AEP Enrollment

End-to-End Enrollment Processing for CMS & MAPD Plan Systems:



CodySoft Enroll™is an end-to-end core membership system designed for MAPD plans to process enrollment intake, validate eligibility, identify uncovered months, correspondence, Transaction Reply Reports (TRRs), and member maintenance. It provides automated processing for clean enrollment applications and identifies incomplete applications including Request for Information (RFI) tracking. It integrates seamlessly with other membership processes such as claims processing, Pharmacy Benefit Managers (PBMs), billing, and reconciliation. It is API-ready for integration with health plan systems, the Centers for Medicare & Medicaid Services (CMS), and all downstream eligibility partners. (In Development)

Enrollment Processing combines BEQ, RFI, TRR processing and Member Correspondence to systematically analyze, process, and issue correspondence.

  • Enrollment Intake options: paper, broker, plan OEC, CMS OEC (API), telephonic and optional online Enrollment web form for broker/member access
  • BEQ Logic determines beneficiary’s Medicare entitlement status
  • State Eligibility determines beneficiary’s Medicaid eligibility for DSNPs
  • Election Period Rules identify election period based on BEQ results
  • Automated Request for Information (RFI) Logic places beneficiary in RFI status, triggers correspondence, and tracks enrollment application during RFI period
  • Automated RFI Denial Process is invoked if additional information is not received

Member Maintenance combines enrollment updates such as plan changes, disenrollments, cancellations, along with demographic, special status, premium payment, and address updates.

  • Automated payment withhold options updates based on CMS Calendar
  • Generate and track CMS required member correspondence
  • 360 view provides a holistic look into member’s transactional history

LEP Management and Maintenance provides Gap Identification, Attestation Mailing, Tracking and Submission to CMS and Maintenance.

  • Automated late enrollment penalty calculation based on BEQ data
  • Uncovered months (NUNCMO) reported to CMS
  • Generate/track required member correspondence & maintain tables for appropriate billing
  • Submit “73” transactions for disenrolled members and update member data based on TRCs

Other key features and functions include:

  • High automation of Transaction Reply Code (TRC) processing
  • Plan, PCP, and Service Area Maintenance streamlines membership and Enrollment processing
  • Beneficiary Eligibility Query (BEQ) and State Eligibility integration with CMS and States to provide real-time eligibility data
  • DSNP Enrollment Logic including state eligibility verification and LIS deeming/loss process
  • Member Correspondence/Letter Management enables letters to be triggered based upon variable factors such as contract, PBP, plan type, letter type, etc.
  • Enrollment Dashboard provides insight into overall volume and plan-type.
    Tracks enrollments by application-received signature dates and CMS accretion.
  • Best Available Evidence (BAE) and Low-Income Subsidy (LIS) processing
  • Downstream Data Exchange Part C & D (PBM) claims system integration and other downstream eligibility vendors
  • Pharmacy Benefit Manager (PBM) Reconciliation
  • CMS Data Exchange option—submit to CMS or integrate with plan’s data exchange process
  • Part C & D Reporting complies with CMS Requirements