Launching a Medicare Advantage Prescription Drug Plan

Averaging more than 15 years of experience in the healthcare industry, our consultants have worked in a variety of management positions within commercial and government payer organizations, so we understand your challenges firsthand—including competitive pressures, organizational obstacles, and limited resources.

Case Overview:

A Medicare Advantage Prescription Drug (MA-PD) Plan, focused on addressing the healthcare needs of underserved seniors, sought assistance from the Change Healthcare Consulting team for startup activities including advice on securing regulatory approvals, developing and contracting the provider network, and establishing policies and procedures. Plan leadership aggressively targeted go-live with a short five-month timeline and chose to work with a platform that included HealthEdge® solutions HealthRules® Payor, HealthRules® CareManager, HealthRules® Connector, HealthRules® Answers(TM), and HealthRules® Answers Ad Hoc to support claims and care management. This plan wrapped with other vendor solutions, including WIPRO for enrollment, Appeals and Grievance, EDPS & RAPS, along with Revenue Reconciliation, print/fulfillment, EDI gateway, mailroom, claims imaging, ClaimsXten(TM) solution, and InterQual® clinical criteria. The client had two required CMS back-to-back deadlines—the first was for enrollment and the second was to accept and process claims and authorization requests—both with short turnaround times. By the time work began on the implementation, the first deadline loomed only three months away.


At initiation of the implementation, the health plan had limited resources with very little experience executing large-core system implementation projects. In addition, the plan had more than a dozen trading partners, requiring a substantial IT build effort to integrate with HealthRules® Payor. The tight timeline put substantial risk on all project phases, and the testing phase, in particular, was at risk of being squeezed to the point of being ineffectual.

Change Healthcare staffed the team with experienced consulting project leaders and subject matter experts who understood HealthEdge HealthRules® Payor, HealthRules® Answers(TM), HealthRules® Answers Ad Hoc, and HealthRules® CareManager.

With this accelerated timeline, the consulting team leveraged our expertise around HealthRules® product configuration and integration capabilities to establish an agile delivery approach focused on the crucial system functions and business processes required for the October and January deadlines.

A risk profile with mitigations was developed and reviewed with the plan weekly; many of those mitigations had to be implemented to ensure the MA-PD plan’s timely entry into the Medicare market.


The consulting team, along with the health plan’s leadership, implemented creative solutions to overcome roadblocks and challenges. Change Healthcare’s regulatory experts enabled the client’s processes, and deliverables complied with CMS requirements. Proper planning and risk management allowed the execution of risk mitigations before they became issues. Change Healthcare’s HealthRules® Payor and CareManager configuration and technical teams ensured that system capabilities supported adjudication and integration requirements.


Despite the challenges of an abbreviated timeline, Change Healthcare successfully met the back-to-back enrollment and claims deadlines. HealthRules® Payor and CareManager were configured and integrated. As of April 2020, all CMS regulatory mandates, including new coronavirus mandates, have been implemented, and claims processing in Q1 achieved 100% accuracy. Many of the manual processes that had to be implemented as temporary workarounds have been automated. Change Healthcare Consulting and the health plan are currently working together to expand products and service areas for next year.

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