High Level Overview Normal Work Flow

The purpose of the benefits application is allowing the auditing of insurance plans to make sure they have been setup correctly.

Relevant RoleTypes:

Gate Keeper
Quality Reviewer
Business Owner
Business Owner Manager
SME

Intake Form Creation

The audit begins with an intake form. This form is used to provide necessary information that will be used during the auditing. There are multiple forms with different fields depending on the type of audit that needs to be performed, which is defined by the Sample. These forms can be created by a Gate Keeper. Once they have filled out the intake form they can release the intake form. This will mark the intake form as ready to be picked up/worked on by a Quality Reviewer.

[For more information see Intake Form]

Checklist Setup

Once an intake form is released, the Quality Reviewer can pick it up. There are a variety of rules that determine which intake forms a certain QR can grab. (See Sample Documentation for more information). The QR then selects the checklist/sections that will be use to determine errors with the way the benefits were set up for the account specified from the intake form. These checklists are at the Account Level and/or Plan Level. The QR will select the section of the checklists that are relevant for the given audit. Once they are done, the audit moves to QR Review.

[For more information see Checklist Setup]

QR Review

The QR then audits the fieldlists from the section lists selected in the previous step. They specify whether each field meets the criteria or if there are any errors with it. If there are any errors, the audit is sent to BO Review. Otherwise, the audit can be closed and finalized as it has no error.

[For more information see QR Review]

BO Review

A Business Owner is always assigned to an audit. It is either the BO that created the intake form initially or the BO that the QM specifies when creating the intake form. This BO will review any audits with errors from the QR Review. They will inspect each error and determine whether the error was correctly assessed or not. (agree or disagree). Once they have inspected every error, the audit will be sent back to the QR for their review.

[For more information see BO Review]

QR Recheck

This step is where the QR will look at the BO's responses and decide how to proceed. For each error they can Uphold, Resolve, or Remove. Uphold means the QR thinks the original error is still correct and wants further information from the BO. Resolve means that the QR is saying that they believe it's an error and will close the error without any more input from a BO. Removed means that the error will be removed from the audit and the QR wrongly assessed the error. If all errors are Resolved or Removed, the audit can be closed and finalized. If any errors are Upheld, the audit will be sent back to the BO in BO Review, but only the Upheld audits can be responded to. This back and forth between QR and BO can continue in perpetuity until the QR Resolves or Removes all the errors.

[For more information see QR Recheck]

SME Rebuttal

This is a process in which a BO can re-open a closed audit. This will happen if the BO believes a Resolved error should not be resolved, but instead removed. The BO will select the error for rebuttal and request a Business Manager to re-open the audit. If the BM approves the audit, it will be sent to the SME who will have final say on whether to Remove or Resolve the error. If the BM disapproves the re-opening of the audit, the audit will stay closed. This process can only happen 3 days after an audit is closed. Otherwise a QM must manually allow the audit to be re-opened.

[For more information see SME Rebuttal]