The Billing & Administration System is a HIPAA compliant comprehensive solution that provides either an independent, stand-alone system or to work as a component of  a fully integrated Health Care Benefits Administration system.

The system handles many types of insurance billing - including..

Eligibility and premium information is generated in report and electronic format for transmission to third-party insurers.

 

Members Enrollment

The Members component maintains benefit and eligibility information by employer groups, subgroups, locations, and classes. It assigns a unique identification number to the responsible party as well as each of the defined dependents. The system has the ability to identify or access a member’s file by member name, dependent name, AKA, member SSN, dependent SSN, or an alternate ID assigned to either the member or dependent.

Some of the confidential and coverage information that is stored in the database includes: social security number of both the insured and the dependents, dates of birth, address, home and business phones, gender, and employment information. The family register is maintained for all dependents and eligibility is automatically terminated based on user defined age restrictions. Events such as marriages, divorces, adoptions, and student enrollment dates which affect eligibility are tracked by the system and automatically update eligibility to reflect dependent effective or termination dates.

Member elections define the election period, insurance plan, coverage category, and plan options such as dollar volume, salary bracket, smoking/non-smoking, etc.

Since all of the election parameters are user defined, each system can be customized to meet an organization’s specific needs.

Employer Groups

Employer groups can be maintained at different levels allowing flexibility in billing and reporting.  Employers can be divided into divisions or subgroups, each of which can be associated with a legal entity or business segment.   Divisions can be further separated into locations, which allow options for plan election and premiums.  Policies are created for each billing unit and can be related to the employer, division or location.  Each policy defines the statement format to use and the sequencing and totaling of the statement roster.

Policyholders are billing entities that may be employer groups, individual members, or COBRA participants.  Statements are calculated automatically based on the member, employer, division, location, and rate tables.  Rates can be prorated down to a quarter of a month and all retroactive adjustments based on changes in enrollment are automatically calculated and billed.

Premiums & Statements

Premium schemes are defined by employer group and each scheme directs the billing module to a specific premium table. Premium tables are date effective and premium amounts are defined by coverage and type of eligibility. Under each premium table is an additional table that further breaks down the premium amounts into user defined charge codes,  amounts, and underwriters for reporting and allocation.

The system accommodates monthly, quarterly and annual billing periods. Statements can be generated by policyholder upon request or by a predefined billing cycle.  The first page of the statement lists the balance forward, all payments and other transactions since the last statement, a total of retroactive and current billing, and any add-on administration fees.  This page is designed to be returned with the payment.  The roster portion of the statement first lists all retroactive adjustments by subscriber and covered period and then lists all covered subscribers for the current covered period.

 

 

Accounts Receivable

When a statement is produced, an open invoice is created in accounts receivable and any unapplied credits are posted to the invoice.

The accounts receivable component provides the ability to track and age open invoices, balance and apply payments, issue adjustments and write-offs, and create bulk invoices for new policyholders. 

Payments are batch entered or imported from a bank, lockbox, or credit card file where they are balanced and posted.  Payments automatically post to the oldest open invoice first and receivable inquiry allows on-line viewing of invoices, payments, adjustments, charges, and details of posting.

The system provides collection tools including a delinquency report, delinquency notices, and a receivables aging report by policyholder.  Holds can be placed on or removed from any policy that becomes delinquent.  A hold ends all members’ eligibility under that policy effective the day of the hold and can also prevent further billing of the policy.

 

Eligibility

EnCore provides control of eligibility status by active members until they are terminated by subscriber, employer group or by administrative hold.  In addition, the system can advance the eligibility date based on billing or payments received.

When payments and/or adjustments are applied to an invoice, the premiums are automatically distributed to the member billing records. Prior to updating eligibility, either current or retroactive changes can be made through enrollment including the addition of new members, termination of members, and changes to benefit coverage.  Eligibility is updated to reflect the paid benefit coverage and any changes made are reflected on the subsequent billing. 

 

Commissions

Commissions can be calculated and paid to agents, brokers and direct sales representatives.  Commissions schedules are calculated using straight percentages, or multi-tiered plans can be created with graded percentages and cutoff levels.

Commissions can be based on billed premiums or payments received.  Upon calculation, commission records are created and can be reviewed and adjusted prior to payment.  An on-line commission history is available for commission questions and sales planning. 

 

COBRA

 

COBRA administration capabilities are part of the Administration package. In addition to the standard data stored for each member, the system tracks all events which can affect COBRA eligibility for members and their dependents.  Notification letters are automatically produced for COBRA candidates and show the type of coverage available, the eligibility period, premiums for the coverage, payment requirements and options, and an election form to be returned with the first payment.  Notification letters for COBRA termination are also produced along with various COBRA reports.

 

 

Reporting

 

A variety of reports are routinely produced and can be run for any time interval.  In addition, the system produces member ID cards, PC export files, and labels for subscribers, members, employers, policyholders, brokers and agents.  For more on reporting, see EnCore Reporting.