Membership Maintenance & Enrollment

Addition or Deletion of Dependent, Cancellation or Re-instatement of Member, Change of Benefit Options, Conversion to Post-termination Coverage (COBRA), Creation of Dependent Coverage, etc

We handle enrollment and eligibility processing for Group health plans which involves updating Client’s Mainframe with Subscriber related data. Our SMEs have detailed domain knowledge on various types of Medical, Dental and Vision plans and various benefit options. Moreover, in production environment they have effectively processed various changes in the subscriber’s data with reference to benefit options – be it adding, changing or terminating the benefit option, defining and allotting Network, selecting PCP, determining primacy of coverage of dependent child etc. They are well-versed in a variety of indemnity and managed care plans such as, PPO, EPO, PPPO (Passive PPO), POS, HMO, POSOA, OAP and Conversion to post-termination coverage (COBRA).

Be it ‘New Enrollment’ or ‘Maintenance’, before updating the Mainframe the SME has to make sure that the subscriber has provided all the information that is necessary for processing the request. Secondly, whether the subscriber is entitled to have particular plans and benefits as per the company’s rules. For taking the decisions on these matters, SME has to review each case in the light of two basic documents. The first one is the Business Rule Guide prepared and updated by our team with the guidance from the Client and the other is Structure Spreadsheet, an account-specific document prepared and updated version provided daily by the Client. If the subscriber’s request is disqualified, technically known as ‘failed’ on any basis, nothing will be updated into Mainframe and the request will be returned along with suitable reason for failure being selected.