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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 [email protected]

  • Enrollment: Contact Courtney Eiswald at [email protected]

  • Reconciliation: Contact Courtney Eiswald at [email protected]

  • Technical: Don [email protected]


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