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GEMMS - Employer / Union Sponsored Group Enrollment and Administration

Download PDFOur staff possesses in-depth knowledge of the regulations and sub-regulatory guidance that have been established by the Centers for Medicare and Medicaid Services (CMS). Our Medicare expertise has allowed us to develop a comprehensive suite of administration tools that provide clients with an end-to-end solution that ensures full compliance with Medicare requirements. Features include:

  • Designed specifically for Employer / Union sponsored PDPs and MA-PDs
  • Designed and built by leading industry experts proficient in EGWP processing, auditing, consulting, and client installations
  • Design reflects key EGWP features:
    • CMS Rule repository to insure compliance (job one)
    • Flexible software to accommodate client specific rules, data and interfaces
    • File processing focused
    • Audit and controls hard wired into the system
    • BPO interfaces
      • Secured / scalable internet access for online enrollment management
      • Mail file creation and tracking
      • Operational reporting including dashboards
      • Empowerment of client/ operation via reporting portal

Enrollment / Eligibility

  • Enrollment file production (to support claims adjudication)
  • Daily TRR Files & Reporting
  • BEQ Reports
  • Error Reports
  • Involuntary Disenrollment Report
  • Locked Fields Report  (demographic no change report)
  • Null client TRR Report
  • Participant Status Report
  • Client Enrollment File Reject Report
  • Attestation Report
  • Pended Members Report (Aging Report)

BPO Services

  • Retroactive enrollment processing
  • Manual TRR processing
  • Payment discrepancy remediation
  • Avoidable TRR root cause analysis
  • LIS discrepancy remediation
  • Client requested analytics / ad hoc reporting
  • Manual HICN corrections
  • Client data clean-up
  • Request for Information Support

Client Billing

  • PM/PM Billing File (client billing file)
  • PM/PM reconciliation

Late Enrollment Penalty (LEP)

  • LEP Administration
  • LEP Billing
  • LEP Reporting

Premium Billing

  • Member invoicing

Client Financial Reporting

  • LICS Reinsurance Report
  • LIS Billing & Register  Report
  • LIS Refund Report
  • Monthly Risk Score by HICN Report
  • EGWP Payment Summary
  • Self Insured Direct Subsidy Report
  • Fully Insured Direct Subsidy Report
  • Payment Discrepancy Reporting
  • Annual Reconciliation Support

Member Communications

  • Letter Files
    • RFI
    • Denial
    • TRR
    • Opt Out
    • LEP
    • COB Surve

LIS Administration Including Split Premium

  • BAE Report
  • LIS Split Validation File
  • LIS Split Report
  • Acumen Match Rate Submission File
  • Monthly LIS reconciliation analysis

HPMS ReportingSubmission

  • Quarterly Reports
  • P2P Reporting
  • DIR Reporting

Compliance and Audit

  • EDV audit support and submission
  • Audit support (internal, external and CMS)
  • CMS Activity Report
  • FWA Report

COB Administration

  • Other Health Insurance (OHI) file to support COB
  • MARx COB Processing and Reporting
  • ECRS Submissions

Accounting Materials

  • Plan to Plan AR / AP Reports
  • GL File and reporting

GEMMS - Commercial Group Enrollment and Administration

GPS' experience was built from servicing the commercial group market. This experience includes:

  • Creation of a system to support enrollment for all types of benefit coverage (medical, dental, vision, pharmacy, etc)
  • Allowance of enrollment tracking based on individual or family coverage
  • Development of and enrollment system module to support payers with Section 111 MSP reporting responsibility
  • Enrollment file creation and submission for COBA participants
  • Creation of features to support managed care products (e.g. PCP elections, network selection, etc.)
  • System flexibility that allows for trouble-free production of different enrollment file layouts to support claims payers

Enrollment / Eligibility

  • Enrollment system to support multiple benefit types (med, dental, vision, Rx)
  • System features to support managed care products
  • Enrollment file production (to support claims adjudication)
  • Error reports
  • Involuntary Disenrollment report
  • Locked Fields report  (demographic no change report)
  • Participant Status report
  • Client Enrollment File Reject report
  • Pended Members report (Aging Report)

BPO Services

  • Client requested analytics / ad hoc reporting
  • Manual enrollment support
  • Client data clean-up
  • Request for Information support

 

Premium Billing

  • Premium capture and  tracking
  • Member invoicing by benefit type

Client Financial Reporting

  • Fully Insured Premium report
  • Reconciliation reporting

Member Communications

  • Enrollment packages
  • Summary plan documents / Material Modification documents
  • Disenrollment notifications
  • COBRA letters
  • Creditable Coverage notices

Client Billing

  • PM/PM Billing file (client billing file)
  • PM/PM reconciliation

Section 111 Reporting

  • File generation
  • Submission and response processing

Compliance and Audit

  • Audit support (internal, external and CMS)
  • FWA Report

COBA Administration

  • Enrollment file generation
  • Submission and response processing

Accounting Materials

  • GL File and reporting