Premium & Eligibility Reconciliation

Minimize the overpayment of premiums, administrative fees, and claims for non-eligible employees and dependents.

Carewise Premium and Eligibility Reconciliation facilitates eligibility data transfers to support complex interactions between employers and multiple carriers of group health and welfare benefits. Many employers overpay administrative fees, claims and premiums by as much as four percent each year. CareWise Health helps employers control costs, ensure operational reliability, and reduce administrative burden.

• Custom data interfaces and audits. Carewise Health builds each interface for data transmission using the carrier’s preferred format which minimizes potential conversion errors. Random audits of interfaces are performed using a set of unique transactions to validate that eligibility files were processed correctly within the carrier’s system.
• Management of carrier error reports. Each data transfer is completed with the management of carrier-reported errors to ensure data is corrected before it impacts the participant’s coverage or the employer’s financial liability.
• Eligibility and financial reconciliation. Carewise Health periodically performs a comprehensive review to identify any eligibility or other data errors in the carrier’s system. Monthly payment discrepancies reported by carriers are managed immediately to eliminate the backlog of year-end financial reconciliation.
• Online detailed remittance. All health and welfare benefits premiums are consolidated into a single invoice, made available through a secure web-based tool. The invoice includes participant-level detail of all financial transactions, including retroactive adjustments resulting from late enrollments and terminations. Employers are able to execute one monthly payment which is then distributed electronically to each carrier.

Carewise Health is provided by SHPS, Inc., a provider of integrated health solutions. SHPS has been serving large and mid-size employers, health insurance carriers, third-party administrators and government agencies for more than a dozen years. Premium and eligibility reconciliation easily integrates with Carewise eligibility and enrollment solutions.