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Medicaid Solutions

Accurate, efficient, and cost-effective management.

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Optimize Claims and Encounters Management.

Gainwell’s Claims, Encounters, and Financials module supports your state’s modernization journey with intelligent automation and interoperability. Our solution ensures efficient operations, provides data-driven results, and prepares you to meet evolving challenges, allowing the focus to remain on delivering essential services to beneficiaries.

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1 Billion

Claims Worth More Than $153B Processed Annually

898 Million

Encounters Managed; $8.27B in Savings & Recoveries

3 Billion

Providers & 58M Beneficiaries Processed Annually

Real-time Processing

Gainwell’s CEF module enables the efficient adjudication and accurate processing and payment of large volumes of claims and encounters in real time. This capability ensures that claims are handled promptly, reducing delays and improving the overall efficiency of the healthcare system.

Robust Adjustment Auditing & Pricing

Robust adjustment auditing and pricing mechanisms allow for comprehensive auditing of claims adjustments and accurate pricing based on various methodologies, including Medicaid and Medicare fee schedules, resource utilization group data, and custom fees. This ensures transparency and accuracy in claims processing.

Data Access

Gainwell’s CEF module provides extensive data access capabilities, allowing users to gain insights and make better business decisions. The system captures detailed metrics and maintains an audit trail for each business rule applied during adjudication. This data is available through interactive dashboards and reports, facilitating continuous quality monitoring and informed decision-making.

State-specific Adaptability

Highly adaptable to state-specific needs, CEF allows for rapid adjustments to address unique requirements. Business analysts can define, update, and maintain rules directly in the system without programming intervention. This flexibility ensures that the module can quickly respond to policy changes and evolving healthcare needs.

Compliance

We meet federal Medicaid modularity requirements, ensuring compliance with standards such as the Medicaid Information Technology Architecture (MITA), HIPAA, and the Medicaid Enterprise Certification Toolkit (MECT). CEF is designed to support long-term technology refreshes and is proactively updated to align with advancements in the Medicaid market.

Additional solutions making healthcare more efficient and effective.

Provider Solutions

Delivering equitable, impactful care through person-centered solutions.

Systems Integration & Interoperability

Connecting vital systems and unlocking data to drive greater access, efficiency, and transparency.

Pharmacy Solutions

Enhancing outcomes by removing barriers to care, reducing friction, and optimizing cost efficiencies.

Human Services & Public Health Solutions

Delivering equitable, impactful care through person-centered solutions.

Actionable insights that
empower healthcare progress.

We’re passionate about delivering ideas that can help shape the future of
healthcare, using education and transparency to improve health outcomes for all.

How can we support you?

Start the conversation today.