Our comprehensive enrollment system provides health plans with a solution that manages both enrollment i.e. data capture, BEQ processing and post-enrollment processes like Cancellation, Disenrollment and reinstatement.

Salient Features: Enrollment Processing:

• Enrollment data capture
  • Enrollment data capture from different sources – Website, CMS OEC, file import, paper etc.
  • CSO screen for manual enrollment data entry
• BEQ processing
  • BEQ request generation for all enrollments including auto and facilitated
  • BEQ response processing
  • Update of member records with BEQ data
• Assess and track Late Enrollment Penalty (LEP)
  • Determine number of uncovered months based on information on BEQ and member attestation
  • Submit transaction to CMS and process response to update late enrollment penalty information
• Process employer sponsored and SPAP enrollments
  • Accept and process employer sponsored enrollments through group enrollment mechanism
  • Accept and process SPAP enrollments through a SPAP file import
• Validate enrollment data and identify bad enrollments
  • Validate enrollment applications for valid election data, election period etc.
  • Attempt completing/fixing bad/incomplete enrollments based on member data sources available
  • Identify bad enrollments for user action
  • Deny incomplete enrollments after wait period
  • Create work items for user assignment
• Identify enrollments for review based on business rules
  • Identify enrollments requiring user review or research for e.g. ESRD enrollments, SNP enrollments
  • Create work items for user assignment
• CMS transaction submission and TRR response processing
  • Submit enrollment transactions to CMS
  • Process TRR responses – individual and combinations and apply appropriate workflow

Post Enrollment Processing

• Cancellations, Disenrollments and reinstatement processing
  • Support cancellations through bulk file upload or manual entry
  • Support web, paper and phone disenrollments
  • Provides user interface to allow plan initiated involuntary disenrollments
  • Process disenrollments, cancellation and reinstatement TRCs
• Member profile maintenance
  • Process address changes
  • Process payment withhold option changes
  • Process plan changes
  • Allow other changes to member profile and appropriate CMS or internal system updates
  • Process CMS responses to record update transactions
  • Store all member/applicant information in one view – plan, applications, LIS, LEP information, Letters and other Correspondence.
• Manage auto and facilitated enrollments
  • Process TRCs received from CMS for auto and facilitated enrollments
  • Find plans and auto and facilitate enroll part C members
  • Generate notifications to member for auto and facilitated enrollments
• Letter Generation
  • Trigger letters to members based on configurable business rules
  • Integrate with letter authoring tool for template maintenance and letter generation
  • Maintain letter history
  • Allow bulk/individual holding and re-queuing of letters for corrections