Premium Billing, Eligibility, and Enrollment Platform

The vendor is required to provide premium billing, eligibility, and enrollment platform for agency covered and to support all related premium billing, enrollment (on and off exchange), eligibility, reconciliation, and member communication functions for the covered state marketplace.
- Tasks and activities
• End-to-end enrollment processing (on and off exchange)
• Eligibility ingestion via 834 files (all transaction types)
• Premium billing operations including invoicing, proration, refunds, billing rules, auto-pay, non-payment workflows, suspension, and termination
• Integration with merchant services, lockbox payments, and payment channels
• Daily cash posting and reconciliation
• Revenue reconciliation across, state subsidy, abortion credit, and member premiums
• Generation of all required covered state notices
• Loading and processing weekly reconciliation files and submitting monthly response files
• Production of go-back files per covered state data integrity process guide
• Daily outbound 834 files for confirmations and updates
• Reporting (membership, financial, operational, aging, fallout)
• System controls for unusual financial changes, job failures, and completeness checks.