02 — Capability · BC-1870.10
Member Enrollment & Eligibility
Enroll members from employers, exchanges, government programs and individuals accurately and on time, keep each member's eligibility and coverage dates current, and bill premiums to whoever owes them. A provider checking a patient's coverage is patient access.
- Membership Accounting
- Enrollment and Billing
- Member Eligibility
In scope
- Enrollment file intake and reconciliation
- Eligibility spans, coverage changes and terminations
- Premium billing, subsidies and grace periods
- Member ID cards and welcome materials
Out of scope
- Coverage verification by a provider before service (see BC-1810.30)
- Benefits enrollment for the organization's own employees (see BC-350.40)
- Receivables accounting for premiums received (see BC-250.40)
- Calculating and paying broker and agent commissions (see BC-440.50)
Realized by · 1
- HealthEdge · Membership and Enrollmentstrong via BC-1870.10.10
Used in · 2
Build it · 1
Decomposes into · 5
- BC-1870.10.10Member Enrollment ProcessingLoad enrollment from group files, exchanges, government programs and individual applications, and resolve errors before coverage starts.
- BC-1870.10.20Member Eligibility MaintenanceKeep coverage dates, dependents and plan changes current for every member, and share eligibility with providers and partners.
- BC-1870.10.30Health Plan Premium BillingBill premiums to groups, members and government programs, apply subsidies, reconcile payments and run grace periods for nonpayment.
- BC-1870.10.40Member ID & WelcomeIssue ID cards, welcome materials and online access to new members so they can use their coverage from the first day.
- BC-1870.10.50Group & Broker AdministrationSet up and renew employer groups and their plan elections, record the broker or agent of record on each, and supply the data commissions are paid from.