Member Enrollment, Eligibility, and Maintenance

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CMS Compliance, Member Letters, and Maximizing Revenue
Can be Agonizing

Enrolling members into government programs is complex and involves layers of regulatory requirements. Time wasted with manual processes can impede staff productivity and profitability.

Getting the timing, language, premium amount, and CMS required language for member correspondence can be difficult and, if not done correctly, can initiate potential audits.

Reveleer's Solution Can Help You With Operational Efficiency

Reveleer’s Enrollment and Eligibility solution provides health plans with a highly automated solution that utilizes extensive pre-submission validations resulting in:

  • Reduced manual labor
  • Simplified enrollment status checking
  • Highly accurate enrollment processing

System validations are done to ensure the data entered or batch submitted is formatted correctly (numbers in number fields, alpha characters in alpha fields, etc.). Eligibility validations are done via Batch Eligibility Query (BEQ) based on the information on the election. The system includes business rules regarding when certain elections can be used and what corresponding effective dates are viable.

Our member correspondence makes it simple as all CMS model letters are built within our system which helps automate the majority of your correspondence with intervention only required on exceptions found by our analytics. You have the ability to:

  • Automate 95% of member correspondence
  • Create, customize, or edit letters within the system
  • View all past correspondence per member

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  • Accept MA-PD, MA, and PDP enrollment data
  • Export enrollment/disenrollment, correction, and change transactions for submission to CMS
  • In-load daily Transaction Reply Report (TRR)
  • Integrated and Automated near real-time BEQ verification
  • Export approved/eligible members to the core claims system
  • Utilize manual entry of election form data
  • Import data files containing election transactions
  • Utilize the flexible rules engine to edit election data for errors and workflow
  • Manage exceptions by creating work items placed in work queues
  • Allow examiners the ability to review/document and create correspondence and correct election data
  • Build correspondence packages from stored Word document template libraries
  • Automatically initiate correspondence from the rules engine or manually
  • Integrated CMS 3rd party submitter
  • Export enrolled members into a core claims system
  • Export queued correspondence for electronic print and fulfillment
  • Full automation for all CMS data and reporting processes
  • MMR monthly member and payment reconciliation at the member level
  • Full visibility to all CMS reports and process at the member level
  • Users will be able to manage, develop, maintain, audit all of the member correspondence – multi-language capabilities
  • Flexibility on creating and maintain a multi-state service area, benefit, PBP, and Segment ID configuration
  • Member correspondence on-demand PDF attachment along with supporting documentation attachment capability