Health Plan Member Services, Eligibility & Enrollment Solutions

Health Plan Services to Empower Plan Members and Improve Satisfaction While Reducing Your Burden

Envolve has decades of experience in business process outsourcing (BPO), providing member support tactics to ease the administrative burden on health plan payers, and engaging members to take control of their own health.

At Envolve, we process hundreds of thousands of inbound member and member calls a month on topics related to benefits and eligibility, appointment scheduling, access to social or service resources, and much more.

Our quality health plan member support services lead to improved plan satisfaction among members and help empower members to take better control of their own health outcomes.

By handling a variety of call topics, our healthcare experts can pass along these learnings to our clients, to become more knowledgeable about the types of concerns members may have about their health plans.

Along with our expertise in answering member phone calls, Envolve conducts thousands of outbound calls each month to help engage members in their health.

These calls cover a variety of topics, and may include:

  • Welcoming new members
  • Conducting over-the-phone health screenings
  • Reminding members of upcoming appointments and
  • Helping close gaps in care that may threaten plan performance

Eligibility and Enrollment Management Solutions Designed to Enroll Individuals in the Right Programs Right from the Start

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 customer service excellence and improving the lives of members the first time they call.

Envolve’s eligibility and enrollment team always strives for first-call resolution and satisfying any concerns a caller may have about their current and future healthcare elections.  

We Meet Members Where They Are

Our approach to member engagement is to meet members where they are. This means being culturally appropriate, person‐centered, and accessible to all individuals.

Our goal is to ensure members have the information and support they need (and give them a platform to voice any concerns related to the care or service they received. We always work to ensure your members are making the most informed choices about their health and healthcare.

Eligibility & Enrollment Policies and Procedures 

Envolve’s enrollment team has a set of established policies and procedures in place to ensure accurate health plan enrollment while providing covered benefits in accordance with the individual’s eligibility group.

We coordinate with the state as needed for Medicare and Medicaid managed care enrollment procedures.

We make it easy to enroll covered individuals in the programs right for them. Along with discussing enrollment options with members, our 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  as required
  • Integrates information while keeping total data integrity from enrollment files across all client functions.
  • Distributes data to other integrated functional components including:
    • Claims processing systems
    • Care management platforms
    • Secure web-based Provider and Member Portals
    • Member mobile applications

Better Eligibility Management Equals Improved Efficiency, Cost Effectiveness and Reductions in Wasteful Spend 

Our rigorous healthcare enrollment processes enable us to resolve any discrepancies between eligibility files and internal membership records before processing is completed.

  • We conduct weekly reconciliations of the enrollment/disenrollment file and daily enrollment/disenrollment activity against our records.
  • We will notify you of any discrepancies found within the data on the file within 10 calendar days via written notification.
  • We reconcile premium payments with enrollment information monthly and will 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 at any given time.

With our technical management capabilities, we gather, analyze, and report data to identify and act against inappropriate plan utilization.

By taking a proactive approach to fraud, waste, and abuse, we helped save affiliated health plans $1.2 billion in savings in 2016.

Experience has shown that the best approach to cost avoidance is to minimize the need to recover costs in the first place.

Health Plan Enrollment Management and Data Intake

Our enterprise management information system ensures the provision of covered benefits in accordance with each member’s eligibility group. We work with the State and other stakeholders to ensure member data quality when working with Medicaid and Medicare plan payers.

Encounter Data Extraction and Preparation

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.

This helps minimize bottlenecks and the need for manual intervention, and ensures 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. We produce Professional and Institutional Encounter files in the MMIS in HIPAA compliant 837P (Professional) and 837I (Institutional) format.

Get Leading Support for Your Members with Envolve Health

From ensuring your members have the knowledge they need to make better decisions about their health to knowing they are enrolling in the right programs for them, Envolve Health has member services covered.

Start today with Envolve Health. Contact us today!

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For Member Services and assistance, please contact the telephone number on the back of your Member ID card.

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