A regional Medicaid health plan needed confidence that its benefit configuration was accurate, current, and defensible. Benefit rules were spread across contract language, fee schedules, and medical policy, with no single source of truth connecting them to how the plan’s core administration system was adjudicating claims. Add to that a state fee schedule that changes coverage and prior authorization requirements on a regular basis, and the plan faced a persistent risk: configuration drift that could silently create claims errors, authorization gaps, or member and provider confusion.

Anoteros partnered with the health plan to create a formal benefit grid and conduct a comprehensive audit of the plan’s benefit configuration, systematically comparing it against source materials including the Medicaid managed care contract, the state Medicaid fee schedule[MA1.1][VG1.2], provider handbooks, member materials and medical management policies. Our team traced benefits down to the individual code level, confirming how coverage and authorization rules actually behaved in the system against how the contract and policy documents said they should.

Anoteros treated this as a cross-functional priority from the outset, bringing leaders from Clinical, Operations, and IT to the same table throughout the engagement rather than working in departmental silos. Clinical leadership weighed in on medical policy intent and coverage decisions, Operations brought the day-to-day perspective of how benefits play out for members and providers, and IT grounded the discussion in what the system was actually configured to do — shared ownership that let the team resolve discrepancies with full context rather than a back-and-forth between departments.

Rather than deliver a static, point-in-time benefit grid, Anoteros also built a framework the plan can use on an ongoing basis to compare future fee schedule updates over time. Because the state publishes coverage and prior authorization changes frequently, this gives the plan’s own team the ability to assess the impact of future benefit changes without repeating a full manual audit each cycle.

The audit surfaced concrete, actionable findings: claims processing anomalies, redundant and overlapping benefit configurations, and inconsistencies between authorization requirements under the contract and policy documents and system behavior. Comparing consecutive fee schedule cycles alone revealed more than 1,100 net changes, including roughly 70 shifts in prior authorization requirements and 450 shifts in coverage status — the exact kind of silent drift that, left unreconciled, would have continued to create claims errors and authorization gaps between review cycles.

The review also found a meaningful number of procedure codes still active in the core system after the state fee schedule had reflected them as terminated codes; the plan closed that exposure immediately, before it could result in inappropriate claims payment. On the provider network side, the audit confirmed a need to revise out of network benefit configurations to create greater consistency and accuracy of out of network claim adjudication.
Beyond claims accuracy, the engagement identified an opportunity to modernize how the plan organizes its procedure codes: a fragmented, inconsistently maintained set of legacy code groupings was consolidated into a streamlined structure aligned to industry-standard clinical categories, cutting the plan’s code taxonomy by roughly three-quarters and materially reducing the ongoing burden of maintaining it.

The lasting deliverable is a formal Benefit Grid that now serves as the health plan’s single source of truth for coverage, authorization requirements, and related codes. Benefit logic once scattered across contracts, policies, and institutional memory is now captured in one governed reference that both the plan’s teams and its regulators can rely on — making recurring compliance work more manageable and helping the plan stay ahead of changes before they can affect a claim.

This audit and the resulting Benefit Grid mark the first phase of a broader engagement led by Anoteros, which continues with benefit structure redesign and utilization management automation — work aimed at improving auto-adjudication and streamlining authorization decisions for the providers and members the plan serves