Enrollment & Eligibility Module
Member enrollment lifecycle management from initial enrollment through eligibility verification, plan assignment, and disenrollment — supporting all lines of business.
Organization Relevance
How It Works
Member enrollment data arrives via EDI 834 transactions, employer census files, CMS/state enrollment files, or member portal applications. The system validates eligibility, assigns plan benefits, and maintains real-time eligibility status. Crossover coordination handles dual-eligible members. Retroactive enrollment processing manages backdated effective dates with claims reprocessing triggers.
Requirements
- EDI 834 enrollment/disenrollment processing
- Real-time eligibility verification (X12 270/271)
- CMS MARx or state Medicaid enrollment file processing
- Plan benefit configuration and mapping
- Member ID card generation capability
Target Audience
Enrollment Specialists, Member Services, Employer Group Administrators, CMS/State Reporting Teams
Pages (9)
| Page | Purpose | Key Features |
|---|---|---|
| Enrollment Dashboard | Overview of enrollment volumes, eligibility status, and membership trends | Enrollment metrics, Trend analysis, Status distribution, Processing queue |
| Carve-Outs | Manage carved-out benefit programs (behavioral health, pharmacy, dental) | Carve-out configuration, Vendor mapping, Eligibility sync, Claim routing |
| Crossover Coordination | Manage dual-eligible member coordination between Medicare and Medicaid | Dual-eligible identification, Crossover claim routing, COB coordination, State file processing |
| EDI 834 Processing | Process inbound and outbound EDI 834 enrollment transactions | File processing, Error handling, Reconciliation, Audit trail |
| Eligibility Verification | Real-time member eligibility lookup and verification | Real-time lookup, Benefit display, Coverage history, Verification response |
| Member Portal | Member self-service enrollment, plan selection, and account management | Plan comparison, Enrollment application, ID card access, Account management |
| PACE Enrollment | Program of All-Inclusive Care for the Elderly enrollment management | PACE eligibility, Enrollment workflow, Assessment tracking, CMS reporting |
| Plan Benefits | Configure plan benefit structures and coverage details | Benefit design, Cost sharing rules, Coverage limits, Accumulator tracking |
| Retroactive Enrollment | Process backdated enrollment changes with claims impact analysis | Retroactive processing, Claims reprocessing, Impact analysis, Approval workflow |
API Integrations
X12 834 Enrollment ProcessingX12 270/271 Eligibility VerificationMember search APIEligibility inquiry API (FHIR Coverage)Member portal API
Referenced Resources
X12 834 Benefit EnrollmentX12 270/271 EligibilityCMS MARx Technical GuidanceCAQH CORE Operating Rules
Expected Results
Accurate, real-time member eligibility with seamless enrollment processing across all lines of business, supporting claims accuracy and member access to care.