quality reporting, enrollment and eligibility records, care management and the financial settlement that goes with them. Each is a separate scope on the delegation record, so the IPA can show a plan exactly what it is accountable for.
Requests enter by web form, EDI 278 transaction or as referrals from the eKlotho EMR. Auto-approval rules clear the services your contract lists; everything else moves to nurse review and then the Medical Director queue, where the determination is recorded with rationale and a PDF letter is generated. Appeals are tracked as their own records.
NPI status is verified live against the NPPES registry and written to the PSV ledger with its source and result. Other primary sources — licensure boards, OIG and SAM exclusion lists, NPDB — are pluggable drivers on the roadmap; today their evidence is recorded as attachments and attestations.
Professional, institutional and dental claims are entered directly, submitted through the API or scanned from paper. The examiner works each claim in an adjudication queue with the contract's fee schedule, benefit design and accumulators beside it; status changes go through a state machine. EDI 837 batches are tracked by file; X12 parsing of 837/835 is on the roadmap.
Measures are tracked per delegation and measurement year on the shared patient record, and a qualifying lab signed in the EMR closes the numerator for that patient and year. RAF is recomputed from signed encounter diagnoses using the CMS-HCC V28 model and surfaced on the RAF dashboard and patients-by-RAF roster. A nightly HEDIS batch engine is on the roadmap.
The eKlotho EMR reads and writes the same patients table, so a referral placed in the chart opens a UM review in your queue, a signed encounter builds a draft claim and recomputes HCC, and care gaps appear in the chart — with no interface engine between the two.
Capitation batches are computed against enrolled member-months per delegation and period, with the enrolled-vs-capitated variance surfaced. Risk pools track withhold balances and surplus or deficit per contract; interim and final settlement runs are computed with their history preserved, alongside a shared-savings summary and MLR reporting by period — so the year-end reconciliation with the plan starts from traceable numbers.
A REST API for direct submission and retrieval, EDI 834 enrollment file intake, 837 batch tracking, a 278 transaction log, CAQH-format and payer roster exports, and signed-URL document exchange through AWS S3. Live 270/271 eligibility inquiry and X12 parsing of 837/835 file contents are on the roadmap.
We walk through it with your data and your team — not a canned demo.
Program and billing eligibility are determined by each practice and its payers. Results and alerts do not constitute a medical diagnosis. Third-party names are trademarks of their respective owners and do not imply endorsement.
