The Eligibility Optimization Assessment includes a complete reconciliation of healthcare claims against eligibility during the chosen time period. The result is a comprehensive reporting package which details the ineligible claims by reason of ineligibility, grouped by both family unit and individual: everything you need to show to your health plan vendor. As part of the reporting package, you will receive a roadmap to solve the underlying inefficiencies and ensure your claims and eligibility are correctly processed in the future.
Ineligible claims happen for several reasons, usually around a time of employee or dependant transition; below are just a few examples:
The Eligibility Optimization reporting tool would provide a report to enable you to re-adjudicate the claims in these scenarios because traditionally when a retroactive eligibility is submitted there is no automated re-adjudication process.
The ineligible claims have been processed and paid by your insurance carrier. The underlying issues however, may span your internal systems and processes, your benefits administrator as well as your insurance carrier. Once we identify the ineligible claims, we will provide you with a reporting package including a roadmap of how to align all of the stakeholders to address the issues and ensure that both claims and eligibility are processed correctly in the future.
You can! In fact, we would be happy to walk you through the process and the tools you need to perform the reconciliation internally. Contact us to schedule a quick conversation about Eligibility Optimization.