Health Insurance │ Software Development

Cloud-based Integrated Data Verification System Supports Medicaid Eligibility for 1.6M Subscribers

Confirming Medicaid eligibility for beneficiaries can be challenging. Wovenware created a centralized hub, which integrates with eight local government agencies so that the Puerto Rico Medicaid Program (PRMP) can automatically validate eligibility of citizens according to the standards of the Centers for Medicare and Medicaid Services (CMS). This reduces the need for in-person renewals and ensures a speedier process for the current 1.6M participants

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“Wovenware helps Puerto Rico’s Medicaid program improve the Medicaid eligibility process via a cloud-based centralized hub that integrates with key local government systems, to validate citizens’ information through secure batch and real-time interfaces, feeding into Medicaid’s local eligibility system known as MEDITI3G.”

Automating the Medicaid Eligibility Process

Medicaid is a vital service, providing medical coverage to those in need. Yet, determining eligibility each year was time consuming and error-prone. Medicaid is required to validate eligibility of approximately 100 to 300 thousand participants each month and send them eligibility determination notices via the U.S. Post Office, 30 days prior to eligibility expiration dates.

By creating a centralized State Data Verification Hub that complies with NIST and MARS-E security standards, the Wovenware interfaces enabled it to extract citizen data from 8 different local government agencies, and integrate it into the newly developed Medicaid Eligibility System known as MEDITI3G, which was built by RedMane Technology, using the IBM Cúram platform.

This integration reduces the number of citizens having to go to each individual agency to gather the necessary documentation to prove their eligibility, and then also to the Medicaid office to submit the evidence. This also helps reduce fraud, waste, and abuse since the data is being validated directly with government agencies.

As part of the process, Wovenware is creating two types of interfaces with each local government agency, such as the Department of Labor or the Department of Treasury. One interface is for monthly renewals (batch) and one for real time data, for new participants, those that visit the office and case workers who are validating and attending the claims.

Automating the data validation process for Medicaid eligibility through a centralized hub

Since eligibility of Medicaid beneficiaries was traditionally done manually, Wovenware automated the data validation process so that Medicaid’s eligibility system can determine eligibility automatically and proactively. We worked closely with eight local government agencies, Medicaid and other software vendors, such as RedMane, Intervoice PR, Cognosante and BerryDunn to implement the first centralized hub in Puerto Rico, capable of accessing data from the various agencies.

The challenges and insights

  • Centralize data verification services from 8 government agencies required for Medicaid eligibility, enabling auto-renewals and real-time eligibility status.
  • Validate government data sources for Medicaid application information for income, demographics, etc.
  • Comply with Federal and HIPAA regulations, as well security standards, such as NIST and MARS-E, to protect the privacy and integrity of citizen data.
  • Provide reliable 24/7 backend services for the new Medicaid System (MEDITI3G), allowing 1.6M citizens to have their eligibility safely and securely validated.

The Wovenware Approach

Wovenware built government interfaces to the new cloud-based MEDITI3G system for Puerto Rico Enrollment and Eligibility (PREE), which provides the data needed for the system to validate eligibility using Medicaid’s business rules. Data interchange with key local government agencies needed to be accessible through a state data verification hub, the first hub in Puerto Rico that receives data from multiple government agencies.

Wovenware built the hub on an Azure Government Cloud tenant, which complies with Federal regulations and security standards, such as NIST and MARS-E. A robust back end was built using REST APIs and domain- driven design.

Technologies we take advantage of