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Medicaid Use Cases

Value Statement

Use Case

Improve the timeliness, accuracy, quality and completeness of the data received

Medicaid employees would be able to log into the VHR and search for clinical information on their participants.  This information includes lab reports, radiology reports, transcription reports, medication history, problem lists, immunizations, discharge summaries and advanced directives.  Data access must comply with HIPAA and HITECH.

Improve the ability of Medicaid to assist in the management of care for high cost individuals, especially those with chronic conditions wo consume 70% of the resources and prevent re-hospitalizations from lack of adequate discharge education, care transition planning and information exchange

NeHII will implement disease registry functionality that will be available to all providers to enhance the management of individual participants as they transition across the continuum of care from acute care to post acute care, long term care facilities and home care.  This will improve the quality of care and help control costs.

Monitor episodes of care and manage coordination of services to ensure services are medically necessary, provided in the appropriate setting, and meet quality standards

NeHII will implement pre-treatment prior authorizations and utilization review using disease registry functionality

Reduce prescription errors which contribute to hospitalizations and re-hospitalizations

Medicaid employees would have access to comprehensive and real-time medication history on all participants and monitor the use of generic drugs when applicable

Identify and reduce fraudulent practices and other forms of payment abuse

Medicaid employees can view the complete medical record for individual participants, with all services, ADT records, and clinical information.  Trending of information across the entire population will identify patterns of inappropriate or abusive billing practices enabling focused educational or recovery activities.

Improve patient medication compliance with fill notification information

Medicaid employees would have access to comprehensive and real-time medication history on all participants

Reduce the over utilization of lab testing and radiological diagnostic procedures with the availability of test results

Providers treating Medicaid patients would have the ability to view all clinical information on patients, reducing the number of duplicative tests

Assist in real time claim processing with the development of an All Payers Claims Database to manage eligibility and pull data for all payers from a single source

Medicaid employees would be able to log into the VHR and search for clinical information on their participants.  This information includes lab reports, radiology reports, transcription reports, medication history, problem lists, immunizations, and advanced directives.  Data access must comply with HIPAA and HITECH.

Provide Medicaid eligibility at the point of service to verify eligibility, claims history and status, obtain billing information and determine benefit coverage and service limitation

Providers would be able to log into NeHII and view up to date eligibility information and claims processing status for all patients, eliminating the need to call or utilize other portals, saving Medicaid call volume or support costs.

Medicaid personnel would be able to log into NeHII and view other insurance carriers to determine coordination of benefits.

Improve Medicaid provider administration functions, including provider enrollment, licensure verification, provider communications and support other self-service administrative functions

Medicaid would have access to state Provider Directory being developed and maintained by NeHII

Potential payment reform catalyst beyond the standard fee-for-service model

Quality Reporting functionality would expand the information available to Medicaid, resulting in new innovations for payment reform.  This functionality would be used to support Patient Centered Medical Home (PCMH) and Accountable Care Organizations (ACO), among others

Enhance the ability of the provider to track percentage of Medicaid patients

NeHII will allow for real time calculation by providers for the percentage of Medicaid patients they treat for the determination of their qualification for Meaningful Use measures

Increase provider compliance with clinical evidence based guidelines and improve the quality of care delivered to all participants

NeHII will implement disease registry functionality that will be available to all providers. The registry will identify gaps in care for individual participants and the overall population allowing focused quality improvement activities.

Additional Value

  • Improve efficiencies in the Medicaid program through the availability of claims information for eligibility verification, status reporting, filing and payment to providers
  • Avoid redundant state expenditures in building a secondary infrastructure to support Medicaid functionalities
  • Support the State's healthcare providers in achieving Meaningful Use requirements and receiving CMS incentive payments for their efforts
  • Supply the Statewide Provider Directory for the State of Nebraska in support of the NHIN Direct exchange of ePHI
  • Support Medicaid's electronic exchange of information with federal agencies such as DOD, VA, SSA, CMS, ONC, CDC, FDA, and IHS through the activities of the Nw-HIN