Are Your Systems Ready to Properly Process the CMS Annual Coordination of Benefits-Other Health Insurance (COB-OHI) Files?

The CMS Annual COB-OHI process is quickly approaching, and health plans must be prepared to complete mandatory processes to remain compliant. The Centers for Medicare and Medicaid Services (CMS) play a crucial role in ensuring efficient coordination of benefits for individuals with Medicare coverage. The CMS COB-OHI File is an essential resource that facilitates seamless…

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2024 Oversight Activities – Utilization Management Changes

CMS notified Medicare Advantage Organizations (MAOs) on October 24, 2023, that it will be conducting strategic conversations on the new Utilization Management (UM) requirements effective January 1, 2024. Following these conversations, CMS will start conducting routine and focused audits of the new prior authorization and related rules published in April of this year in the…

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2024 AEP – Now is the Time to Prepare!

It may seem early to start preparing for the 2024 Annual Enrollment Period (AEP), but after the Memorial Day holiday, the season comes quickly. Now is the time to prepare by—identifying your resource needs, updating your training programs, and planning for system changes. Don’t wait until July to start these activities; begin now to ensure…

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Medicare Secondary Payer (MSP) Processing—What’s Your Revenue Recovery Potential?

Medicare Secondary Payer (MSP) is generally used when another entity is responsible for paying before Medicare. The MSP regulations were put in place to protect Medicare Trust Funds by preventing Medicare funds from being used to pay for items and services that other health insurers are primarily responsible for paying. Primary payers essentially have the…

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End-of-Year 2022 Enrollment and Payment Systems Processing—What You Need to Know

As the CMS Annual Rollover process quickly approaches, health plans must prepare to complete critical End-of-Year (EOY) tasks. Now’s the time to ask—Are your systems configured to process rollover files seamlessly? Does your staff know how to process transactions requiring manual intervention? Any mishaps during this process will create a negative member experience regarding access…

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AEP 2023—Essential Readiness Tips & the Latest CMS Guidance

Medicare Advantage Annual Enrollment Period (AEP) runs from October 15 to December 7. Since most health plans recognize growth this time of year, it is imperative to be prepared to enroll members seamlessly and accurately. Are your systems configured with the latest guidance from CMS? Has your staffing and training efforts increased to ensure work…

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Why Consolidating COB & MSP Data Collections Are Crucial for Health Plan Revenue Recovery & Compliance

The Centers for Medicare and Medicaid Services (CMS) requires MA and PDP health plans to update systems timely and accurately. Consolidating and analyzing COB & MSP data collections while maximizing recovery options and complying with CMS regulations is a challenging task. Incorrect data sets can easily contribute to non-compliance and lead to inaccurate claims payments,…

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AEP Enrollment Processing Tips—Do’s & Don’ts from End-to-End (E2E)

How well your organization handles a new enrollment during the Annual Enrollment Period (AEP) generally sets the tone for the upcoming contract year for you and your new member. Beginning with Sales and flowing to Enrollment Operations—it’s critical to understand specific actions that trigger reconciliation challenges and member abrasion. With CMS shifting the weight of…

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