From policy update to claim edit: How a Medicaid plan keeps edits current

Policy changes move fast. Translating those changes into accurate, up-to-date claim edits typically does not, and the lag creates real financial exposure for health plans.

Turning policy documents into production-ready edits for a large Medicaid plan

For a large Medicaid health plan in the US, constant policy updates were difficult to track and keep up with in the plan's edit logic. New rules came in from government programs and internal sources, but the alignment between the teams writing those policies and those coding accurate payment rules could be stronger. Edits fell out of date, or new areas of exposure did not have coverage. Shift used agents to ingest source policy documents and turn them into machine-ready claim edits, delivering immediate savings:

• Agents processed both internal plan policies and government sources (Medicare and Medicaid), converting these unstructured policy documents into production-ready edit logic
• Edits were deployed quickly, with immediate uplift on savings. The heavy lifting of policy interpretation was handled with AI-capabilities, with expert human-in-the-loop collaboration to ensure quality and effectiveness
• Agentic AI extends the capability further: agents now analyze post-payment claims feeds, identify areas of exposure, track applicable policies, and generate new edits for expert review and deployment

To hear more about how Shift is using agentic AI to keep health plan edits current with policy change, watch Shift's Senior Product Manager for U.S. Health, Mark Starinsky, in the video below.