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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

Reconciliation Processing

May 24, 2013

9:00 – 10:30 AM

overview requirements
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 requirements1
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
membership error report
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”
membership error report1
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
membership urgent resolution
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.
membership monthly audit
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.
payment reconciliation
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.
payment reconciliation make up
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.
acknowledgement files
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
next steps
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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