Eligibility and Reconciliation

ELIGIBILITY MAINTENANCE AND RECONCILIATION PROCESSING

Accurately maintaining member eligibility files is one of the most taxing and important tasks for Medicare Advantage and Part D plans.  CMS weekly TRRs, monthly TRRs and monthly MMRs need to be reconciled against the Health Plan’s files and data.  Attestation reports are required monthly, summarizing discrepancies against CMS data.  TMG Health has developed a set of proprietary applications and processes to automate the TRR and MMR reconciliation process and to maintain accurate eligibility data.

Our TMG Resolve® TRR processing software intakes, categorizes, automatically activates accreted members and changes to our eligibility system or routes items for action based on the transaction (acceptance, maintenance, rejection) codes received from CMS.

TMG Resolve® features include:

  • High volume throughput capacity via automated intake and categorization of
    CMS transaction codes
  • Automated resolution of acceptance and maintenance codes
  • Scheduling control system to automate staff work assignments including
    productivity monitoring, work balance and distribution
  • Tools for manual research and resolution of specific maintenance and
    rejection codes requiring manual intervention
  • Compliance timeliness measurement
  • Member Tracking Status
  • Library of instructions & FAQs for processors


TMG Recon® is our proprietary application for the comparison of monthly CMS eligibility file data (MMR) with TMG eligibility system data at the individual member level. TMG Recon® produces discrepancy lists through an extensive array of reports facilitating the timely resolution/ correction of demographic and/or special status data.

SINGLE MAINTENANCE UNIT
In order to expedite timely resolution of complex eligibility variances, TMG Health created a Single Maintenance Unit (SMU) of seasoned processors. This group is responsible for reviewing all variances that exist between CMS provided eligibility information and data contained in TMG's managed care information system. Based on an accumulated set of best practices, they then determine the resolution action that needs to be taken. Variances are identified through various processes such as the Monthly Attestation Report, PDE rejections and routes. The types of variances that are reviewed can range from member eligibility to demographic information, as well as low income data, indicator fields such as Part A and B eligibility, and State, County, and Out of Area issues.

MONTHLY ATTESTATION REPORTING
TMG Health performs monthly reconciliation of member status against CMS records (MMR) for each member and produces the Monthly Attestation Report. TMG Health performs all recurring file submission, exchange and resolution including:

  • Downloading plan payment TRR, MMR etc. reports from CMS
  • Reconciliation analysis
  • Resolution of discrepancies
  • Retro-submissions (e.g. batch electronic and IntegriGuard submissions)


To optimize the Reconciliation Work-flow process, TMG Health has also developed and implemented routines supporting the development of the data needed by plans to submit their monthly Enrollment Attestation to CMS, and quality control of data inputs. Features of this process include:

  • Pre-edit system to reduce false discrepancies
  • Attestation to TRR cross-walk for proper disposition
  • Output measures true to MMR representations
  • Dynamically accounts for CMS issues correlated to HICN# (CMS alerts, Help Desk, etc.)
  • Creation of attestation "true discrepancy" work orders
  • Certification process and final report generation
  • Workflow tracking data base that houses attestation discrepancies and IG Inventory
  • Inventory monitoring, tracking and reporting


TMG Health provides Clients with monthly performance reports for those enrollment and reconciliation services performed by TMG Health. All services conform with CMS standards and all Medicare/state regulations and Client requirements. In addition to producing updated member eligibility data and the attestation, the TMG Recon® process also serves to detect any issues causing repetitive errors.

TMG Health provides "End-to-End" eligibility maintenance and member reconciliation. We become the "source of truth" assuring plans of a true accounting of all member statuses and back this process up with the production of the monthly Attestation Report. Correct membership data ensures that our Health Plan clients receive 100% of the reimbursements to which they are entitled. Our highly automated and complete tracking of all TRR/MMR discrepancy codes means compliance with CMS requirements and delivers our clients a sense of control over their membership data.