Member Eligibility, Reconciliation & Management

Member Eligibility, Reconciliation & Management

 Objectives. Participants will learn how to:

  1. Conduct intake and determine member eligibility and assignment under capitated arrangements
  2. "Enroll" members at the point of care and identify members who should be assigned to pilot sites
  3. Receive, manage and reconcile eligibility files
  4. Assign members to specific providers, care teams and clinic sites
  5. Conduct panel management and review at the clinic, site and provider level
  6. Capture and document CPT and diagnosis codes appropriately to identify conditions, severity of illness, etc.
  7. Submit claims or encounters for alternative visit types and services (e.g., phone visits, e-mails, nurse visits, class and group visits, case management and navigation)
  8. Work claims denials

 Curriculum Description

  1. Managed care member eligibility overview:
    1. Managing health plan eligibility files and reconciling member eligibility, including: receiving, loading and analyzing member eligibility files from health plans, reconciling member lists with health plan change files (retro adds, changes and deletes) and reconciling payment with eligibility files and services rendered
    2. Managing on-site verification of eligibility and member site assignment
    3. Coordinating membership determination and management with front-office staff functions (e.g., scheduling)
    4. Developing work flows to support scheduling of member visits to assigned member clinic sites
    5. Tracking, accounting for and managing member visits across pilot and non-pilot sites
    6. Developing processes to account for and manage members with no visits, encounters or touch points (e.g., linking to population health, outreach, clinical processes) and conducting outreach to assigned members with no clinical encounters or alternative touches
    7. Addressing issues with "administrative, non-linked members"
  2. Assignment and panel management:
    1. Understanding differences between empanelment and panel management
    2. Clinical and operational requirements for member and patient empanelment
    3. Managing and reconciling member assignment to clinic sites and providers to support panel management
    4. Understanding, distinguishing, accounting for and managing members and patients on active panels
    5. Benchmarking, opening and closing panels
  3. External state and plan requirements (e.g., SB 137)
  4. Coding and claims overview:
    1. Capturing alternative touches for all staff through CPT/HCPCs and/or other coding schemas
    2. Linking alternative visits to appropriate NPI and clinic site
    3. Coding multiple visits on the same day
    4. EHR coding and charge capture changes
    5. Capturing condition acuity in clinical, claim and encounter files using: CPT I, CPT II, and HCPCS codes.
    6. Appropriate use and impact of ICD-10 coding to capture, document and account for risk-adjustment, population health and social determinants of health (SDOH) issues.

Suggested team member participants:  C Suite (CEO, COO), Finance, Billing, Member Management, Coding, Panel Management

If you have any dietary restrictions, please email Charlotte Reische,

8/3/2017 9:00 AM - 4:30 PM
Cal State East Bay 1000 Broadway Oakland, CA 94607 UNITED STATES

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