Our Eligibility teams consists of professionals have experience in Member enrollment, Eligibility verification and Capitation payments.
Department’s main functionality includes:
- Input electronic eligibility downloads from the health plans
- Processing of member eligibility information electronically and loading it into eligibility database
- Eligibility processing using various systems. Allowing to have 100% of conflicts and rejects worked prior to final eligibility loads.
- Eligibility tracking and verification
- Eligibility Verifications on Pended Authorizations and Claims
- Enrollment of groups and members/benefits
- 834 Files
- Capitation Management:
- Capitation file maintenance and payment processing
- Reconciliation of eligibility for capitation payment for PCPs, specialty physicians, ancillary providers, hospitals, or other providers contracted with the client to receive capitated reimbursement