Eligibility Management for Members: Member Services, Eligibility & Enrollment

Enrolling Individuals in the Right Programs Right from the Start

Envolve has decades of experience providing business process outsourcing (BPO) capabilities to members. Envolve receives and addresses hundreds of thousands of inbound member calls a month on topics including questions related to benefits and eligibility, appointment scheduling, access to social or service resources, etc. Envolve conducts thousands of outbound calls to members each month to engage them in their health (e.g., new member welcome calls, conducting member health screenings, appointment reminders, and care gap closures).

We strive to provide excellent service with every member interaction by training our eligibility and enrollment services team to provide anticipatory service specific to the member’s needs. We ensure that every team member is focused on how we can improve the lives of members through customer service excellence including first call resolution. Our member engagement approach is to “meet members where they are” by being culturally appropriate, person‐centered, and accessible to all individuals. Our goal is to ensure members have the information and support they need (e.g., inquiries related to benefits, services, access) and have a platform to voice any concerns related to the care or serviced they received (e.g., member complaints) to make informed choices about their health and healthcare.

Envolve has established policies and procedures for eligibility and enrollment categories to ensure accurate health plan enrollment and to provide covered benefits in accordance with the individual’s eligibility group. We coordinate with the state, as needed, on health plan enrollment procedures.

Envolve’s Eligibility Management Team Also:

  • Facilitates the acceptance of electronic member roster files and reviews 834 audit files against internal records
  • Conducts systematic reconciliations for all membership changes to ensure individuals receive all benefits due to them
  • Reconciles enrollment transactions between state interfaces and our internal systems on a daily, weekly and/or monthly basis as required
  • Integrates information keeping total data integrity from enrollment files across all client functions.
  • Distributes data to other integrated functional components including
    • Claims processing system
    • Care management platform
    • Secure web-based Provider and Member Portals
    • Member mobile application

Our rigorous processes enable us to resolve any discrepancies between eligibility files and internal membership records before processing. We conduct weekly reconciliations of the enrollment/disenrollment file and daily enrollment/disenrollment activity against our records. We will notify any discrepancies found within the data on the file within 10 calendar days via written notification. Each month, we reconcile premium payments with enrollment information and will then address any discrepancies via an exception report. Our technology and staff ensure that each member is enrolled in the correct program and receiving entitled benefits.

With our technical management capabilities, we gather, analyze, and report data to identify and take action against inappropriate utilization of services and quality of service concerns. This proactive approach to fraud, waste, and abuse, including the Coordination of Benefits savings, cost avoidance and recovery activities resulted in over $1.2 billion in savings in 2016 through all of Envolve’s affiliated health plans. Experience has shown that the best approach to cost avoidance is to minimize the need to recover costs in the first place. 

Ensuring the provision of covered benefits in accordance with the member’s eligibility group is supported by our enterprise Management Information System. We work with the State and other stakeholders to ensure member data quality. 

Our integrated encounter system is configured to systematically extract claim data from our data warehouse into the encounter repository based on the claim paid date to minimize bottlenecks and the need for manual intervention, as well as ensure we meet timeliness requirements for encounter data submission. The encounter system is configured to submit encounter data that complies with all State standards for electronic file submission. We also adhere to HIPAA, NCQA, AMA coding, UB-04 editor, and NCCI standards regarding the definition and treatment of critical data elements captured on claims. The encounter solution produces Professional and Institutional Encounter files for the MMIS in HIPAA compliant 837P (Professional) and 837I (Institutional).

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