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
The existing Medicaid Management Information System (MMIS) that was outdated and with its inflexible programming, was costly to maintain, operate and enhance.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.
Additionally L&T InfoTech resources were been involved in HIPAA compliance projects. We helped in development and implementation of HIPAA changes required for the MMIS (Medicaid Management Information System).
Medicaid systems typically comprise of the following functions/modules:
Claims
Adjudicates payment requests from all health benefit plans administered by the State Health Department.
Provider
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.
Enrollee
Collects, edits, maintains and reports enrollee eligibility data on a wide range of benefit packages established by State Health Department to sustain the accurate and timely processing, payment and reporting of Medicaid claims.
Financial
Monitors and controls cash disbursement and recoupment of program funds to providers and other payees through a combination of automatic and manual functions.
Reference
Maintains data supporting the processing requirements of other MMIS subsystems
Surveillance and Utilization Review (SUR)
Contains the following applications:
- Sampling Support
- Automated Exception Analysis
- Returned Explanation of Medical Benefits (EOMB) Tracking
- Assessments Peer Intensity Rating System (PIRS)
- Utilization Tracking
Early and Periodic Screening Diagnosis and Treatment (EPSDT)
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.
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