RISK AND REVENUE INTELLIGENCE
When regulatory change hits your bottom line.
Starting December 31, 2026, every Medicaid expansion state must redetermine eligibility every six months instead of annually. Seven to ten million people are projected to lose coverage — most for paperwork reasons, not eligibility reasons. Every one of those is a patient who stops showing up and a claim that never gets paid.
We codify your state's redetermination and managed care billing requirements into a deterministic rules engine that checks every patient record before a renewal date passes or a claim goes out. Your team gets a prioritized list of what needs attention, and why, in plain language.
The deadline is federal. The paperwork is yours.
Dec 31, 2026
SIX-MONTH REDETERMINATIONS BEGIN — NO OPTION TO DELAY
7–10M
PROJECTED COVERAGE LOSSES NATIONWIDE
74%
OF PRIOR DISENROLLMENTS WERE PROCEDURAL, NOT ELIGIBILITY
2X
THE ADMINISTRATIVE SURFACE AREA, STARTING IMMEDIATELY
Under H.R. 1, Medicaid expansion adults move from annual to six-month eligibility renewals for renewals occurring on or after December 31, 2026. Traditional Medicaid populations — children, pregnant women, elderly, and disabled enrollees — remain on annual cycles. The provision cannot be waived under Section 1115.
For behavioral health providers and FQHCs, this doubles the number of times each year a patient can fall out of coverage because a form did not get returned. The population least equipped to manage recurring paperwork is the population you serve.
Implementation timing and state rules vary. Some states began early enforcement during 2026. Others delayed portions to January 2027. Several — including Indiana and West Virginia — have proposed applying six-month redeterminations beyond the federally required expansion group. We build against your state's actual rules, not the federal floor.
Sources: H.R. 1 (Working Families Tax Cuts legislation) §71107; CMS State Medicaid Director letter SMD #26-001 (March 6, 2026)
Three places revenue leaks — and none of them are clinical.
The renewal nobody tracked
A patient's redetermination date passes. Nobody flagged it. Nobody knew the address on file was stale. Coverage lapses mid-treatment, the patient stops coming, and the sessions you already delivered become unbillable.
The claim that was almost right
The documentation was thorough. The care coordination happened. But a modifier did not match the managed care plan's specific requirement, and the claim came back denied — weeks later, when reworking it costs more than it recovers.
The audit you can't answer
The state Medicaid agency asks how a service met medical necessity. The documentation exists, somewhere, across three systems and a shared drive. Assembling the answer takes a week of staff time you did not budget.
A rules engine for the requirements. A copilot for your team.
Redetermination risk monitoring
Every patient scored against their renewal date, contact information currency, and documentation completeness. Your care coordination team gets a weekly prioritized outreach list — who needs attention, what is missing, and how many days remain.
Plain-language guidance
When something fails a check, your billing specialist sees what failed, why it matters, and the specific steps to fix it — with a citation to the exact state or plan requirement behind it. No decoder ring required.
Pre-submission claim evaluation
Every claim checked against the specific documentation, coding, and modifier requirements for that service, that payer, and that program — before it is submitted, not after it is denied.
An audit trail that already exists
Every evaluation is timestamped and immutable. When your state Medicaid agency or a managed care plan asks how a determination was made, the answer is already assembled — data, rule, reasoning step, outcome.
We take the documentation and eligibility requirements your organization actually operates under — the federal six-month redetermination mandate, your state's managed care billing standards, and each plan's specific modifier and coding requirements — and codify them into deterministic rules that evaluate every record before it matters.
Built for the organizations carrying the most exposure.
Behavioral health providers
SUD treatment programs, outpatient mental health practices, and community behavioral health agencies where Medicaid is the majority of revenue. Your patients are disproportionately affected by redetermination churn, and behavioral health documentation requirements are among the most complex in any state's program.
Federally Qualified Health Centers
FQHCs managing renewal navigation across large patient panels, often with community health worker teams doing it patient by patient. We turn that into a systematic, prioritized weekly workflow.
County and managed care behavioral health plans
Organizations accountable for network-wide compliance performance, where a provider's documentation gap becomes your state contract problem.
We have already built this architecture in a regulated environment.
For Luveo Health, an enterprise pharmacy operations platform, we codified 28 compliance rules across 7 operational workflows — covering DEA, DSCSA, HIPAA, USP 797, and state Board of Pharmacy requirements — then layered a governed AI copilot that translated every rule outcome into cited, plain-language guidance for pharmacy technicians.
Across a 30-scenario structured evaluation, the copilot scored 97% on explanation accuracy and 100% on chat accuracy, with zero hallucinated rule keys, zero fabricated regulatory citations, and zero guardrail violations. The rules engine was load-tested at 35 events per second.
Different regulations. Same architecture. Delivered in two 4-week cycles.
Reasonable questions.
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If your state expanded Medicaid, yes — the six-month redetermination mandate is federal and cannot be waived. If your state did not expand, that specific provision does not apply to your panel, though managed care documentation and denial exposure usually still do. We establish this in the first ten minutes of a scoping call.
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Your billing company submits claims. This evaluates whether a claim will survive submission before it goes out, and whether a patient's record supports continued eligibility before their renewal date. Most billing partners welcome it — fewer denials to rework is good for both of you.
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Documentation quality and documentation compliance are different problems. A thorough note can still fail a plan-specific modifier requirement. The question is not whether your clinicians document well — it is whether anything systematically checks that documentation against the requirement that applies to that specific claim, payer, and program.
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Yes, and it is built for that. We execute a BAA before any data access, work in isolated environments, and tokenize PHI at the ingestion boundary so protected data never reaches the AI layer directly.
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That is exactly why the cycle is four weeks. A cycle started this quarter is in production well before the first six-month renewal wave. A cycle started in November is not.
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Partially, and not reliably. H.R. 1 allocated $200 million in FY 2026 to help states modify eligibility and enrollment systems — far less than states will actually spend, and federal guidance on those system changes has been slow to arrive. States are under-resourced on the systems side. Assuming the state will catch your documentation gaps is a risk, not a plan.
Find out in 30 minutes whether this fits.
We will ask you three questions: which workflow is leaking, what data sits behind it, and what "fixed" looks like to you. If we can scope it into a four-week cycle, we will tell you exactly what that includes and what it costs. If we cannot, we will tell you that too.