Medicaid

Project:

The overall goal of the submission of the Medicaid encounters is for the state to be able to evaluate the health of their Medicaid population. The State pays the health plan on a capitated per member per month basis. Encounter data is used in capitation rate setting and in financial and utilization reports.

Business made a decision to use Cosmos system as the strategic claim payment system for this new implementation and NEMIS system for the encounter processing and submission.

This process begins with the identification, selection and extraction of paid and adjusted Evercare of New Mexico, Coordination of Long-Term Service (COLTS) Medicaid encounters from the COSMOS system and ends with the Assistance Division in the 837 and NCPDP formats. The scope is limited to medical (professional and institutional), dental, vision, transportation and pharmacy claims.

My role was to fetch the data from the Finalized database based on the given selection criteria for that particular state and type.

Inserting the data into appropriate tables in the NEMIS database.

Updating the Submitted Flag field in the Header and Detail tables.

And execution of extract is also done it is only one-time process.

Once the process of extraction is over the following checks were required to be done:

1) The submitted flag for the erroneous claims should be updated as ‘E’ in the Header and Detail tables. For other claims the submitted flag should be updated to ‘S’.

2) For erroneous records an entry has to be made in the claim_errors table.

3) Generating the Test Cases for Extraction.