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Medicaid Enterprise

Modern, accurate, and cost-effective.

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Efficient Claims, Encounters, and Financials management.

Gainwell Enterprise™, our claims, encounters, and financials (CEF) module, supports your modernization journey with intelligent automation and interoperability. Our longstanding experience ensures that your Medicaid program runs efficiently, with accurate data for decision-making, better provider reimbursement, and enhanced beneficiary care.

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#1

CEF Solution on NASPO

1.2 Billion

Encounters Managed Annually

3.7 Million

Providers Served

Core Operations

Gainwell streamlines Medicaid operations by integrating claims and encounter management, provider contracts, capitation and financial management, and member benefits. These modular tools improve efficiency, simplify administration, and ensure seamless program delivery for state agencies.

EDI Gateway & Clearinghouse

Gainwell EDI solutions allow providers to submit all their claims centrally, significantly simplifying provider Medicaid billing, ensuring compliance and resulting in improved timeliness and quality. Our quality claim data provides a higher first pass rate from MCO to provider, which means providers receive payment more quickly.

Auto Determination for Prior Authorization

Using a rules-based workflow that integrates with a state Medicaid agency’s existing claims system or directly with our CEF module, we perform review of prior authorization in near real-time, reducing administrative burden, minimizing provider abrasion, and improving member satisfaction. We provide quick responses on select authorization requests back to the provider.

Customer Experience

Personalized, seamless, and omnichannel interactions with contact center staff equipped with state-of-the-art technology and training.

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Additional solutions making healthcare more efficient and effective.

Provider Solutions

Delivering seamless experiences for providers to enhance care and optimize efficiencies with Gainwell Provider+™.

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Systems Integration & Interoperability

Accelerating modernization, connectivity, and operational efficiency with Gainwell Connect™.

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Pharmacy Solutions

Optimizing medication management to lower the total cost of care while improving patient outcomes with Gainwell Rx™.

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Human Services & Public Health Solutions

Improving the well-being of communities through person-centered, data-driven approaches with Gainwell Assist™.

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Actionable insights that
empower healthcare progress.

We’re passionate about delivering ideas that can help shape the future of
healthcare, using education and transparency to improve health outcomes for all.

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Modernization vs. Modularization: Understanding the Difference

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Can Data Help Solve Longstanding Challenges in Medicaid?

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Transforming Medicaid: The Unsung Heroes Behind a Better Tomorrow

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Explore All Insights

How can we support you?

Start the conversation today.

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