Dependent Eligibility Verification | Claims Audit | Pre-payment Claim Review

Dependent Eligibility Verification

Benetech’s Dependent Eligibility Verification validates that the dependents covered by your employees are eligible for the coverage—resulting in both healthcare savings and eligibility data that is accurate for IRS reporting (necessary as part of the Affordable Care Act).

We know that employees don’t always notify HR when life changes occur:

  • A young adult no longer eligible due to student requirements
  • A divorce or separation (which leaves a former spouse covered)
  • A deceased child or spouse (monthly data validations against the Social Security Death Master File)
  • A young adult that is married or has coverage available elsewhere (possibly making them ineligible for your sponsored coverage)

While this may seem more like a data maintenance issue at first, covering ineligible dependents costs you in unnecessary premium costs and claims exposure. This may also lead to reporting improper data to the IRS for purposes of the ACA (IRS Form 6056).

Benetech's Eligibility Review Program:

  • Reduces costs by removing ineligible dependents from your plans;
  • Mitigates your fiduciary exposure and liability through a methodical verification and documentation process; and
  • Increases the accuracy of your reporting to the IRS for the purposes of the ACA.

Claims Audit

Auditing your medical plan can substantially reduce healthcare costs—Benetech’s statistically valid auditing program can help achieve results.

It is often taken for granted that administrators or claims payers (e.g., insurance carriers, Third Party Administrators, etc.) have all of the necessary controls in place to process claims with a high degree accuracy and with a great deal of attention to appropriateness of services rendered.

Whether self-insured or fully-insured and experience-rated, the administrator has little or no financial risk on their part. In other words, they are paying claims with your money.

Because of the magnitude of the dollars involved, it's both critical and essential for organizations to know how well their administrators are performing.

Our program consists of (but is not limited to) verifying:

  • Eligibility of Benefits
  • Proper payment amounts
  • Adherence to Summary Plan Description
  • Proper Application of Coordination of Benefits
  • Application of deductibles, co-pays, coinsurances, etc.
  • Work flow of claim processing procedure
  • Timeliness of payments

Pre-Payment Claims Review

If you are self-insured and funding your own claims we can ensure the accuracy of your claims payments with our Pre-Payment Claims Review solution. Our service validates your weekly claim file against eligibility (enrollment data) to approve each claim before any payments are made, including validation of data against the Social Security Death Master File on a monthly basis.

Implementing this process on an ongoing basis is both a corrective and preventive measure and helps to avoid miscellaneous expenditures.

Some of the features include:

  • Edit report indicating the potential ineligible claims selected for review
  • Outcome report detailing the review of the potential ineligible claim and the final disposition of claims
  • Savings report which tracks the actual dollars saved by preventing an ineligible claim from being paid
  • Reports are generated each claims payment cycle and can be generated on a cumulative basis

Dependent Eligibility Verification | Claims Audit | Pre-payment Claim Review

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