Our client requested the development of a blockchain solution to act as an exchange clearinghouse for Managed Care Organizations (MCOs) to identify and report Medicaid claims while also providing the state full visibility of data submitted by MCOs, pharmacies and other entities. The clearinghouse transfers data and shared savings arrangements among MCOs, pharmacies and participating Medicaid safety net providers while allowing the state to seamlessly monitor/audit the results and rules for processing claims.
The blockchain solution was created to be scalable to handle a large volume of claims as well as the set-up of new MCOs and safety net providers across the country. Flexibility was required as MCOs operate in more than one state and the processing protocols per state may vary. When processing claims in the clearinghouse section of the blockchain, each claim must pass predefined business rules and matching logic provided by the client, such as: identifying brand name medications, medical equipment names, financials, and formulary tests. This blockchain application relies on external data for cross-referencing and retrieving information regarding Cost of Goods Sold (COGS), Wholesale Acquisition Cost (WAC), brand vs. generic, and more.