A Comprehensive Membership Management System
A member’s Medicare eligibility is verified using the Centers for Medicare and Medicaid (CMS) Medicare Beneficiary Database (MBD) as applications are entered either by batch or online. During the verification process, CMS member-specific data such as ESRD, Medicare eligibility dates, LIS, and LIC are automatically added to Member360.
Wipro's solution produces high acceptance rates by validating enrollment transactions for eligibility, format, and avoidable TRR errors prior to submission to CMS. On the basis of membership change triggers, Member360 sends CMS transactions automatically and also captures, stores, and processes CMS TRR and MMR transaction data.
Member360 maintains a complete history of member activity including: eligibility, CMS transactions, correspondence, and billing transactions. Standard work queues allow enrollment, finance, and customer service staff to efficiently research issues and answer questions related to an individual member or a group of members.
As membership changes occur, Member360 automatically ensures correct transaction types are transmitted to CMS. Standard membership extracts are sent to the client's claims, PBM, and fulfillment vendors. Multiple summary and detail reports describing membership are available as part of the standard offering, as well as instant ad hoc reports through the online interface.
Member360 Transaction Reply Report (TRR) processing includes:
The Member360 billing subsystem is a feature-rich design that enables you to manage your billing cycles for Employer Groups and members. Split billing is used to manage CMS balances independently from member balances. CMS subsidy, LEP, and SSA payments are automatically applied at the member level, including CMS negative payment processing.
Billing processing includes:
Member360 allows for correspondence management through both automatic and manual processes.
CMS Model Letters for MA, MAPD or PDP can be created in English and Spanish, and can be customized to include logos, plan IDs, signatures and special footers.
Letters comply with CMS requirements and client business rules, and can be auto-generated based upon member workflow status or TRC codes. Generated letters can be viewed prior to submission to print. For audit purposes, Member360 can easily track and retain all correspondence.
Wipro's Appeals & Grievances is a standalone system that can be bundled with Member360 or used by itself to comprehensively manage appeals, grievances and complaint processes.
Key features of this system include management and supervisor aging dashboards, ad hoc queries, letter generation, email assignments, and the management of document attachments and case files.
A&G360 includes:
