Changes in NC Medicaid Claims Processing

nc medicaid claims processing system

On July 1, 2013 a much anticipated change will take place in the North Carolina Medicaid system when the state’s 34-year-old claims processing computer system, known as Legacy, will be retired and replaced by the new system, NC Tracks. After being awarded a contract in 2008, Computer Sciences Corporation (“CSC”), a Virginia-based company, developed the system based on a similar system currently in place in New York. CSC will manage call centers, claims processing, prior authorization reviews, pharmacy processes, and medical policy reviews.

The old system, administrated by Hewlett Packard, is no longer able to adapt to the numerous changes happening across the landscape of state and federal healthcare law. NC Tracks has been developed to grow and change as healthcare changes and has the ability to expand if additional programs or government payers are added. NC Tracks has many other capabilities that will be of more immediate benefit. The system has the ability to process claims from multiple divisions of the Department of Health and Human Services. Also, it will combine the old Legacy system that processes claims for the Division of Medical Assistance (DMA), the Integrated Payment and Reporting System (IPRS) used by the Division of Mental Health, and the Purchase of Medical Care Services (POMCS) that handles claims for both the Division of Public Health and the Office of Rural Health and Community Care.

The new system will have the following online capabilities:

-recipient eligibility verification

-prior approval request

-claims submissions-secure email messaging

-electronic remittance advice reports

-view claim status in real time

While the Legacy system has some of these attributes, the NC Tracks system is designed for improved paperless processing and a higher level of efficiency for providers. It also claims to “streamline the claims process” and provides the ability for online enrollment, verification, and credentialing.

Despite the benefits reported by CSC and DHHS about NC Tracks, not everyone is so confident. In a report recently released by State Auditor Beth Wood’s office, multiple questions were raised about the readiness of the new system. There is concern that the system is not prepared for the onslaught of claims from the over 70,000 enrolled providers. The major is that the system has not been properly tested. There were issues with a portion of the test cases run, as well as unease that not all the testing has been completed with barely a month left before implementation. Also causing distress is the computer code used to write the software. CSC used an antiquated style of code from the 1950’s that is rarely used today. Detractors of the system are complaining that most people trained in writing the code are retired, and programmers from India had to be brought in to develop the system.

With the July 1st deadline looming, CSC has many promises to fulfill. After running two years over deadline and costs rising from the projected $265 million to $484 million, faith in NC Tracks is waning. Providers are hoping that the new system will be more user-friendly and make providing healthcare and supplies to Medicaid recipients easier, as promised. If NC Tracks fails to meet the demands of DHHS, this will be the mostly costly mistake in the state’s history.