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Reconciliation Processing

Reconciliation Processing. May 24, 2013 9:00 – 10:30 AM. Agenda. Overview-Requirements. Carriers are required to perform enrollment and payment data reconciliation at least monthly Report discrepancies to the Exchange Business errors File transactional errors. Overview-Requirements.

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Reconciliation Processing

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  1. Reconciliation Processing May 24, 2013 9:00 – 10:30 AM

  2. Agenda

  3. Overview-Requirements • Carriers are required to perform enrollment and payment data reconciliation at least monthly • Report discrepancies to the Exchange • Business errors • File transactional errors

  4. Overview-Requirements • Demographic changes must be reported to the Exchange • Encourage individuals reporting changes to carriers to report changes to the Exchange • Discrepancy reports will be manually processed by Exchange staff, updates to enrollee data will be passed in the daily 834 transaction • Exchange will need a primary contact(s) for questions related to business errors • Exchange will need a primary contact(s) for questions related to file errors • Exchange will have a Reconciliation Team as a primary contact for carriers

  5. Membership Error Report • Carriers send standard error reconciliation report by the end of business each Tuesday for the daily 834 files sent during the previous week • No Error report sent for daily files the week following the receipt of the monthly 834 Audit file. • For example, theWeekly Carrier Membership Error Report on 04/16/2013 will cover the Enrollment Transactions sent from 04/08/13 – 04/14/13. • Report all QHPs in one report • File name will make a distinction between plans • No errors or discrepancies, send an empty report with “No errors found”

  6. Membership Error Report • Provide enough information that will allow Exchange staff to identify and resolve the discrepancy. • Subscriber ID • Dependent ID (if necessary) • Enrollee name • Type of error i.e. • Description of error • Amount • Send file via the SFTP error folder with standard file name

  7. Membership-Urgent Resolution • Errors that prevent the carrier from establishing membership or providing coverage. • This would include retroactive transactions or enrollment, but not transactions impacting future effective dates. • Examples • Invalid Social Security Number. Must be in the format ###-##-#### or #########. • Error, no coverage specified.

  8. Membership-monthly audit • Carriers to submit the standard HBE Error Report by the end of business on the 5th business day after the audit file is posted • Audit report will be available on the morning of the 24th of every month.

  9. Payment Reconciliation • Carriers to reconcile the full 820 payment file with the ACH • Carriers to reconcile the full 820 payment file with membership • Carriers to complete the error report by the end of the fifth business day after the full 820 payment file was generated.

  10. Payment Reconciliation-make up • Carriers to reconcile the “make up” 820 payment file with the ACH • Carriers to reconcile the make up” 820 payment file with membership • Carriers to complete the reconciliation report by the end of Tuesday for the make up files sent the during the previous week along with the discrepancies from the 834. • For example, theWeekly Carrier Payment Error Report on 04/16/2013 will cover the Payment Transactions sent from 04/08/13 – 04/14/13.

  11. Acknowledgement Files • Carriers to generate a receipt file for each file received • Generate a 999 acknowledgement file each time a file is received by the carrier and able to be read/processed • Generate a TA1 file that identifies problems in the interchange control structure

  12. Sample Carrier Discrepancy

  13. Next Steps • Testing: Contact Paul Price at Paul.Price@WAHBExchange.org • Enrollment: Contact Courtney Eiswald at Courtney.Eiswald@WAHBExchange.org • Reconciliation: Contact Courtney Eiswald at Courtney.Eiswald@WAHBExchange.org • Technical: Don CoteyDon.Cotey@WAHBExchange.org

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