Our Eligibility teams consists of professionals have experience in Member enrollment, Eligibility verification and Capitation payments.

Department’s main functionality includes:

  • Eligibility:
    • 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