Claims and MMIS Testing
■ MEDICAID MANAGEMENT INFORMATION SYSTEMS
PAST AND CURRENT SERVICES
- Perform analysis of claim adjudication to determine compliance with state coverage and reimbursement policies.
- Develop testing program and agreed-upon procedures based on professional standards. (May include statistically valid sample or focused sample, analysis of the adjudication of fee-for-service claims, managed care capitation claims, administrative fees, or financial transactions, all provider categories and service delivery systems.)
- Assist in the implementation strategy of a new enterprise system.
- Provide independent verification and assurances of claim adjudication.
- Analyze member program eligibility status and rate cell assignments.
- Analyze the claim adjudication processes to confirm claim processing and financial transaction accuracy.
- Compute overpayments and underpayments of test claims and/or population estimates.
- Prepare analysis to assist in prioritizing mispayment issues.
- Perform analysis of claims population to improve the system editing and auditing of claims.
- Identify and prepare claims processing system correction tickets.
- Prepare estimates of the annual financial liabilities and receivables related to paid claims.
- Perform analysis of system documentation manuals and companion guides.
- Perform analysis of data matching and/or conversions.
- Preparation of an agreed-upon procedures report that can be relied-upon by financial statement auditors in order to complete annual audit of financial statements.