Problem Statement

A health plan should pay only when it's the responsible payer, and only after any primary payer has met its obligation. Keeping that straight depends on accurate coordination-of-benefits data — who's primary, what's active, and through what dates — but that information constantly drifts as members gain, lose, and change coverage. Reconciling it manually against payer reports and member records is slow and error-prone, and when COB data is wrong the plan pays as primary when it shouldn't, misses recoverable dollars, or denies claims it actually owes. CMS's MARx system is the system of record for Medicare Advantage and Part D enrollment, so the plan's own member data has to agree with it. Each member's insurer, policy, and effective and termination dates in Facets have to be compared against the MARx report, with mismatches flagged for review and member letters generated where required. Reconciling this manually across the membership is repetitive and error-prone, and undetected mismatches put enrollment accuracy and payment at risk.

Automation Solution

This automation compares member insurer, policy, and effective and termination data in Facets against the MARx report, flags mismatches for review, and generates auto-letters as needed.