Medicaid Claims

Is your state’s Health Care Services agency overwhelmed with the continual changes, volume and complexity of processing claims for Medicaid and other funding sources?

Does your system produce the federal CMS-64 report automatically?

Is producing payments a complex manual or spread sheet based process utilizing diverse and antiquated systems?

Can payments be produced at a summary level by program with “drill down” to the Claims Detail?

Can the different Federal Financial Participation (FFP) programs be applied automatically, without re-programming your software?

Are reimbursement invoices generated automatically reflecting FFP or other agency participation, and including automatically collated “backup” detailed reports?

Is importing Claims into the financial system automated?

Do you provide warrant/EFT payment information to the entities being paid at the claim level?

Are claims and reimbursements automatically journalized into the state financial system?

Does your software meet the latest ACA EFT requirements?

Accelerate the reimbursement of Medicaid claims to the state’s counties or other entities

Provide a consolidated series of reports for internal & external auditors and other stakeholders

Reduced the time to process claims to three (3) weeks

Eliminate manual processes substantially reducing staff effort

Provide counties with on-line reimbursement status of claims

Automate claims collection from counties or other state agencies, etc.

County Claims e.g., Affordable Care Act, Children’s Services, Breast Cancer, Mental Health, etc.

Social Services e.g., adoption, child welfare, healthy families, food, etc.

Differentiate, classify, and validate claims according to type for Federal or State Participation (FFP, SGF) and/or other funding sources

Based on claim type, source, aid codes, medical eligibility group, etc.

Table-driven rules to allow insertion of new aid codes without costly software changes.

User-defined medical eligibility groups and/or other classifications by program.

Provide summary/detailed reports to adjudicate, validate, and track claims

Automated rules-based filtering and categorization/detailed

Workflow for claims processing

Success/Failure metrics

Claim level details with start/finish historical reporting

Apportion claims based on pre-defined allocation rules

By percent, multiple pools, contract rules, etc.

Table based to accommodate change, e.g., federal aid codes

Validate aid code percentages applied during adjudication

Invoice and distribute claims to funding sources with full audit trail

Electronically by EFT and/or wet signature

Specialized invoice by funding source with supporting/accompanying “backup” reports (MEG, FFP, etc.) automatically collated.

Participation metrics captured for later federal/state stakeholder audit reporting.

Track receipts from funding sources and reconcile claims

Exceptions, adjustments, liquidations

Invoice host (State or Agency) for non-participatory amounts

AR Cash receipts automatically release AP claim schedules for payment

Disburse funds to original claimants

Showing share of each participating funding source

Report warrant/EFT used to pay claim schedule down to the service provider and detailed claim level

Produce Claim Schedules & Reports:

At summary levels with drill down to detail claim

By Funding Source, Program or Category

Claim Schedule face sheet accompanied by supporting detail reports

Provide reports, analysis and audit trails:

In PDF, Excel, etc.

For claimants

For Host Agency e.g., State Government, other agencies

For Funding Sources e.g., Federal Government

Statutory Reports e.g., CMS 64, other agencies/funds

Full USL Database, Module, Menu, Function, Action and Account Level security options relative to the system security.

Full security by Delivery Location in PO and PQ.

Departmental Security via Workgroups in A/P, A/R, GL, and PQ.

Security by Project, Sub-Project, and Funding Source (Grant).

Relative to system security, The AP module has special menu items for administrative processing. Supervisor can see all the data entry users entries and is able to post it.

SERVERS

Dual Core, 2.3 GHz or better

4GB RAM (32-bit Windows Server) sized by need

8GB RAM (64-bit Windows Server) sized by need

Windows Server 2008 – 2012 (R2 supported) (64-bit recommended)

SQL SERVER

Microsoft SQL Server 2008 – 2014 (R2 supported) (64-bit recommended)

TERMINAL SERVER (if utilized):

Dual Core, 2.3 GHz or better

4GB RAM (32-bit Windows Server) sized by user count

8GB RAM (64-bit Windows Server) sized by user count

Windows Server 2008 – 2012 (R2 supported) (64-bit recommended)

CLIENT WORKSTATIONS

Core 2 Processor, 2.3 GHz or better

2GB RAM or better

Microsoft Windows 7 (SP1) – Windows 10 Pro

Microsoft Office Professional 2007 – 2016 (32-bit only)