HR-XML 3.0 Standards, 2009 September 23.
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This document outlines a set of messages that employee benefit record keepers and health plans implementing HR-XML’s Benefits Enrollment specification may find useful in conducting periodic audits. As a "Technical Note," these messages are not a normative part of the HR-XML library. The message set is offered as merely guidance. Please see the separate documentation for information on the U.S. Enrollment specification.
In the U.S. market for employee benefit services, many employers use a benefit administrator or record keeper in addition to one or more employee health plans (an insurance carrier, health maintenance organization, etc.). The benefit administrator typically is the "source of truth" for determinations of who is currently eligible to participate in a health plan (typically employees and their dependents and/or retirees and their dependents). The health plan, in turn, is responsible for making determinations of whether claimants are eligible for reimbursement or services under the plan. These two types of 'eligibility' determinations are separate and distinct, but depend on accurate information being shared between the benefit record keeper and the health plan. While a variety of means are employed to ensure data integrity, periodic audits (e.g., monthly or quarterly) are a common way to maintain data accuracy.
The way audits commonly work is for the plan record keeper to send a complete record to the health plan for each 'contract' (a subscriber, such as an employee, or dependent of such subscriber). The health plan then compares each record against the information in its system and returns information to the record keeper about results. Broadly speaking, two outcomes are possible from such a comparison:
- Match
A match indicates that the information on the record keeper’s system is consistent with what is on the health plan’s system.
- Mismatch
A mismatch indicates that there is a 'material' difference between the information on record keeper’s system compared to that on the health plan’s system. What constitutes a “material” difference would generally be defined by the trading-partner agreement. A “no match” means that a record for an individual subscriber or dependent is on one system, but not the other system.
As mentioned above, audits typically are "full-file" comparisons of the records from one system against another. The most common way to accomplish this might be through use of the SyncUSEnrollment BOD. The message sets below include explanations and recommended "actions" in response. Note that the action descriptions are intended as a general description of the business action that needs to be accomplished. These descriptions are not specific data management instructions with respect to using HR-XML BODs.