Eligibility reconciliation is one of the key factors in realizing revenue for Part D sponsors. Incorrect eligibility data will result in wrong claims adjudication thereby increasing member’s dissatisfaction and rejection of PDE data by CMS which directly affects CMS payment to the Plan sponsors. iProjects Enrollment team with the aid of software and tools strives to maintain highest level of accuracy in maintaining member’s eligibility data and continuously validates data with CMS eligibility data through proper reconciliation with TRR and MMR files. This process also generates monthly attestation reports. Our LIS match rate is given very high rating because of our best practices in reconciling our data with CMS. This also helps in accurately generating premium invoices and collections.
Our rule based software and standardized process enables us to maintain and reconcile eligibility data.
This is performed through the following tasks or steps:
- Correct interpretation of TRR codes and processing of TRR files based on a tested TRR processing logic
- Generation of exception reports at every stages of enrollment processing which in turn reduces errors and triggers corrective action measures
- Resubmission of rejected transactions by analyzing BCSS file and keeping track of all pending transactions
- Compare member’s eligibility data with MMR file and generating exception report for appropriate follow up action for timely resolution and correction of member’s eligibility data
- Measuring compliance timeliness and comparing member’s data with “NORX” file
- Assigning case workers (SMEs) for specific task like eligibility data correction, resubmission of eligibility etc.
- Tracking and monitoring of individual cases for timely resolution
- Preparing daily, weekly and monthly enrollment reports
- Auditing of reports and random checking of resolved cases
- Defined manual process for analysis, investigation and resolution based on various exception reports with data mining support from database programmers
We believe in maintaining correct eligibility data by eliminating errors / discrepancies at source point and then by validating eligibility data with CMS’ data by comparing with TRR, MMR files periodically. This also helps us in identifying discrepancies for monthly attestation reporting and taking corrective actions for submission of retro-enrollment transactions to CMS (IntegriGuard). Finally, the eligibility reconciliation team performs monthly reconciliation of member status against CMS records (MMR) for each member and produces the Monthly Attestation Report. Our continuous process of data validation and reconciliation activities help in correctly synchronizing plan member’s data with CMS records.
We provide weekly and monthly reports to our Clients which are based on our enrollment and reconciliation process outcome. Our enrollment team is trained on HIPAA and carried out enrollment functions strictly following CMS guidelines which help our clients to meet or exceed CMS performance standards.