Challenge
Medicare beneficiary, eligibility, and premium withholding information is at the center of all operational transactions that support the Medicare enrollment, eligibility and payment workflows. There are hundreds of text files of Beneficiary data extracted from the CMS mainframe system that feed into a hundred downstream systems. The extract process prevents CMS and its trading partners to operate in real-time and incurs significant maintenance cost.
Solution
eSimplicity agile team delivers big on this effort by building a cloud-based, highly available (HA) and scalable beneficiary data services through an efficient, latency free API. CMS trading partners and downstream systems can query beneficiary demographics, entitlement, enrollment, premium, health status, and other coverage information. Trading partners can also subscribe for real-time/deferred-event notification.
Outcomes
The team improves quality and timeliness of services to Medicare beneficiaries by modernizing Medicare Information Systems through the BIC API and service catalog:
* Deliver real time transactional services
* Eliminate/minimize redundant copies of beneficiary information
* Improve information security
* Eliminate latency and inconsistency in processing
* Improve Medicare System-wide efficiencies
API that works. The Beneficiary Data in the Cloud (BIC) enables real-time transactional process to support the Medicare payment ecosystem for CMS and its trading partners including healthcare providers, pharmacies, and clearinghouses. Ultimately, the API will eliminate a hundred beneficiary extracts, helping the agency and its trading partners to deliver better services and experience at a lower cost to Medicare beneficiaries.
Areas of Expertise
Current Service Catalog
Currently CMS trading partners can access a service catalog with API for the following beneficiary information. The team continues to add more datasets.
Core Beneficiary Info:
* Identifier History (MBI, HICN, SSN, RRB#)
* Name History & other demographics
Medicare Part A & B:
* Part A & B Entitlement
* Premium, Direct Billing, and Collection
* Third Party Payers
Health Status:
* End Stage Renal Disease (ESRD), Hospice, Institutional Status, etc.
Medicare Part D:
* Part D Eligibility
* Low Income Subsidy – Deemed, LIS Awards
* Dual Eligible, Supplementary Support Income (SSI)
Part A/B Utilization:
* Benefit Periods & Deductibles, Smoking Cessation, Preventive Services, Blood Deductible, Part B Therapy, and Home Health
Other Coverage:
* Other Health Insurance
* Part D Coordination of Benefits (COB)
* Retiree Drug Subsidy (RDS)
Medicare Advantage (MA) and Part D:
* Enrollment, Premium, and Premium Withhold