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Eligibility Management

Effective payer processes rely on accurate eligibility data

Eligibility data is at the heart of many payer processes, from enrollment to coordination of benefits and claims payment.  So when eligibility data is incomplete or inaccurate, it causes significant downstream headaches, including inefficiencies and excess costs due to confusion over primary health plan COB payments.

Healthcare organizations are under more market pressure and regulatory scrutiny than ever. To remain competitive and responsive to regulatory demands, payers must manage critical eligibility data more strategically across their enterprise. A single, accurate, updated source of eligibility data means better claims management, improved reporting and compliance, and increased efficiency across the claims process.

Proactively manage eligibility data to improve the bottom line

Ajilitee’s Eligibility Data Management Services are designed to deliver more accurate, current and consistent member eligibility data to fuel processes across the payer environment. Our offerings include a variety of strategy services and workshops that help payers overcome challenges involved with data integration, governance, enterprise information management, and eligibility analytics. Ajilitee provides in depth services that help payers plan, architect and develop the following eligibility data management solutions:

  • Integrate, cleanse and transform disparate eligibility data in a centralized, transactional repository that allows effective eligibility information management and automated interfaces with other systems (claims payment, eligibility reporting, etc.)
  • Build an enterprise Eligibility Reporting and Analytics Hub that will focus on providing required reporting and insights to action
  • Assist with eligibility data governance that will institute policies for guiding the use of member data, establish decision rules, document member data definitions and processes and assign data stewards to manage data quality, availability, archive and access control

When payers are able to integrate eligibility-related data across all sources, including provider files, enrollment systems, electronic health records, and a number of other sources, the result is a single, comprehensive source of eligibility data that feeds downstream claims processes. They pay the right claims accurately and promptly; spend less time verifying claims and responding to ad hoc member inquiries; and experience higher adjudication rates.

Get your eligibility data management solution to market faster with our healthcare-focused accelerators

A collection of business and technology accelerators leverage the experience across our healthcare client network to greatly improve speed to market and reduce overall project risk.

  • Business requirements and key performance indicators: Get to your implementation faster by starting with base level requirements captured and refined from across our healthcare client work. We’ll help you tailor them to meet your specific business needs.
  • Data quality framework: Apply a consistent, objective approach to eligibility data quality, using our comprehensive approach, which includes data governance/data stewardship, data integration, master data management, and metadata management.
  • Reference architecture and data models: Our predefined models give you a starting point that you can tailor for your eligibility data environment and business needs. They promote speed to market, reusability, consistency, standards, architectural governance, reduced cost of ownership, and a single version of the truth.
  • Data governance framework: Use our framework to help define how your organization will manage the collection, availability, integrity, use, and security of eligibility data across entities. Our framework provides you with templates for your mission statement, policy creation, and process flow; defines suggested roles and responsibilities; and outlines workflows, data flows, pain points, and much more.

Business value of a strong eligibility data foundation

Reduce expenses: Identify ineligible dependents, improve payment recoveries, reduce costs associated with overpayments, improve IT efficiency, enable comprehensive, automated self-service
Avoid costs: Avoid regulatory noncompliance costs, avoid future redundant data and systems, avoid costs associated with overpayments
Increase revenue: Protect revenue against premium adjustments based on erroneous information
Enhance member and provider interaction: Improve member and provider communications, improve complaint resolution, and reduce transfers
Raise barriers for competitors: Raise service experience expectations, optimize enrollment accuracy and loss ratios, increase member service effectiveness
Improve management: Improve quality of decision data, improve speed of access to decision data



Inc 5000 2014 LaunchPoint 100

Inc. magazine has ranked LaunchPoint, parent company of Ajilitee, #100 in its 2014 Inc. 5000 list of fastest-growing privately held companies in the U.S.