HIX Integration Solution

Transcription

1 HIX Integration Solution HIX Integration enables health plans to adjust and meet frequent regulatory changes enacted by the FFM and State-based Exchanges. Solution Brief HIX Solution

2 HIX Integration Solution Introduction Health plans operating in new health economy have been on a whirlwind right from the word go. At the onset of marketplaces, carriers were torn between choice of participation in the exchange and avoidance of the unknown risk. Round one of Open Enrollment saw health plans battle constantly evolving guidelines, incorrect subsidy calculations and billing issues. The second Open Enrollment period was a smoother ride for the consumers but health plans continued to struggle in the background; given the inability of state exchanges to generate EDIs, handle renewals and change of circumstance events. The forthcoming Open Enrollment will test health plan readiness to manage SHOP business along with Individual enrollments. The carriers need to develop capabilities to handle nuances of SHOP enrollment processing such as holding of SHOP initial enrollments until employer group creation has been confirmed. Amidst these challenges, health plans are currently operating in a lower margin environment, marked by higher-than expected actual claims, rising administrative and medical costs, changes in premium subsidy, lower reimbursements of Medicaid & Medicare Advantage and increasing price sensitivity of consumers. In such a challenging and volatile market, it is imperative for health plans to streamline back-end operations to smoothly scale their business. Edifecs extends existing payer capabilities to succeed in a retail-oriented world with adaptable administrative backend solutions. Edifecs HIX Integration Solution serves as a health plan s single gateway to the federal marketplace, statebased marketplaces and private exchanges. It serves as a guardian for a carrier s HIX business, shielding and monitoring HIX interactions with exchanges, financial institutions and the federal government to ensure that only accurate, timely information is sent to core membership systems or to the federal government. 2

3 Key Capabilities Payers can seamlessly integrate with federal, multiple state and third-party private exchanges and effortlessly adjust to meet the frequent regulatory changes. Standardize IFP and SHOP enrollment intake across all public and private exchange marketplaces Reconcile premiums and subsidies to enrollment records Monitor premiums and claims expenditures: actual vs. expected APTC payments to identify over/under payments and received CSR funds vs. claim CSR expenditures Handle payment information from multiple sources (billing services, exchanges, internal financial systems for paper checks) Resolve discrepancies with federal, state and third party entities Enrollment Dashboards 1. Dashboards provide real time status of accounts and enrollment transactions throughout the processing lifecycle. 2. Enrollment operations and audit staff can drill down to view transaction-level detail to inspect and repair pended items 3. Dashboards are updated in real time as transaction status changes 3

4 Why Edifecs Edifecs HIX Integration Solution makes managing IFP and SHOP enrollment simple and trouble-free. Benefits Minimizes disruptions to existing enrollment processing due to HIX integration requirements Features Provides a single intake interface at the edge of the enterprise for all lines of business Provides a dedicated and isolated HIX enrollment processing to ensure uninterrupted employer group workflow Insulates core membership systems from problematic processing of change of circumstance (COC) transactions and renewals by state run exchanges Hosted solution model reduces impact on internal systems and existing membership and enrollment processes Maintains compliance with EDI transaction standards and the most current federal government guidance Simplifies reconciliation of enrollment and payment remittance data Process different formats of inbound and outbound 834s and 820s like 5010x220A1 834 FFM, x307, x306 and data in custom file format such as CSV, DFF, XML etc. Process enrollment transactions coming in different formats from different exchanges Avoid the cost of remediating legacy systems to produce and receive EDI-compliant transactions Automates payment and EFT notification to drive reconciliation of premium payments from employer groups, tribal entities and individual subscribers, as well as APTC payments from federal government, to the member enrollment record Holds payment and initial enrollment record until first month premium obligation is met or until member or employer group has been successfully created Tracks post adjudicated claims expenditures on a per claim / per service line basis to reconcile CSR provider and subsidy payments 4

5 Enhances member satisfaction and retention Serves as a single source of truth on enrollee membership to reliably manage membership records between internal systems, state exchanges and the federal government Automates reconciliation of premium payments against the member enrollment record to accelerate billing and payment issue resolution Reduces onboarding time for new accounts (large and small employer groups) by handling enrollment data in any format: custom or non-standardized 834s Transmits provider network and roster information to exchanges to support the shopping experience Streamlines HIX membership issue resolution Automates enrollment record discrepancy detection and reconciliation Validates incoming enrollment data based on validation and business rules Reduces incidences of manual correction and its associated costs by leveraging business rules to detect errors in enrollments at the edge of the enterprise Provides end-to-end visibility of enrollment lifecycle Dashboards that provide a complete view of enrollment activity, premium remittance, exception resolution, etc. Discrepancy reporting upon each enrollment update Handles large volumes of data Accommodates spikes in transaction volume so that enrollment processing SLAs are maintained Edifecs Inc. is a global healthcare software company committed to improving outcomes, reducing costs, and elevating value of healthcare for everyone. Edifecs delivers the industry s premier IT partnership platform to providers, insurers, pharmacy benefit management companies, and other trading partners. By mobilizing its leading solutions at the front end of the healthcare information pipeline, Edifecs provides a unified platform for partners to flexibly pilot and scale new initiatives using their existing enterprise system. Since 1996, hundreds of healthcare customers have relied on Edifecs partnership solutions to future-proof their leading initiatives in the midst of a dynamic healthcare landscape. Edifecs is based in Bellevue, WA, with operations internationally. Learn more about us at edifecs.com Edifecs Inc. All rights reserved SB