Medicaid Enterprise Systems are going through a historic paradigm shift and gearing to pivot to the next generation Medicaid systems, capabilities, and technologies. States are adjusting their focus from a monolithic MMIS system to an integrated delivery of health and social assistance services – providing highest value solutions that improve outcomes for members, providers, and program stakeholders. This means supporting the work of multiple agencies, exchanging information, and providing a single-entry point to access services in a well-coordinated and seamless way.
By combining our business operations excellence with innovative technology and a mission to move Medicaid forward, we have designed our Conduent Medicaid Suite (CMdS) —a production-ready application portfolio that supports states’ migration from a legacy MMIS to digital, interoperable, and scalable enterprise. CMdS is a modular solution that enables program optimization and is delivered as Software as a Service (SaaS). It fully supports MITA goals and aligns with CMS Seven Standards and Conditions. CMdS is federally compliant system that provides an assurance of applicable security standards — all backed by 49 years of Medicaid experience.
provides accurate, prompt, and real-time adjudication of claims and encounters to support state healthcare programs with over 1,300 flexible edits and audits, a powerful COTS-based rules engine, and support for simple and complex pricing methodologies – using configurable program and benefit plan capabilities to accurately and quickly process claims
provides accounts payable, accounts receivable, and financial management solutions. Eliminating the need to piece together information from multiple payment and recovery systems – instead have a global view of expenditures, enforce budget limits, have fine grained control of payment, and track funding back to sources and the chart of accounts.
is a HIPAA/HITECH compliant and ENHAC accredited clearinghouse specializing in the ANSI 5010 X12N transaction set translating and delivering in excess of half a billion healthcare transactions annually across its healthcare footprint to over forty thousand active trading partners. Certified at minimum for Phases I and II of CAQH CORE compliance, the platform offers support all industry standard real-time, batch, and safe harbor channels for trading partners.
offers real-time comprehensive NCPDP-compliant claims adjudication functionality that automatically evaluates eligibility, drug coverage, benefit limitations and pharmacy network enrollment prior to dispensing, eliminating conflicts and inappropriate use, and includes:
- Flexible Rx – completely adjudicates claims submitted via POS, paper, or batch and offers true prescription benefit management capabilities with real time performance and reliability.
- SmartPA – real-time prior authorization (SmartPA)
- RetroDUR – population-based interventions to target sub-optional therapies and educate providers on best practices
- Flexible Rx Rebate – rebate management that maximizes program rebate dollars by optimizing identification, invoicing, and collection
offers comprehensive reporting functionality to meet federal reporting requirements. Along with flexible, user-defined capabilities it includes the ability to perform functions ranging from standard reports to advanced ad hoc queries and analytics. The primary components includes:
- SURS: the fraud and abuse detection (FAD) component provides extensive surveillance and utilization review (SUR) capability
- MARS: management and administrative reporting component supports required federal and state reporting (MAR/reports and T-MSIS extracts) for programs and financial functions.
- T-MSIS: compilation, reporting development, and submission of program data to CMS for assessment and improvement activities
is a business intelligence, information management, and analytics solution. It provides program insights, trends and actionable knowledge to support Medicaid programs’ transformation, fiscal management, waste and abuse avoidance and overall program quality. The solution combines analytics and predictive modelling, scalability and flexibility to support the evolving needs for state programs along with intuitive visualizations that delivers informative program information.
uses data matching for the recovery of funds to the limit of the legal liability from insurance companies, another person, or any other entity that is liable for health care costs. Includes health insurance benefits, Medicare recoveries, HIPP, casualty/accident claims, product liability claims, medical malpractice, worker’s compensation claims, and estate recovery to ensure Medicaid is the payer of last resort.
of Government healthcare experience
innovation through five generations of Medicaid systems
team has many hundreds of years of combined Medicaid experience
successful CMS certifications
to have a system certified wholly based on MECT criteria
to receive modular certification within Medicaid – by implementing a CMdS module