Evolent Health Services

Cutting Through the Clutter of Member Eligibility Data

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Excellence in Action Cutting Through the Clutter of Member Eligibility Data Evolent Health Services helps Medicaid members get the home- and community-based services they need, without unnecessary delay. THE CHALLENGE The home- and community-based services (HCBS) Medicaid waiver program allows enrollees to receive services they need without leaving their familiar surroundings or loved ones. For example, the HCBS program can provide for in-home nursing care or household help for people to stay at home instead of going into a nursing facility. Eligibility for these wide-ranging services is often determined by a variety of state agencies, making it difficult for Medicaid plans to identify which members are eligible for what services, and for what period. Recently, Evolent Health Services collaborated with a Medicaid plan partner and the health departments in one state to establish clear-cut eligibility data for waiver members. As in many states, sources of data were housed at different agencies, with information sometimes conflicting and no clear hierarchy dictating which agency took precedence. Further complicating things, data formats and delivery mechanisms varied wildly from agency to agency, from flat files to individual emails, requiring time-intensive workarounds OUR APPROACH Evolent worked with its Medicaid plan partner to streamline eligibility processing for the HCBS population. We developed a process to aggregate data across multiple sources to ensure members were allocated to the appropriate HCBS plan, with accurate effective dates, in a timely fashion to improve the member and provider experience and ensure continuity of care. evolenthealthservices.com WHAT WAS AT STAKE Confusion surrounding member eligibility can have clinical and financial impacts. For example: • Claims paid or denied in error, resulting in dissatisfied providers. • Customer service representatives and care coordinators unable to speak with newly eligible members about available services

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