Initial Dependent Audit Service Options if a service Option 1 - Initial Dependent Audit Service – One-time dependent eligibility audit service parameters (query, identify, and request confirmation) ▪ Audit Services Implementation o Identify the timeline for the audit with Customer. o Review the Customer’s Summary Plan Descriptions (SPDs) for definition of eligible dependent. o Clarify whether Verification has been performed on the dependent population within the last 12 months and whether these dependents should be included in the audit. o Work with Customer to confirm what action / disciplinary action will be levied against those who do not respond, provide incomplete / incorrect documentation, or refuse to provide verification documentation. o Recommend Customer review their Corporate Code of Conduct regarding employee fraud. o Identify parameters of the audit with the Customer (standard or optional services detailed below): • Standard: Full audit which includes all dependents on active Medical, Dental, or Vision coverage • Optional: Develop system data queries to identify incorrectly enrolled participants including: o Relationship status o Last name mismatch o Age / Date of Birth mismatch o Develop a letter-based employee communication program tailored to the Customer’s needs and corporate culture: • Amnesty Letter – Serves to announce the audit to the employee population, educate the employees on who is eligible, and allow employees to drop ineligibles without penalty or questions asked. • Initial Verification Letter – The letter will list the dependents being verified and will request confirmation of dependent status and employee signature. • Resubmit Letter – This notifies members when inadequate information has been received. • Follow-up Letter – Notifies non-responders of “last chance.” • Confirmation – This is sent when all requirements are received or at the end of the audit once final action is taken and dependent(s) verified dates are displayed. • Appeal Form – Loaded to reference center and outlines their appeal process. o Establish receipt and electronic image capture and storage processes for verification documentation evidencing compliance with SPD eligibility requirements and HIPAA. o Establish Service Center processes to support employees and resolve questions throughout the audit process utilizing inbound and outbound Service Center support and secure web-based solutions. o Establish processes to review the exceptions (i.e., dependents who fail the audit). o Identify Custome...
