Product talk: ER&R Automation

Product talk: ER&R Automation

Issuers are continually concerned about providing exceptional service to their members. One of the major pain points in achieving this goal has been making sure adequate subsidy payments from the Centers for Medicare and Medicaid Services (CMS) are fulfilled. To alleviate it, Softheon has created an innovative reconciliation and dispute process to modernize the member experience.

What is ER&R? 

Product Owner Bret Harrison introduces Softheon’s new process, ER&R Automation (Enrollment Resolution and Reconciliation). ER&R allows issuers to dispute a discrepancy between their core system/Softheon and CMS. This procedure is handled by a 3rd party processor on behalf of CMS and can be submitted as an excel or PSV file via SFTP. Additionally, ER&R allows for enrollment data discrepancies that cannot be resolved through the automated reconciliation process to be disputed for manual intervention. For issuers, functionality has been enhanced to include additional metadata fields highlighting disputable discrepancies on all correction member details created. Furthermore, new addons were generated to identify enrollment disputes directly from the RCNO.    

How does ER&R relate to CMS Reconciliation? 

The issuers are expected to review the RCNO (CMS’s outbound reconciliation file) for data discrepancies. Bret told us “Every month CMS participates in reconciliation of enrollment data of their issuers, a standard by product of reconciliation is identifying and managing discrepancies between 2 systems.”  

He further explains how these discrepancies can be categorized in 2 ways: 

  • Data that should be updated by the issuer 
  • Data that should be updated by CMS 

Within both processes, CMS has built a dispute workflow that allows issuers to apply grievances to data discrepancies.  

How is ER&R used? 

Using specific information found on the RCNO file, issuers are expected to fill out specific tabs on the formal ER&R excel provided by CMS. Issuers can submit the file as is, or using a CMS add-on, convert the file to PSV. For Softheon’s ER&R automation, we are generating a direct PSV file. Disputes are broken into several buckets by the ER&R contractor: 

  • Discrepancy Disputes  
  • Reinstatement End Date 12/31 
  • Mailing Address
  • Agent Broker
  • Newborn Premium
  • Enrollment Blocker
  • Rejected Enrollments 

How will ER&R enhance Softheon? 

Bret explained “Our value add with this process is how it will streamline the issuers’ ability to generate and submit these disputes based on data discrepancy with the goal of creating a full match between CMS and the issuers system.” The resulted benefits are to ensure issuers can recoup from expected subsidy funds from CMS. Lastly, CMS can withhold payments for members if the data is not aligned. The innovation within ER&R includes a more robust feature for the reconciliation process that allows automation for the ease of the user. Bret also mentions how ER&R works directly with our existing secure EDI processing product, Gateway. He said, “The Gateway work stream is tasked with receiving and importing enrollment information from CMS as well as generating required transactions for reconciliation.”  

What pain points does ER&R solve? 

The implementation of ER&R dispute automation removes the burden of issuers having to manually create dispute forms. Softheon allows for bulk submissions of disputes with minimal carrier intervention, allowing for quicker and more accurate disputes to be submitted. A major concern for issuers is ensuring adequate subsidy payments from CMS. Perfecting this process allows for issuers to recover funds, allowing them to continue to provide a high level of care, leading to greater member retention.  

What occurs after the Enrollment Dispute Form is pushed to the carrier? 

Issuers are expected to review the file to ensure they agree/consent so submit disputes for these members and their addressed reasons. Files can be modified to remove rows the issuer doesn’t agree with. All files the issuer wishes to submit will be sent via the standard process, the file Is dropped on the SFTP directory, used to pull files from the issuer and submitted directly to CMS.  

To learn more about ER&R Automation or our Gateway product, please reach out 

The views and opinions expressed by the authors on this blog website and those providing comments are theirs alone, and do not reflect the opinions of Softheon. Please direct any questions or comments to  

Amanda Wolfer

Amanda is the Senior Digital Strategist at Softheon. She works closely with the Marketing team to develop and maintain Softheon’s blog and social media presence. She received her bachelor’s degree in English Language & Literature and Organizational Communication from SUNY New Paltz in New Paltz, New York.

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