02 — Capability · BC-1870.70
Government Program Operations
Meet the obligations of running Medicare and Medicaid managed care plans, by submitting risk adjustment and encounter data, reconciling what government programs pay, filing bids and required reports and overseeing the entities the plan delegates work to. The obligations register itself is compliance.
- Medicare Advantage Operations
- Medicaid Managed Care Operations
- Government Programs
In scope
- Risk adjustment and encounter data submission and validation audits
- Reconciliation of monthly government capitation payments
- Bids, medical loss ratio and other required regulatory filings
- Oversight of delegated and downstream entities and program audits
Out of scope
- Premium rate development (see BC-470.20)
- The program compliance obligations register (see BC-140.10)
- Risk adjustment documentation by providers (see BC-1860.30)
Realized by · 1
- HealthEdge · Revenue Align Edgepartial via BC-1870.70.10
Used in · 0
- Not yet placed on a value stream.
Build it · 1
- technology Health Plan Core Administration Systems via BC-1870.70.20
Decomposes into · 5
- BC-1870.70.10Risk Adjustment SubmissionSubmit members' diagnosis data to government programs completely and by each deadline, reconcile what was accepted, and support validation audits of the submitted conditions.
- BC-1870.70.20Encounter Data ReportingReport every service delivered to members, including those paid under capitation, to state and federal programs in the required format, and correct rejected records.
- BC-1870.70.30Government Payment ReconciliationReconcile each monthly government payment to the plan's own membership and risk scores, and resolve discrepancies with the program.
- BC-1870.70.40Regulatory Filings & MLRPrepare and file bids, medical loss ratio reports and other required program filings accurately and on time.
- BC-1870.70.50Delegated Entity OversightOversee the vendors and provider groups that perform plan functions on its behalf, audit their performance against program rules, and act on what is found.