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Health Information Exchanges (HIEs) allows patients and health care providers to access and share medical information across hospitals/provider networks/health systems. Depending on the nature and extent of a given HIE’s capabilities, investments are expected to lead to improved individual- and population-level health outcomes through improved coordination of care and the use of data to inform health policy decision-making.

A system or subsystem that assigns accurate eligibility categories for all applicable eligibility groups by receiving, ingesting, and processing: Applications, changes of circumstance, renewal forms, and any supporting documentation requested by the state (including telephonic signatures) from individuals.

Provider management module includes processes (initial and ongoing) to screen and enroll providers into Medicaid, as well as to keep provider information current and to provide data to authorized requesters. Provider outreach and communications, as well as responding to provider requests and issues, are included.

PI systems monitor for waste, fraud, and abuse, to ensure Medicaid funds are distributed properly and accurately.

The Decision Support System (DSS) / Data Warehouse (DW) business area covers software tools used by authorized State employees to extract and/or analyze Medicaid data in order to inform program decisions, policy decisions, and report on the delivery of the Medicaid Program.

In some cases, Medicaid beneficiaries may have more than one source of coverage for health care services, such as group health plans, self-insured plans, or managed care organizations. Third Party Liability (TPL) systems identify these situations to ensure that the appropriate party pays for services.