Medicaid Claims Processing

Ensuring Accurate and Timely Medicaid Rebate Payments

For most pharmaceutical manufacturers, processing Medicaid claims is a labor-intensive process subject to costly fines for incorrect payments. As state governments suffer from increasing utilization costs, they are recognizing the advantages of providing state and supplemental benefits and are quickly adding new programs. As a result, manufacturers need to find a means for managing the overwhelming task of processing Medicaid claims.

Model N Medicaid Claims Processing

Model N Medicaid Claims Processing manages all aspects of Medicaid claims, from the setup and maintenance of Medicaid and state programs, to resubmission and dispute handling, payment processing, and generation of required government reporting. Medicaid Claims Processing enables analysts to easily calculate rebate-per-unit (RPU) prices, upload new claims and validate them, approve payments, and generate required reports in compliance with all federal regulations and guidelines set forth by CMS. Seamless integration with Model N Government Pricing ensures accurate and timely Medicaid rebate calculations.

Validation, Compliance, and Auditability

Medicaid and state programs capture contractual rules and formulas used in calculating rebate prices and validating submitted claims. Such rules can be easily managed online and are subject to standard system audit controls. Quarterly URA prices are automatically calculated for each program and are used during validations of the submitted claims. Should government prices be restated for prior quarters, the URA prices will be automatically recalculated for those prior quarters and the affected prior quarter claims will automatically be resubmitted.

New and adjusted claims can be quickly entered or uploaded into the application and run through a set of validations to identify potential input errors and invalid claims. Configurable validation tests can quickly detect units that are in excess of the expected utilization, resulting in recommendations for dispute amounts, which can be further modified.

Claims are automatically grouped into payments by payee and the system automatically calculates any interest owed for overdue claims or settlements of prior quarter disputes. Flexible workflow capabilities manage the payment approval process and automatically select the payment approvers, if required.

The software also ensures regulatory compliance by providing full auditability and management of business processes, such as making sure that claims are paid only after appropriate review and approvals. To complete the process, standard government reports are generated, and approved payments are automatically interfaced with the accounts payable system as check requests.

Medicaid Claims Processing at a Glance