Evolent Health Services

To develop the highly specialized solution to achieve this, Evolent needed to bring together the right combination of people, processes and technology: People: Convening the Right Experts Evolent brought in subject-matter experts on OBRA waiver codes for HCBS claims, waiver services enrollment processes, and enrollee service plans to work with our partner and its state counterparts to elaborate upon and better define the existing requirements. This work allowed us to: • Define clear configuration criteria to automate and streamline enrollment processing for HBCS-eligible members. • Keep eligible members from losing their waiver status, even temporarily, because of conflicting data sources. Process: Defining the Source of Truth Once we understood the configuration criteria, we created a detailed hierarchy pointing to a source of truth for each eligible member. We: • Determined the precedence of files for each scenario where confusion around eligibility dates could arise due to conflicting data or the order in which files were received. • Mapped the workflow of all downstream stakeholders to ensure that the care management entities supporting the plan receive timely member eligibility information, so they can develop member-specific service plans within the state-required timelines. Technology: Automating the Solution Once the hard work of documenting the detailed requirements was complete, Evolent tackled the equally challenging effort to automate and operationalize the complex rules. Evolent's data team: • Configured our Identifi SM solution to draw eligibility from four different (and often competing) data sources and to apply the correct hierarchy to determine what information takes precedence. • Applied advanced analytics to cross-walk these data sources and audit enrollment start and end dates to ensure members could receive the services for which they were eligible. OUTCOMES Because of its success, the eligibility infrastructure developed by Evolent has become a model across Medicaid managed care organizations (MCOs) in the state and identified by an industry association as a best practice for MCOs. Specifically, our solution: • Created greater alignment across Care Management, Utilization Management, Call Center and Claims. • Reduced provider abrasion through more accurate claims processing. • Decreased the number of claims that needed to be reprocessed due to retroactive eligibility determinations. . © 2022 Evolent Health LLC • EHS-2212520-0927 Looking for a Health Plan Partner that Gets Stuff Done? Email EHSPartners@evolenthealth.com to discuss how our unique collaborative approach can help your plan rise to the challenge.

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