Improving Operations and Payment Integrity for Medicaid Programs
The CAQH Member Data Solution is a one-of-a-kind resource that is helping Medicaid programs streamline operations, improve enrollee services and advance payment integrity initiatives.
How Nationwide Coverage Data is Transforming State Programs
Medicaid agencies face persistent and unique challenges when other health insurance information (OHI) is incomplete or outdated, resulting in duplicate enrollments, improper payments, and administrative inefficiencies. With nationwide commercial coverage data on 225M+ covered lives, CAQH helps state agencies and their partners gain the visibility needed to improve enrollee services, protect program dollars, and prevent unnecessary Medicaid expenditures.
Improved Eligibility Determinations
CAQH provides Medicaid programs an analysis of coverage overlap of enrollees, including demographic and contact information, coverage types and dates and payment responsibility.
This information can be used for eligibility, benefit coordination, payment and enrollee outreach activities. A secure payer-to-payer messaging system enables programs to share documents and resolve issues.
Coverage Insights, On Demand
Medicaid agencies often struggle with disenrollments, undetected commercial coverage, and delayed claims due to limited visibility into other health insurance (OHI). COB On-Demand provides quick, point-in-time access to validated COB data from 225M+ commercial covered lives, allowing agencies to compare coverage without sharing information back with other plans. The result: more accurate eligibility determinations, fewer improper payments, and uninterrupted access to care.
Our Impact
From Gaps to Gains: How Accurate Member Data Drove $10M in Retrospective Revenue Adjustments
A health plan based in the southwest with a Medicare Advantage (MA) enrollment of about 28,000 faced a recurring issue when paying claims for these members. Learn how using CAQH COB data helped increase their data accuracy and recover millions from CMS.
8 Pitfalls to Watch Out for in Identifying Third Party Liability
SUPPORTING THE MISSION
CAQH solutions transform eligibility, enrollment, coordination of benefits and third party liability processes for Medicaid programs.
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