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2 Enrollment Resolution

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2 Enrollment Resolution

  1. 1. © FIRSTSOURCE 2022 | CONFIDENTIAL I 8 December 2022 | 1 Enrollment Resolution & Reconciliation (ER&R) Form Automation Client Objectives • The health plan submits ER&R (Enrollment Resolution & Reconciliation) form to CMS to resolve any disputes in enrollment data between the issuer and CMS. • Client was struggling with several errors in the ER&R forms submitted to CMS, especially in the formatting, which significantly impacted CMS acceptance percentage. • Caused extensive payment delays from CMS to the payer and resulted in significant manual rework. Firstsource Solution • Firstsource process excellence experts studied the samples to understand the area of failure • Identified the root causes of formatting issues which were due to manual consolidation done by the supervisors post receiving inputs from the examiners • Built ER&R application which was integrated with the TM (inventory) tool • The tool was equipped with logic pertaining to each submission category and an auto consolidation feature which completely eradicated the manual intervention that was causing an incorrect submission Business Outcomes • 100% of the ER&R volume processed using the automation tool • Improvement in CMS acceptance rate from 39% to 99% within two months • Reduced rework • Quick resolution of CMS disputes and release of pending payments to the client A Fortune 500 company that provides managed health care services under the Medicaid and Medicare programs 100% ER&R volume processed using automation tool $

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