Web Based Enrollment

Employees, using a secured login, can (within the guidelines of the employer) enter or change their own employment, family, and benefit information. Employees can view benefit plan descriptions, summaries, and costs for both the current and the upcoming plan years. Changes can be allowed for qualifying events such as open enrollment, new hires, the addition or termination of a dependent, or to change a member's primary care physician. Changes are pended or approved based on the business rules of the employer. When approved by the employer’s human resource department the change records are loaded into an upload file for validation and loading into the membership files.

The enrollee can view and select appropriate providers based any combination of criteria including specialty, network or plan affiliation, language, and location.

Authorized employer personnel can enter changes directly for an employee. They can also view, or print, application forms, benefit manuals, and enrollment reports.

The advantages are a significant reduction in paperwork. No application forms, no lists, no printed reports, and no benefit manuals are required. All required information can be accessed on line. There’s no redundant entry.

Electronic Enrollment

Employers can send their enrollment information using XML, ANSI X12, or a flat file format. They can send the information by e-Mail, CD-ROM, DVD, floppy disks, or cartridge tape. When received the records are translated to the eligibility upload file format. For EDI transactions a 997 functional acknowledgement is automatically generated and sent to the trading partner.

Enrollment Data Integrity

Records in the eligibility upload file are extensively checked using edits for completeness and accuracy. New additions are checked for possible duplicates with records already in the eligibility database based on Social Security Number, or last name and date of birth. Any exceptions found are put into an exception table/tables with the reason for the exception. These records can, in coordination with the employer group, be corrected and reloaded into the eligibility upload file. This insures the data integrity of the membership database while at the same time making it easy to find and correct exceptions. Eligibility add/change/delete reports are generated for the employer group.

Claim history along with all patient balances is tracked when there is a change in the member’s primary subscriber id.

Manual Entry/Review

Authorized persons can make enrollment and eligibility changes directly into the membership files. Members can be manually deleted from the member files as long as there is no claims or billing history on them. This program includes all necessary edits and checks to ensure that the integrity of the membership database is maintained. A manual request for an ID Card or Certificate can be made with the click of a button.

Certificates/ID cards

Depending on employer guidelines, a request for ID cards, Certificate labels, and address labels is generated whenever the eligibility upload file is processed. These requests can be viewed and maintained before printing.

Web Based Eligibility Checking

Once a member has been enrolled, a provider can log in to view a member's eligibility for a particular benefit.

Member Number

A subscriber id number can be the SSN, the employer’s employee id number, or a system generated sequential number. The member number is a two-digit suffix. Each member’s SSN is always captured within the member record.

Pre-existing, exclusions, COB, Cobra and Dependent Info

Pre-existing conditions, exclusions, COB, Cobra, student status, and medically disabled dependent information can be entered when the information becomes available. Form letters will automatically be generated as qualifying events occur.

Benefit Tracking

Each member in a subscriber unit has an individual profile of benefits, with one record for each benefit (medical, dental, vision, pharmacy, etc). Each benefit record has both a start date and an end date showing the eligibility period for that benefit for that member. Each benefit record also has an assigned primary and secondary provider (for OB/GYN and other specialized services). Each line carries the student status with an expiration date for the status, and a flag for medically disabled dependents.

Each time there is a change in coverage, status, or provider for a particular benefit, a new benefit record is generated. There can be up to 999 changes per benefit allowing for effectively unlimited changes in coverage. When the benefit profile for a member is viewed, only the latest benefit period is shown. Prior periods are shown when the line is double clicked. Claims are adjudicated based on the benefit that was in effect at the time the claim was incurred.

Notes

Extensive free form notes can be entered for a subscriber unit or for each member. These notes are accessible within claim administration. These notes are automatically date stamped with the latest notes shown first. Notes can be flagged to always stay on top no matter what their date.