Eligibility Manager has two great strengths: Its comprehensive and easy-to-use interface and its customization features.
Eligibility Manager can be customized to handle any format or custom processing needs.
Over 45 companies have benefited from Eligibility Manager to process data in over 100 formats from over 70 health plans. Our goal is to reduce time spent handling data issues and increase accuracy. Here is a sampling of the custom logic features we have provided.
IDs
- Generate member ID in Eligibility Manager
- Generate a crossover table for member id changes
- Match records by name, birth date etc. when member id has changed or is not available
- Reformat or blank out pseudo SSNs
- Copy subscriber SSN to member records (when another field links members to subscribers)
Translations
- Custom user-maintained translation tables
- Add new data automatically to custom translation tables and notify user
Miscellaneous Formatting
- Separate suffix from name (e.g. Jones Jr)
- Store street address in separate fields, or combine
- Make PCP or other assignments based on age (e.g. younger than 18, older than 65...)
Record Filtering
- IPA Splitting (by IPA Code or by PCP)
Term members from one IPA when they switch to another - Multiple records per member - select the most recent
- Suppress unwanted records (e.g. "Hold" members, certain PCPs, etc.)
Effective and Term Dates
- Use overwrite plan dates with current dates if PCP (or option) hasn't changed
- Ignore future term dates (blank them out)
- Convert term dates from 1st of month to last day of previous month
- For new members, use PCP effective date as option effective date
- Treat "Reenrolled members" like "New Members" when determining the appropriate effective dates
- Use the 1st of the current month for the option effective date when no date is supplied
- When a member is placed on Medi-Cal hold (LOB = 'L02H'), term them one day before the 'Begin Coverage Date'
COB
- Manage Coordination of Benefits fields based on various information from the health plan
- Export custom report data for various configurable conditions in a single batch
