For each month of coverage, Cap Check calculates the expected payment for each active member. Expected payments are calculated based on contract data configured in Cap Check. This is compared with the payment data from the health plan.
The following is a brief description of the standard process of using Cap Check to monitor cap payments.
Import Eligibility Data
You will have the following options for accessing eligibility data:
- Import fixed-width or delimited text files using mappings that you create.
- Import from an external database.
The configuration screens allow for a lot of flexibility in selecting data sources, configuring data and filtering data.
You can specify up to ten custom eligibility fields.
Import Cap Data
Import cap data from fixed-width or delimited files using mappings that you create.
The following fields will be supported for standard importing:
| Member ID | Last Name | Coverage Data |
| Subscriber | First Name | Member Months |
| SSN | Birth Date | Cap Amount |
| Member SSN | Sex | Copay |
You can specify up to ten custom cap data fields.
Generate Expected Cap Payments
Calculations are totally configurable for each health plan contract. You simply create one record for each step of the calculation. The steps can include simple formulas, data lookups, one of the built-in calculation steps, or a custom-built calculation.
Cap Check will calculate the expected cap amount for each member before reconciling with the plan's cap payment data.
Auto-reconcile
Cap Check groups all unclosed records (no matter when they were loaded) by member id and coverage date. The records for each member in each month are compared. The following groups of records are closed:
- two cap records cancel each other (positive and negative)
- two eligibility records cancel each other (positive and negative)
- a cap record and an eligibility record have matching amounts
- the remaining cap and eligibility records total to the expected payment
After reconciling, unclosed records (exceptions) are classed as follows:
- Member is in the cap data, but not the eligibility data (C)
- Member is in the eligibility data, but not the cap data (E)
- Cap rate data from cap and eligibility files does not match (- or +)
Retro reconciliation
If a payment was missing one month, but the plan makes the payment the following month, this will reconcile using the normal process. The eligibility record loaded in the previous month will reconcile with the late payment record. This will also occur for retroactive subtractions, and retroactive adds and terminations on the eligibility side.
Audit
The Audit screen displays selected data in a simple tabular format. Filtering and sorting is very easy using the Quick Filter, Quick Sort, and Audit Select tools. Exception data can be easily exported for additional analysis.
The layout of the Audit screen is fully configurable. The order and width of columns is saved for each health plan.
Click here to see a sample of the Cap Check Reconcile and Audit tools.
Reports
Several built in reports display exception and payment data by health plan and member month. The standard reports allow you to select data by any filter that you create. You can also export the report data in Excel or text format.
Multiple Contracts
You can configure Cap Check to handle any number of entities and payers. Data for each combination of entity and health plan is kept separate for reconciling and reporting.
You can manage multiple IPAs and health plans at no extra cost.
Customization
Users define the field mappings for importing eligibility and cap data. You can also select standard and custom conversions for dealing with date and currency formats, and other needs.
Cap Check has structures that allow for custom processes to handle special processing needs. Such logic will be to user specifications and be billed an hourly rate.
