Unifying Eligibility Operations on ActiveWARE
One Platform for Eligibility, Coverage Discovery & Out-of-State Medicaid
A B2B partner replaced spreadsheets and siloed tools with ActiveWARE—standardizing screening, automating document workflows, and streamlining end-of-month operations with real-time client visibility.
The Challenge
A B2B partner needed a single platform to consolidate operations across Medicaid Eligibility, Third Party Liability (TPL), Out-of-State Medicaid (OSM), and Coverage Discovery. Their environment was fragmented:
- Minimal integration across multiple vendor tools; heavy reliance on Excel and homegrown utilities.
- Manual end-of-month (EOM) work—payment posting, invoice generation, and performance reporting—was slow and error-prone.
- Critical subject-matter expertise lived in people, not systems, leading to inconsistency and risk.
- No uniform approach to patient screening, coverage discovery, or document automation, and limited activity tracking per program.
- Clients lacked real-time visibility into status and results.
They needed to centralize workflows, standardize screening and documentation, automate coverage discovery, and give clients transparent performance views—while simplifying EOM processes.
The Solution
We deployed ActiveWARE as the operational hub for internal teams, external vendors, and client stakeholders—consolidating work into one governed, auditable platform.
Core Components Implemented
Patient Screening (Mobile-First)
- Rapid, consistent intake to identify qualifying programs per patient.
- Rules-driven triage ensures prioritized focus and uniform outcomes.
Electronic Forms Automation
- Automatic generation of applications and supporting documents.
- Patient/family completion via secure portal (or assisted/manual when preferred).
- E-signature, versioning, and audit trails.
Workflow Management & Deficiency Tracking
- End-to-end case orchestration with SLAs, priorities, and escalations.
- Clear ownership across onsite/offsite staff and hospital case managers.
- Deficiencies tracked to closure; time-stamped actions for compliance.
Patient Portal & Collaboration
- Secure messaging, file upload, guided form completion, and virtual sessions.
- Reduces phone tag and accelerates documentation collection.
Coverage Discovery & Document Automation
- Automated payer lookups, program checks, and packet assembly.
- Standardized evidence collection to support approvals and audits.
Real-Time Transparency Dashboards (Client-Facing)
- Live views of status, throughput, backlog, and projected reimbursement.
- Filters by program, facility, and timeframe to drive proactive collaboration.
Streamlined End-of-Month Operations
- Payment posting, invoice preparation, and status roll-ups automated.
- Eliminates manual EOM crunch; reduces cycle time and exceptions.
Vendor Management Interoperability
- Rapid file outputs tailored to third-party vendor management firms.
- Demonstrates agility and strengthens client confidence with fast custom responses.
Future-Ready Framework
- Modular architecture to plug in new automations and AI agents without rebuilds—future-proofing the investment.
Impact / Results
Operational Efficiency
- Replaced spreadsheets and ad-hoc tools with a single, governed workflow.
- Less swivel-chair work; higher first-time-right rates in screening and submission.
- EOM processing time dramatically reduced through automated posting and invoicing.
Financial Performance
- Faster coverage identification and cleaner documentation → quicker approvals and reimbursement.
- Fewer reworks and denials tied to missing/invalid documentation.
Transparency & Accountability
- Clients gained real-time visibility into every account and program.
- Leadership dashboards surfaced trends, bottlenecks, and performance by site/vendor.
Risk Reduction
- Institutionalized SME knowledge into systemized workflows and rules.
- Full audit trails across screening, forms, routing, and EOM actions.
Scalability
- Unified platform supports Medicaid, TPL, OSM, and Coverage Discovery today—and can extend to new programs tomorrow with minimal lift.
Bottom line: ActiveWARE centralized disparate eligibility operations, automated the heavy lifts, and gave clients real-time clarity—turning end-of-month “fire drills” into routine, reliable closeouts while accelerating time-to-reimbursement.