The Client
A leading provider of integrated clinical management services for public sector healthcare organizations in USA, our client provides tools for managing Medicaid, pharmacy, and mental health and long-term care programs.
The challenge
Our client's had an existing Medicaid Management Information System (MMIS) that was outdated and with its inflexible programming, was costly to maintain, operate and enhance. The Medicaid program has become increasingly complex, with service changes (e.g., hospice, behavioral health), eligibility changes, and new regulations (e.g., HIPAA). The existing system was unable to address these new business requirements.
the solution
We helped to develop a highly integrated data processing system designed to function around the rules of the HCFA (HealthCare Financing Administration) GSD (General System Design), the State Medicaid Plan, the needs of the provider community, the state Medicaid and non-Medicaid enrollees.
This system has the following subsystems:
Claims Processing Subsystem
Adjudicates payment requests from all health benefit plans administered by the Department Of Medical Assistance Services (DMAS)
Provider Subsystem
Maintains information on medical providers who are eligible to submit claims for services rendered to Medicaid Recipients. This information is used for claims processing, administrative reporting, and surveillance/utilization review functions.
Recipient Subsystem
Collects, edits, maintains and reports enrollee eligibility data on a wide range of benefit packages established by DMAS to sustain the accurate and timely processing, payment and reporting of Medicaid claims.
Financial Subsystem
Monitors and controls cash disbursement and recoupment of program funds to providers and other payees through a combination of automatic and manual functions.
Reference Subsystem
Maintains data supporting the processing requirements of other MMIS subsystems
Surveillance and Utilization Review (SUR) Subsystem
Contains the following applications:
- Sampling Support
- Automated Exception Analysis
- Returned Explanation of Medical Benefits (EOMB) Tracking
- Assessments Peer Intensity Rating System (PIRS)
- Utilization Tracking
Management and Administrative Reporting Subsystem (MARS)
Produces reports concerning the functioning of the Medicaid Program for review
Early and Periodic Screening Diagnosis and Treatment (EPSDT) Subsystem
Provides for the collection of data concerning the EPSDT Program administration, including identification of eligible, documentation of case management activities, and the extraction of service delivery information from paid claims.
Automated Mailing
An automated tool for producing reports, form letters, and mailing labels for enrollees and providers based on user defined selection criteria.
|
