Claims Repair

For Healthcare

Medicare customers can incur a late enrollment penalty (LEP) if they were eligible to enroll at the end of an enrollment period, but were not enrolled in the Medicare Part D plan and are not covered under any creditable prescription drug coverage. This applies in case of an extended period of 63 days or more at any time after the end of the customer’s Part D initial enrollment period.

Healthcare Payers receive a significant volume of LEP Attestation forms from the Provider, and therefor need to process them and sends their replies through all available output mediums.

A brief on the LEP Process is explained below:

1. Members who have received the LEP Attestation form from the Provider, sends their replies through Mail, Fax, or calling the Provider Call Center.
2. The response can be received through Phone or Physical copy.
   1. Managed Care Center Phone Call (Manual Initiation) – Without Paper image
   2. Vendor Mail Room – (upload from shared location) - with Paper image
   3. OmniScan^TM – with paper image
   4. Initiation from Fax – with paper image
3. Capture the Creditable Coverage details and calculating Number of uncovered months accordingly in OmniFlow^TM.
4. Integration with Core system and other external systems using web services and pulling the information in the Newgen Unified Front End.
5. Dual data entry for paper responses and Quality check for paper as well as phone responses.
6. Automatically changing a User Audit percentage (for QC) based on Quality standard percentage met by the user.
7. Reminder Calls module to Call member to gather pending information

Advantages of Using a BPM based Automated Solution:

• End to end tracking of policies for applicants
• Reducing manual error through Dual data entry and Quality check concepts
• Processing of general applications using single workflow but accessible to different users at same work step
• Auto Letter generation for selected form types, saves valuable time
• TAT defined in the system helps in measuring the delay and removing bottlenecks to improve efficiency.