An online system for Medicaid file maintenance

Since the volume of data generated by a social service program has become so great, an automated system is required to provide the security, efficiency , and reliability essential to meeting the needs of the people. Increasingly complex governmental regulations further the usefulness of automation. A computer system must be able to handle large masses of data efficiently, detect abuse of the system and probable user error, and keep current , accurate information about all aspects of the social service program. An online system for the maintenance of information is ideally suited to handling these conditions. South Carolina has developed a Medicaid Management Information System (MMIS) that effectively meets all these requirements. It may seem unusual for a division of Clemson University to be designing and implementing a Medi-caid system for the South Carolina Department of Social Services (DSS). The charter of the Division of Information Systems Development of Clemson University (DISD), however, is to handle state-supported contracts. DSS does not have the staff to develop or produce a certifiable Medicaid system of such a large scale, so South Carolina's MMIS is a cooperative effort. The Medicaid program works on the state level in helping to meet medical costs for the needy. There are four main components: recipient-the person receiving Medicaid benefits provider the individual or organization who provides medical services to recipients and who is reimbursed through Medicaid reference information-collection of data used in processing a Medicaid claim Permission to copy without fee all or part of this material is granted provided that the copies are not made or distributed for direct commercial advantage, the ACM copyright notice and the title of the publication and its date appear, and notice is given that copying is by permission of the Association for Computing Machinery. To copy otherwise, or to republish, requires a fee and/or specific permission. • 1980 ACM 0-89791-014-1/80/0200-0044 $00.75 claim-request by a provider for reimbursement. Recipient, provider, and reference information is utilized to ensure that payment is made only to eligible providers for allowable services rendered to eligible recipients. Each of the four components is a subsystem in South Carolina's implementation. The recipient subsystem maintains areas which are queried during claims processing to ensure that the recipient is eligible for the service that he has received. Authorized users of the MMIS online system are able to view data on the screen pertaining to any recipient in the Medicaid …