Because Eligibility is Fluid!

There are countless reasons why Medicaid eligibility changes are frequently missed. Most have nothing to do with internal errors, lack of resources, or the vendors that providers have in place.

That’s because the patient’s Medicaid eligibility status goes far beyond the simple response of “Active”, “Inactive”. There are many variables to a patient’s Medicaid Benefit Profile that can change at any time, even after eligibility is confirmed, that directly impact reimbursement.

As an example, eligibility can be initially denied only to be appealed months later. The patient can be slow to provide proper documentation delaying the final determination. Examples like these can push the patient’s final eligibility decision well beyond their initial date of service. In some cases months, if not years.

Because Change Happens!

Many patients experience multiple coverage disruptions in a single year, sometimes due to missed paperwork, income fluctuations, or administrative hurdles. This constant cycling of patients in and out of coverage, commonly known as Medicaid “churn” is impossible to predict.

A patient’s Medicaid benefits can also expand or contract, changing the reimbursement eligibility of the services provided.

Changes also take place long after the patient’s eligibility is confirmed. Their eligibility can be lost, the scope of benefits can expand or decrease, secondary and tertiary payers can be added and removed.

1 – Continuous Autonomous Monitoring

RetroCAID operates fully autonomously, running silently in the background without the need for manual triggers, user intervention, or scheduled workflows. Its intelligent deterministic engine continuously monitors every applicable patient record, assessing eligibility status, benefit changes, added payers, and coverage expansions in real time. This always on monitoring ensures no reimbursement opportunity is missed throughout the entire timely filing window.

2 – Change Detection & Validation

When a Medicaid benefit change is detected, RetroCAID goes beyond simple identification. The platform validates each change against the specific services delivered to the patient at the claim level, ensuring clinical and billing alignment. By applying advanced rules-based logic, RetroCAID accurately identifies and prioritizes only those encounters that meet the appropriate reimbursement criteria, eliminating false positives and preventing non reimbursable encounters from moving downstream.

3 – Actionable Change Alert

Once a legitimate reimbursement opportunity is confirmed, RetroCAID automatically generates Patient Benefit Alerts (PBAs) for your billing team. These alerts provide access to the critical benefit details and claim ready information needed to act quickly and confidently. By delivering clean, validated, and actionable insights, PBAs enable your team to submit claims more efficiently, reducing rework, accelerating cash flow, and improving overall revenue performance.

Intelligent Benefit Analysis

Captured changes can include:

• Medicaid Eligibility Status Changes
• Benefit Changes (Increased, decreased benefits)
• Payer Changes (Medicaid, MCO, Medicare, Commercial, etc.)
• Dual-Eligibility
• Benefit Redetermination
• Late Addition Secondary, Tertiary and TPL Payers
• Lapsed & Reinstated Benefits
• Spend-down Monitoring
• PCP Changes
• Etc.

Easily Adapts to any Billing Environment

With configurable rules designed for your specific billing environment, RetroCAID easily learns and adapts to even the most challenging billing environments. Custom billing logic can be applied effortlessly, cutting down on repetitive tasks and freeing your team to focus on higher value, revenue driving work.

• No Integration Required
• No Remote Access Needed
• No Software to Install
• Month-to-Month Agreement
• Implemented by Phone in
  Less than 60 Minutes!

100%
Contingency Based!

RetroCAID^® is a 100% contingency based service which includes daily monitoring of unlimited encounters. There are no set-up fees, transaction fees, or fixed costs.

Your facility Pays Nothing unless a change is detected and only after you are reimbursed by the payer as a result!

Our month-to-month agreement can be canceled at any time with a simple email!