Providers, data matches and MCOs: OHCA details claims timeliness, Equifax verification and early managed-care results
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Summary
Agency officials told the committee they monitor MCO claims timeliness and have used data exchanges (including Equifax "work number") to identify ineligible members; they said most clean claims meet contractual timeframes but some providers face claims churn and enrollment hurdles.
The Oklahoma Health Care Authority described steps it has taken to verify eligibility and to monitor managed-care organization performance, telling the Appropriations subcommittee that data matches and operational changes have identified and removed some ineligible members and improved claims processing.
Eligibility verification: Melissa Miller, state Medicaid director, said the agency runs multiple automated data exchanges — including unemployment data and the Equifax "work number" — to match reported member income to external sources. "When we receive those data sets on member income, we immediately match that up against the income that the member has reported to us in their case file," Miller said. She said when a match shows a member is over-income the agency takes action to remove eligibility unless the member can rebut the data.
Claims timeliness and churn: Lawmakers raised provider complaints of delayed payments. Miller and Richards described contractual timeliness standards and monitoring. An agency representative said some contracts require payment of clean claims within 60 days; staff also cited monitoring metrics in which plans achieve 90% of clean claims paid within 14 days and 99% within 90 days. Agency staff acknowledged that incomplete or miscoded claims may sit in a "churn" status for many months before being resolved, particularly for smaller providers.
Operational fixes and town halls: The agency said it held town halls in Tulsa, Oklahoma City and Ada to gather provider feedback and implemented a uniform consolidated roster across all three plans to simplify provider enrollment. Officials said they are working with the MCOs to address common enrollment and claims-processing friction points.
Why it matters: Provider payment delays and verification reliability affect access and provider participation. Agency staff agreed to provide more granular metrics — for example, average claim-payment times by plan and counts of members removed based on data matches — in follow-up to the committee.
