# Account member setup and maintenance

*/Processes/Account_member_setup_and_maintenance*

## Process Profile

**Outcome**: Member records are accurately established and maintained in the core system to support benefit eligibility and claims processing.
**Trigger**: Receipt of new member enrollment files, qualifying life event notices, or demographic update requests.
**Key Steps**:
- Ingest member enrollment and update files
- Validate demographic data and verify account eligibility rules
- Route data exceptions for manual review and resolution
- Establish or update member profiles in the core administration platform
- Trigger generation of member ID cards and welcome materials
- Execute ongoing member maintenance for qualifying life events
**Measured By**:
- [Enrollment Cycle Time](/Metrics/Enrollment_Cycle_Time)
- [Member Data Accuracy Rate](/Metrics/Member_Data_Accuracy_Rate)
- [Auto-Enrollment Success Rate](/Metrics/Auto-Enrollment_Success_Rate)
- [ID Card Turnaround Time](/Metrics/ID_Card_Turnaround_Time)

## Boundary Of Firm

**Outsourced To**:
- [Business Process Outsourcing Provider](/CompanyTypes/Business_Process_Outsourcing_Provider)
- [Membership Administration Service](/CompanyTypes/Membership_Administration_Service)
**Automatability**: augmented
**Routing Summary**:
- Record creation, profile updates, and routine maintenance are automated through a membership management system.
- High-volume enrollment and call handling are outsourced to a business process outsourcing provider.
- Identity verification exceptions and eligibility judgment are kept in-house by member services staff.
**Delivered By Role**:
- [Member Services Representative](/Processes/Account_member_setup_and_maintenance/JobTypes/Member_Services_Representative)
- [Account Administrator](/Processes/Account_member_setup_and_maintenance/JobTypes/Account_Administrator)
**Asset Specificity**: mixed
**Automated By Action**:
- [Create Member Record](/Action/Create_Member_Record)
- [Verify Member Identity](/Action/Verify_Member_Identity)
- [Update Member Profile](/Action/Update_Member_Profile)
**Automated By Software**:
- [Membership Management System](/Software/Membership_Management_System)
- [Customer Relationship Management System](/Software/Customer_Relationship_Management_System)
**Delivered By Department**:
- [Member Services](/Processes/Account_member_setup_and_maintenance/Departments/Member_Services)
- [Operations](/Processes/Account_member_setup_and_maintenance/Departments/Operations)

## Neighborhood

### Parent

- [Direct Health and Medical Insurance Carriers](/Industries/Direct_Health_and_Medical_Insurance_Carriers) — parent · Industries

### Siblings

- [Develop and validate new medical technologies](/Processes/Develop_and_validate_new_medical_technologies) — siblings · Processes
- [Research/Resolve payables exceptions](/Processes/Research%2FResolve_payables_exceptions) — siblings · Processes
- [Manage distribution channels](/Processes/Manage_distribution_channels) — siblings · Processes
- [Manage channel partner master data](/Processes/Manage_channel_partner_master_data) — siblings · Processes
- [Identify research collateral, market trends, and technical capabilities](/Processes/Identify_research_collateral,_market_trends,_and_technical_capabilities) — siblings · Processes
- [Design brochures/collateral](/Processes/Design_brochures%2Fcollateral) — siblings · Processes
- [Perform broker channel management](/Processes/Perform_broker_channel_management) — siblings · Processes
- [Profile brokers and agents](/Processes/Profile_brokers_and_agents) — siblings · Processes
- [Contract with brokers and agents](/Processes/Contract_with_brokers_and_agents) — siblings · Processes
- [Manage sales collateral](/Processes/Manage_sales_collateral) — siblings · Processes
- [Manage proposal templates](/Processes/Manage_proposal_templates) — siblings · Processes
- [Analyze purchasing behavior](/Processes/Analyze_purchasing_behavior) — siblings · Processes
- [Analyze customer campaigns](/Processes/Analyze_customer_campaigns) — siblings · Processes
- [Analyze customer market research](/Processes/Analyze_customer_market_research) — siblings · Processes
- [Manage Campaigns](/Processes/Manage_Campaigns) — siblings · Processes
- [Premium payment profile administration](/Processes/Premium_payment_profile_administration) — siblings · Processes
- [Conduct direct sales to groups](/Processes/Conduct_direct_sales_to_groups) — siblings · Processes
- [Produce proposal](/Processes/Produce_proposal) — siblings · Processes
- [Produce renewals](/Processes/Produce_renewals) — siblings · Processes
- [Enroll and onboard membership](/Processes/Enroll_and_onboard_membership) — siblings · Processes
- [Validate members](/Processes/Validate_members) — siblings · Processes
- [Conduct CMS authorization](/Processes/Conduct_CMS_authorization) — siblings · Processes
- [Verify member information](/Processes/Verify_member_information) — siblings · Processes
- [Determine enrollment eligibility](/Processes/Determine_enrollment_eligibility) — siblings · Processes
- [Profile members](/Processes/Profile_members) — siblings · Processes
- [Create and/or modify manage member identifier number](/Processes/Create_and%2For_modify_manage_member_identifier_number) — siblings · Processes
- [Input or update member demographics](/Processes/Input_or_update_member_demographics) — siblings · Processes
- [Input or update confidential communication profile](/Processes/Input_or_update_confidential_communication_profile) — siblings · Processes
- [Input or update ember provider panel/PCP](/Processes/Input_or_update_ember_provider_panel%2FPCP) — siblings · Processes
- [Manage coverage enrollments](/Processes/Manage_coverage_enrollments) — siblings · Processes
- [Collect associate member healthcare information](/Processes/Collect_associate_member_healthcare_information) — siblings · Processes
- [Coordinate benefits](/Processes/Coordinate_benefits) — siblings · Processes
- [Conduct fulfillment administration](/Processes/Conduct_fulfillment_administration) — siblings · Processes
- [Specify appropriate member welcome Letters](/Processes/Specify_appropriate_member_welcome_Letters) — siblings · Processes
- [Specify ID Card Template](/Processes/Specify_ID_Card_Template) — siblings · Processes
- [Specify Benefit Booklet](/Processes/Specify_Benefit_Booklet) — siblings · Processes
- [Install and maintain account/case](/Processes/Install_and_maintain_account%2Fcase) — siblings · Processes
- [Set up account structure and maintenance](/Processes/Set_up_account_structure_and_maintenance) — siblings · Processes
- [Manage group demographics](/Processes/Manage_group_demographics) — siblings · Processes
- [Manage group contacts](/Processes/Manage_group_contacts) — siblings · Processes
- [Verify group information](/Processes/Verify_group_information) — siblings · Processes
- [Verify group participation requirements](/Processes/Verify_group_participation_requirements) — siblings · Processes
- [Manage rate schedules](/Processes/Manage_rate_schedules) — siblings · Processes
- [Perform policy renewal and maintenance](/Processes/Perform_policy_renewal_and_maintenance) — siblings · Processes
- [Generate pre-renewal material (advance notice of change)](/Processes/Generate_pre-renewal_material_(advance_notice_of_change)) — siblings · Processes
- [Conduct early renewal process](/Processes/Conduct_early_renewal_process) — siblings · Processes
- [Conduct annual renewal process](/Processes/Conduct_annual_renewal_process) — siblings · Processes
- [Conduct late renewal process](/Processes/Conduct_late_renewal_process) — siblings · Processes
- [Manage health care delivery](/Processes/Manage_health_care_delivery) — siblings · Processes
- [Generate medical informatics](/Processes/Generate_medical_informatics) — siblings · Processes
- [Perform existing network analysis](/Processes/Perform_existing_network_analysis) — siblings · Processes
- [Perform gap in care analysis](/Processes/Perform_gap_in_care_analysis) — siblings · Processes
- [Perform service and procedure analysis](/Processes/Perform_service_and_procedure_analysis) — siblings · Processes
- [Perform health program management](/Processes/Perform_health_program_management) — siblings · Processes
- [Manage health programs](/Processes/Manage_health_programs) — siblings · Processes
- [Develop health management programs](/Processes/Develop_health_management_programs) — siblings · Processes
- [Manage health program enrollment](/Processes/Manage_health_program_enrollment) — siblings · Processes
- [Perform health program analytics](/Processes/Perform_health_program_analytics) — siblings · Processes
- [Deliver health programs](/Processes/Deliver_health_programs) — siblings · Processes
- [Perform medical policy management](/Processes/Perform_medical_policy_management) — siblings · Processes
- [Develop medical policy rules](/Processes/Develop_medical_policy_rules) — siblings · Processes
- [Monitor medical policy](/Processes/Monitor_medical_policy) — siblings · Processes
- [Review medical policy appeal](/Processes/Review_medical_policy_appeal) — siblings · Processes
- [Perform utilization management](/Processes/Perform_utilization_management) — siblings · Processes
- [Manage prior-authorizations/pre-certify](/Processes/Manage_prior-authorizations%2Fpre-certify) — siblings · Processes
- [Manage provider referral](/Processes/Manage_provider_referral) — siblings · Processes
- [Enforce medical policy](/Processes/Enforce_medical_policy) — siblings · Processes
- [Support healthcare management](/Processes/Support_healthcare_management) — siblings · Processes
- [Develop healthcare management policy, planning, and strategy](/Processes/Develop_healthcare_management_policy,_planning,_and_strategy) — siblings · Processes
- [Develop and maintain contracting and reimbursement policies](/Processes/Develop_and_maintain_contracting_and_reimbursement_policies) — siblings · Processes
- [Develop and maintain medical policies](/Processes/Develop_and_maintain_medical_policies) — siblings · Processes
- [Develop and maintain network strategy and plan](/Processes/Develop_and_maintain_network_strategy_and_plan) — siblings · Processes
- [Develop contracting standards](/Processes/Develop_contracting_standards) — siblings · Processes
- [Manage contract templates](/Processes/Manage_contract_templates) — siblings · Processes
- [Build and maintain standard fee schedules](/Processes/Build_and_maintain_standard_fee_schedules) — siblings · Processes
- [Manage provider rate sheets](/Processes/Manage_provider_rate_sheets) — siblings · Processes
- [Develop and manage the network](/Processes/Develop_and_manage_the_network) — siblings · Processes
- [Identify and recruit providers](/Processes/Identify_and_recruit_providers) — siblings · Processes
- [Credential and re-credential providers](/Processes/Credential_and_re-credential_providers) — siblings · Processes
- [Negotiate and contract with providers](/Processes/Negotiate_and_contract_with_providers) — siblings · Processes
- [Profile providers](/Processes/Profile_providers) — siblings · Processes
- [Manage provider practice/group arrangements](/Processes/Manage_provider_practice%2Fgroup_arrangements) — siblings · Processes
- [Assemble provider market intelligence](/Processes/Assemble_provider_market_intelligence) — siblings · Processes
- [Assemble provider performance indicators](/Processes/Assemble_provider_performance_indicators) — siblings · Processes
- [Manage and monitor providers](/Processes/Manage_and_monitor_providers) — siblings · Processes
- [Manage revenue cycle](/Processes/Manage_revenue_cycle) — siblings · Processes
- [Develop provider communications](/Processes/Develop_provider_communications) — siblings · Processes
- [Educate and train providers](/Processes/Educate_and_train_providers) — siblings · Processes
- [Maintain provider data and directories](/Processes/Maintain_provider_data_and_directories) — siblings · Processes
- [Manage quality and performance of the network management process](/Processes/Manage_quality_and_performance_of_the_network_management_process) — siblings · Processes
- [Manage ancillary services](/Processes/Manage_ancillary_services) — siblings · Processes
- [Manage lab services](/Processes/Manage_lab_services) — siblings · Processes
- [Manage other ancillary services](/Processes/Manage_other_ancillary_services) — siblings · Processes
- [Perform pre-pay provider reimbursement](/Processes/Perform_pre-pay_provider_reimbursement) — siblings · Processes
- [Process encounter information](/Processes/Process_encounter_information) — siblings · Processes
- [Process capitation reimbursement](/Processes/Process_capitation_reimbursement) — siblings · Processes
- [Process and reconcile specialized reimbursements](/Processes/Process_and_reconcile_specialized_reimbursements) — siblings · Processes
- [Perform medical management](/Processes/Perform_medical_management) — siblings · Processes
- [Conduct utilization management](/Processes/Conduct_utilization_management) — siblings · Processes
- [Perform case management and disease management with members](/Processes/Perform_case_management_and_disease_management_with_members) — siblings · Processes
- [Perform referral management for members](/Processes/Perform_referral_management_for_members) — siblings · Processes
- [Promote wellness and patient education](/Processes/Promote_wellness_and_patient_education) — siblings · Processes
- [Manage service provider relationships](/Processes/Manage_service_provider_relationships) — siblings · Processes
- [Manage provider relationships and loyalty](/Processes/Manage_provider_relationships_and_loyalty) — siblings · Processes
- [Manage provider inquiry intake](/Processes/Manage_provider_inquiry_intake) — siblings · Processes
- [Perform provider research and resolve inquiries](/Processes/Perform_provider_research_and_resolve_inquiries) — siblings · Processes
- [Provide orientation, education, and feedback to providers](/Processes/Provide_orientation,_education,_and_feedback_to_providers) — siblings · Processes
- [Conduct provider performance management](/Processes/Conduct_provider_performance_management) — siblings · Processes
- [Coach and train providers](/Processes/Coach_and_train_providers) — siblings · Processes
- [Terminate Provider contracts](/Processes/Terminate_Provider_contracts) — siblings · Processes
- [Manage Provider service quality](/Processes/Manage_Provider_service_quality) — siblings · Processes
- [Communicate with providers](/Processes/Communicate_with_providers) — siblings · Processes
- [Manage provider communication campaigns](/Processes/Manage_provider_communication_campaigns) — siblings · Processes
- [Manage provider requests](/Processes/Manage_provider_requests) — siblings · Processes
- [Conduct pharmacy benefit management](/Processes/Conduct_pharmacy_benefit_management) — siblings · Processes
- [Review member drug utilization](/Processes/Review_member_drug_utilization) — siblings · Processes
- [Manage drug Formulary](/Processes/Manage_drug_Formulary) — siblings · Processes
- [Negotiate formulary rebate](/Processes/Negotiate_formulary_rebate) — siblings · Processes
- [Perform Mail order pharmacy with members](/Processes/Perform_Mail_order_pharmacy_with_members) — siblings · Processes
- [Adjudicate claims and process reimbursement](/Processes/Adjudicate_claims_and_process_reimbursement) — siblings · Processes
- [Develop claim/encounter informatics](/Processes/Develop_claim%2Fencounter_informatics) — siblings · Processes
- [Manage and report on claim processing activity](/Processes/Manage_and_report_on_claim_processing_activity) — siblings · Processes
- [Manage quality assurance and auditing procedures](/Processes/Manage_quality_assurance_and_auditing_procedures) — siblings · Processes
- [Manage critical inquiry process and appeals](/Processes/Manage_critical_inquiry_process_and_appeals) — siblings · Processes
- [Adjudicate claims](/Processes/Adjudicate_claims) — siblings · Processes
- [Determine coverage/benefits](/Processes/Determine_coverage%2Fbenefits) — siblings · Processes
- [Perform clinical editing](/Processes/Perform_clinical_editing) — siblings · Processes
- [Determine covered service](/Processes/Determine_covered_service) — siblings · Processes
- [Determine eligibility](/Processes/Determine_eligibility) — siblings · Processes
- [Process intake of claims](/Processes/Process_intake_of_claims) — siblings · Processes
- [Enter paper claims into claims system](/Processes/Enter_paper_claims_into_claims_system) — siblings · Processes
- [Enter OCR claims into claims system](/Processes/Enter_OCR_claims_into_claims_system) — siblings · Processes
- [Enter electronic claims into claims system](/Processes/Enter_electronic_claims_into_claims_system) — siblings · Processes
- [Enter interactive claims into claims system](/Processes/Enter_interactive_claims_into_claims_system) — siblings · Processes
- [Create claims imaging and record within claims system](/Processes/Create_claims_imaging_and_record_within_claims_system) — siblings · Processes
- [Assign claim control ID](/Processes/Assign_claim_control_ID) — siblings · Processes
- [Route claims for processing](/Processes/Route_claims_for_processing) — siblings · Processes
- [Conduct pre-edit claims examination](/Processes/Conduct_pre-edit_claims_examination) — siblings · Processes
- [Validate claims](/Processes/Validate_claims) — siblings · Processes
- [Perform claim policy management](/Processes/Perform_claim_policy_management) — siblings · Processes
- [Develop claim policy rules](/Processes/Develop_claim_policy_rules) — siblings · Processes
- [Monitor claim policy](/Processes/Monitor_claim_policy) — siblings · Processes
- [Review claim policy appeal](/Processes/Review_claim_policy_appeal) — siblings · Processes
- [Communicate claim outcomes](/Processes/Communicate_claim_outcomes) — siblings · Processes
- [Generate remittance advise](/Processes/Generate_remittance_advise) — siblings · Processes
- [Generate explanation of benefits](/Processes/Generate_explanation_of_benefits) — siblings · Processes
- [Perform benefits management](/Processes/Perform_benefits_management) — siblings · Processes
- [Provide benefits support](/Processes/Provide_benefits_support) — siblings · Processes
- [Provide benefits administration](/Processes/Provide_benefits_administration) — siblings · Processes
- [Prepare and process claims](/Processes/Prepare_and_process_claims) — siblings · Processes
- [Process reimbursement and notification](/Processes/Process_reimbursement_and_notification) — siblings · Processes
- [Manage other party liabilities](/Processes/Manage_other_party_liabilities) — siblings · Processes
- [Provide explanation of benefits to members](/Processes/Provide_explanation_of_benefits_to_members) — siblings · Processes
- [Manage service protocols](/Processes/Manage_service_protocols) — siblings · Processes
- [Develop service policies and procedures](/Processes/Develop_service_policies_and_procedures) — siblings · Processes
- [Manage service routing and workflow](/Processes/Manage_service_routing_and_workflow) — siblings · Processes
- [Manage documented service level agreements](/Processes/Manage_documented_service_level_agreements) — siblings · Processes
- [Conduct correspondence management](/Processes/Conduct_correspondence_management) — siblings · Processes
- [Track correspondence to case](/Processes/Track_correspondence_to_case) — siblings · Processes
- [Retrieve correspondence image upon request](/Processes/Retrieve_correspondence_image_upon_request) — siblings · Processes
- [Perform member outreach](/Processes/Perform_member_outreach) — siblings · Processes
- [Plan product information](/Processes/Plan_product_information) — siblings · Processes
- [Provide wellness information to members](/Processes/Provide_wellness_information_to_members) — siblings · Processes
- [Manage appeals and grievances](/Processes/Manage_appeals_and_grievances) — siblings · Processes
- [Receive provider claims grievances](/Processes/Receive_provider_claims_grievances) — siblings · Processes
- [Conduct provider claims appeals process](/Processes/Conduct_provider_claims_appeals_process) — siblings · Processes
- [Receive member service grievances](/Processes/Receive_member_service_grievances) — siblings · Processes
- [Perform membership inquiry/eligibility and coverage procedures](/Processes/Perform_membership_inquiry%2Feligibility_and_coverage_procedures) — siblings · Processes
- [Perform billing and payment support processes](/Processes/Perform_billing_and_payment_support_processes) — siblings · Processes
- [Request invoice by member](/Processes/Request_invoice_by_member) — siblings · Processes
- [Update billing and payment profile](/Processes/Update_billing_and_payment_profile) — siblings · Processes
- [Request payment status by member](/Processes/Request_payment_status_by_member) — siblings · Processes
- [Send payment reminder to member](/Processes/Send_payment_reminder_to_member) — siblings · Processes
- [Maintain nurse line help desk](/Processes/Maintain_nurse_line_help_desk) — siblings · Processes
- [Provide wellness support to members](/Processes/Provide_wellness_support_to_members) — siblings · Processes
- [Supply pre-PCP visit support](/Processes/Supply_pre-PCP_visit_support) — siblings · Processes
- [Perform service analytics](/Processes/Perform_service_analytics) — siblings · Processes
- [Manage customer relationships and billing](/Processes/Manage_customer_relationships_and_billing) — siblings · Processes
- [Create account paperwork](/Processes/Create_account_paperwork) — siblings · Processes
- [Manage account relationships](/Processes/Manage_account_relationships) — siblings · Processes
- [Manage account and member setup](/Processes/Manage_account_and_member_setup) — siblings · Processes
- [Maintain member relationships and inquires](/Processes/Maintain_member_relationships_and_inquires) — siblings · Processes
- [Manage member relationships and loyalty](/Processes/Manage_member_relationships_and_loyalty) — siblings · Processes
- [Manage member inquiry intake](/Processes/Manage_member_inquiry_intake) — siblings · Processes
- [Perform research and resolve inquiries](/Processes/Perform_research_and_resolve_inquiries) — siblings · Processes
- [Perform tracking, follow-up, and reporting](/Processes/Perform_tracking,_follow-up,_and_reporting) — siblings · Processes
- [Manage and Process Risk Adjustments](/Processes/Manage_and_Process_Risk_Adjustments) — siblings · Processes
- [Collect data related to Medicare and exchange business](/Processes/Collect_data_related_to_Medicare_and_exchange_business) — siblings · Processes
- [Coordinate experience analysis with medical management](/Processes/Coordinate_experience_analysis_with_medical_management) — siblings · Processes
- [Validate clinical codes and documentation](/Processes/Validate_clinical_codes_and_documentation) — siblings · Processes
- [Update risk scores assumed in pricing](/Processes/Update_risk_scores_assumed_in_pricing) — siblings · Processes
- [Report updated information to CMS](/Processes/Report_updated_information_to_CMS) — siblings · Processes
- [Estimate risk-score related adjustments](/Processes/Estimate_risk-score_related_adjustments) — siblings · Processes
- [Coordinate with finance about payable/receivable](/Processes/Coordinate_with_finance_about_payable%2Freceivable) — siblings · Processes
- [Record and report CMS true-up](/Processes/Record_and_report_CMS_true-up) — siblings · Processes
- [Perform liability and insurance reserve valuations](/Processes/Perform_liability_and_insurance_reserve_valuations) — siblings · Processes
- [Reconcile claim cash flows](/Processes/Reconcile_claim_cash_flows) — siblings · Processes
- [Compile check register entries](/Processes/Compile_check_register_entries) — siblings · Processes
- [Compare check register to cash flow invoices](/Processes/Compare_check_register_to_cash_flow_invoices) — siblings · Processes
- [Reconcile differences](/Processes/Reconcile_differences) — siblings · Processes
- [Process prior period membership eligibility-related adjustments](/Processes/Process_prior_period_membership_eligibility-related_adjustments) — siblings · Processes
- [Process prior period inter-company subrogation-related adjustments](/Processes/Process_prior_period_inter-company_subrogation-related_adjustments) — siblings · Processes
- [Allocate other top side adjustments](/Processes/Allocate_other_top_side_adjustments) — siblings · Processes
- [Apply valuation standards](/Processes/Apply_valuation_standards) — siblings · Processes
- [Compile claim data into required format](/Processes/Compile_claim_data_into_required_format) — siblings · Processes
- [Validate data form and content](/Processes/Validate_data_form_and_content) — siblings · Processes
- [Apply business conditions, operating environment and other assumptions](/Processes/Apply_business_conditions,_operating_environment_and_other_assumptions) — siblings · Processes
- [Perform calculations per actuarial and regulatory standards](/Processes/Perform_calculations_per_actuarial_and_regulatory_standards) — siblings · Processes
- [Reconcile and validate results for changes in business and/or operating environment](/Processes/Reconcile_and_validate_results_for_changes_in_business_and%2For_operating_environment) — siblings · Processes
- [Review results of analysis with management](/Processes/Review_results_of_analysis_with_management) — siblings · Processes
- [Process ledger entries to line of business and legal entity](/Processes/Process_ledger_entries_to_line_of_business_and_legal_entity) — siblings · Processes
- [Issue actuarial opinion by qualified actuary](/Processes/Issue_actuarial_opinion_by_qualified_actuary) — siblings · Processes
- [Manage reserving controls, policies and procedures](/Processes/Manage_reserving_controls,_policies_and_procedures) — siblings · Processes
- [Establish scope and governance of reserve setting function](/Processes/Establish_scope_and_governance_of_reserve_setting_function) — siblings · Processes
- [Establish and publish security and controls guidelines](/Processes/Establish_and_publish_security_and_controls_guidelines) — siblings · Processes
- [Document reserve setting protocols and responsibilities](/Processes/Document_reserve_setting_protocols_and_responsibilities) — siblings · Processes
- [Monitor reserve setting and claim reconciliation procedures](/Processes/Monitor_reserve_setting_and_claim_reconciliation_procedures) — siblings · Processes
- [Audit reserve setting procedures](/Processes/Audit_reserve_setting_procedures) — siblings · Processes
- [Revise and update reserve and liability determination procedures for regulatory or controls related items](/Processes/Revise_and_update_reserve_and_liability_determination_procedures_for_regulatory_or_controls_related_items) — siblings · Processes
- [Develop and confirm internal controls](/Processes/Develop_and_confirm_internal_controls) — siblings · Processes
- [Define system security requirements and permissions](/Processes/Define_system_security_requirements_and_permissions) — siblings · Processes
- [Manage reserves compliance](/Processes/Manage_reserves_compliance) — siblings · Processes
- [Procure update national association insurance commissioners guidelines](/Processes/Procure_update_national_association_insurance_commissioners_guidelines) — siblings · Processes
- [Update procedures manual and tools](/Processes/Update_procedures_manual_and_tools) — siblings · Processes
- [Manage data collection](/Processes/Manage_data_collection) — siblings · Processes
- [Validate associated reported amounts within each risk based capital risk categories](/Processes/Validate_associated_reported_amounts_within_each_risk_based_capital_risk_categories) — siblings · Processes
- [Manage collection of documentation supporting each entry](/Processes/Manage_collection_of_documentation_supporting_each_entry) — siblings · Processes
- [Update reported amounts and documentation](/Processes/Update_reported_amounts_and_documentation) — siblings · Processes
- [Manage application of risk factors](/Processes/Manage_application_of_risk_factors) — siblings · Processes
- [Validate risk exposures against enterprise risk management risk appetites](/Processes/Validate_risk_exposures_against_enterprise_risk_management_risk_appetites) — siblings · Processes
- [Record quantified risk amounts in models](/Processes/Record_quantified_risk_amounts_in_models) — siblings · Processes
- [Manage collection of calculated amounts](/Processes/Manage_collection_of_calculated_amounts) — siblings · Processes
- [Validate regulatory guidance and policies](/Processes/Validate_regulatory_guidance_and_policies) — siblings · Processes
- [Design sensitivity tests and scenarios](/Processes/Design_sensitivity_tests_and_scenarios) — siblings · Processes
- [Review testing parameters with business owners](/Processes/Review_testing_parameters_with_business_owners) — siblings · Processes
- [Perform sensitivity tests](/Processes/Perform_sensitivity_tests) — siblings · Processes
- [Discuss risk and sensitivity results](/Processes/Discuss_risk_and_sensitivity_results) — siblings · Processes
- [Escalate risk awareness against strategies and market objectives](/Processes/Escalate_risk_awareness_against_strategies_and_market_objectives) — siblings · Processes
- [Conduct actuarial services](/Processes/Conduct_actuarial_services) — siblings · Processes
- [Develop trends analysis](/Processes/Develop_trends_analysis) — siblings · Processes
- [Develop cost trend projects](/Processes/Develop_cost_trend_projects) — siblings · Processes
- [Conduct actuarial informatics/reporting](/Processes/Conduct_actuarial_informatics%2Freporting) — siblings · Processes
- [Manage experience rating](/Processes/Manage_experience_rating) — siblings · Processes
- [Perform pre-sale underwriting review](/Processes/Perform_pre-sale_underwriting_review) — siblings · Processes
- [Review claim experience](/Processes/Review_claim_experience) — siblings · Processes
- [Determine premium](/Processes/Determine_premium) — siblings · Processes
- [Perform pool/block rating management](/Processes/Perform_pool%2Fblock_rating_management) — siblings · Processes
- [File with department of insurance](/Processes/File_with_department_of_insurance) — siblings · Processes
- [Develop rating methodology](/Processes/Develop_rating_methodology) — siblings · Processes
- [Publish pool/block rates](/Processes/Publish_pool%2Fblock_rates) — siblings · Processes
- [Manage rating tools](/Processes/Manage_rating_tools) — siblings · Processes
- [Conduct pool/block underwriting](/Processes/Conduct_pool%2Fblock_underwriting) — siblings · Processes
- [Review experience and history](/Processes/Review_experience_and_history) — siblings · Processes
- [Determine pool/block premium](/Processes/Determine_pool%2Fblock_premium) — siblings · Processes
- [Provide underwriting support](/Processes/Provide_underwriting_support) — siblings · Processes
- [Manage regulatory requirements and compliance](/Processes/Manage_regulatory_requirements_and_compliance) — siblings · Processes
- [Manage ORSA regulatory compliance process](/Processes/Manage_ORSA_regulatory_compliance_process) — siblings · Processes
- [Manage fraud, abuse, and payment integrity](/Processes/Manage_fraud,_abuse,_and_payment_integrity) — siblings · Processes
- [Agree on pre-adjudication approach and technology](/Processes/Agree_on_pre-adjudication_approach_and_technology) — siblings · Processes
- [Agree on post-adjudication approach and technology](/Processes/Agree_on_post-adjudication_approach_and_technology) — siblings · Processes
- [Agree on retrospective/post payment approach and recovery](/Processes/Agree_on_retrospective%2Fpost_payment_approach_and_recovery) — siblings · Processes
- [Conduct a vendor selection process](/Processes/Conduct_a_vendor_selection_process) — siblings · Processes
- [Manage government review](/Processes/Manage_government_review) — siblings · Processes

### Related (signature process)

- [Public Employee Retirement Systems (PERS)](/CompanyTypes/Public_Employee_Retirement_Systems_(PERS)) — signature process · CompanyTypes
- [Wholesale Central Station Monitor](/CompanyTypes/Wholesale_Central_Station_Monitor) — signature process · CompanyTypes

### Industries where this operates

- [Direct Life, Health, and Medical Insurance Carriers](/Industries/Direct_Life,_Health,_and_Medical_Insurance_Carriers) — operates in · Industries

### Rolled up to process group

- [Service products after sales](/Processes/Service_products_after_sales) — rolled up to process group · Processes

### Problems this exposes

- [820 premium-payment reconciliation desyncs from member effective-date changes, stranding paid-but-inactive or active-but-unpaid members](/Problems/820_premium-payment_reconciliation_desyncs_from_member_effective-date_changes,_stranding_paid-but-inactive_or_active-but-unpaid_members) — exposes problem · Problems
- [member tier set up at enrollment must map to the carrier's EOC/SBC benefit-package config, or adjudication applies the wrong benefits](/Problems/member_tier_set_up_at_enrollment_must_map_to_the_carrier's_EOC%2FSBC_benefit-package_config,_or_adjudication_applies_the_wrong_benefits) — exposes problem · Problems
- [834 EDI enrollment files from employer groups load with eligibility mismatches that silently deny member claims at point of care](/Problems/834_EDI_enrollment_files_from_employer_groups_load_with_eligibility_mismatches_that_silently_deny_member_claims_at_point_of_care) — exposes problem · Problems
- [member added without correct effective-date and plan-tier mapping forces retroactive premium and claim reprocessing](/Problems/member_added_without_correct_effective-date_and_plan-tier_mapping_forces_retroactive_premium_and_claim_reprocessing) — exposes problem · Problems
- [annual open-enrollment plan-year rollovers re-key every member record, surfacing terminations that should have lapsed coverage](/Problems/annual_open-enrollment_plan-year_rollovers_re-key_every_member_record,_surfacing_terminations_that_should_have_lapsed_coverage) — exposes problem · Problems
- [PHI scoping for member-services reps must satisfy HIPAA minimum-necessary, which generic role-to-entitlement mapping never models](/Problems/PHI_scoping_for_member-services_reps_must_satisfy_HIPAA_minimum-necessary,_which_generic_role-to-entitlement_mapping_never_models) — exposes problem · Problems
- [subscriber/dependent hierarchy set up wrong breaks coordination-of-benefits primary/secondary ordering across payers](/Problems/subscriber%2Fdependent_hierarchy_set_up_wrong_breaks_coordination-of-benefits_primary%2Fsecondary_ordering_across_payers) — exposes problem · Problems
- [break-glass and shared service accounts lack owners, rotation, and an audit trail](/Problems/break-glass_and_shared_service_accounts_lack_owners,_rotation,_and_an_audit_trail) — exposes problem · Problems
- [JML (joiner-mover-leaver) approvals stall in email threads with no SLA or audit record](/Problems/JML_(joiner-mover-leaver)_approvals_stall_in_email_threads_with_no_SLA_or_audit_record) — exposes problem · Problems
- [access-review attestations are rubber-stamped in spreadsheets, so SOX/SOC2 reviewers can't prove least-privilege](/Problems/access-review_attestations_are_rubber-stamped_in_spreadsheets,_so_SOX%2FSOC2_reviewers_can't_prove_least-privilege) — exposes problem · Problems
- [duplicate and merged member records from M&A or rehires break SSO mapping and license counts](/Problems/duplicate_and_merged_member_records_from_M&A_or_rehires_break_SSO_mapping_and_license_counts) — exposes problem · Problems
- [license seat reclamation is missed for dormant accounts, inflating per-seat SaaS spend](/Problems/license_seat_reclamation_is_missed_for_dormant_accounts,_inflating_per-seat_SaaS_spend) — exposes problem · Problems
- [manual provisioning across disconnected SaaS apps means new hires wait days for full access](/Problems/manual_provisioning_across_disconnected_SaaS_apps_means_new_hires_wait_days_for_full_access) — exposes problem · Problems
- [orphaned accounts persist after offboarding because HR termination events never reach the directory/IdP](/Problems/orphaned_accounts_persist_after_offboarding_because_HR_termination_events_never_reach_the_directory%2FIdP) — exposes problem · Problems
- [privileged/admin group membership accretes with no expiry, widening the standing-access blast radius](/Problems/privileged%2Fadmin_group_membership_accretes_with_no_expiry,_widening_the_standing-access_blast_radius) — exposes problem · Problems
- [role-to-entitlement mapping drifts as job titles change, leaving stale group memberships in AD/Okta](/Problems/role-to-entitlement_mapping_drifts_as_job_titles_change,_leaving_stale_group_memberships_in_AD%2FOkta) — exposes problem · Problems
- [self-service password/MFA resets flood the help desk when enrollment lapses or device changes](/Problems/self-service_password%2FMFA_resets_flood_the_help_desk_when_enrollment_lapses_or_device_changes) — exposes problem · Problems
- [Onboarding Members From Inconsistent Enrollment Inputs](/Problems/Onboarding_Members_From_Inconsistent_Enrollment_Inputs) — exposes problem · Problems

### Automated by

- [Customer Relationship Management System](/Software/Customer_Relationship_Management_System) — automated by · Software
- [Membership Management System](/Software/Membership_Management_System) — automated by · Software
- [Update Member Profile](/Activities/Update_Member_Profile) — automated by · Activities
- [Verify Member Identity](/Activities/Verify_Member_Identity) — automated by · Activities
- [Create Member Record](/Activities/Create_Member_Record) — automated by · Activities

### Outsourced to

- [Membership Administration Service](/CompanyTypes/Membership_Administration_Service) — outsourced to · CompanyTypes
- [Business Process Outsourcing Provider](/CompanyTypes/Business_Process_Outsourcing_Provider) — outsourced to · CompanyTypes

### Delivered by

- [Account Administrator](/JobTypes/Account_Administrator) — delivered by · JobTypes
- [Member Services Representative](/JobTypes/Member_Services_Representative) — delivered by · JobTypes
- [Operations](/Departments/Operations) — delivered by · Departments
- [Member Services](/Departments/Member_Services) — delivered by · Departments