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Eligibility Maintenance
A key component to accurate and efficient claims processing is the maintenance of accurate and timely updated eligibility records. Our eligibility system includes complete data for plan participants such as coverages, benefits, dependents, and COB information. Benefit types can be maintained separately for employees and their dependents (e.g., an employee has medical and dental benefits while a dependent only has dental benefits). We have the capacity to receive eligibility data in an electronic format from the plan sponsor to expedite the process and reduce manual processing errors. Also, we can send eligibility data in paper or electronic form to other plan vendors such as an EAP, PBM or separate dental and vision carriers. Part of our eligibility process includes the distribution of required COBRA continuation notices and HIPAA certificates of creditable coverage to terminated participants.
On a monthly basis, a reconciliation of the eligibility is performed to arrive at an accurate count of eligible participants. This information is used to pay vendors compensated on a per eligible basis such as a stop loss carrier. We can produce the payments to these vendors or provide the client with the necessary data to make the payments.
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