EDI Renewals: Best Practices and Policies

Open enrollment often represents the most active time for enrollment changes. When you have an established EDI feed with a carrier, these changes are reported to the carrier directly from your Maxwell portal, which eliminates the need to deliver open enrollment elections manually and reduces the risk of data entry errors. The below guidelines and best practices will ensure the best possible experience in processing your EDI renewal with each carrier:

Important Steps to Follow

  1. Note that only members in either a confirmed or enrolled/processed status at the time the renewal file is sent will be transmitted on the EDI file as enrolled.
    • Those that have not completed their enrollment by checking out will either not be sent on the file or will be sent as a termination if they previously had coverage.
  2. Review your discrepancy reports and audit your bills. Once the renewal has been sent via EDI, it is critical that the next discrepancy report received from the carrier is thoroughly reviewed by the broker or the employer.
    • The report will note any issues with member elections, missing members, and missing information.
    • We also always recommend auditing your carrier bill on a monthly basis to confirm that all enrollees are correct.
  3. After your renewal file is sent, you or your broker must submit current year’s enrollments as it will not be sent on the EDI file. 
    • After the renewal is sent, any enrollment changes affecting the remainder of the current plan year should be manually updated direct with the carrier. Inquire with your carrier on the best method for any manual updates.
  4. Make sure open enrollment ends before the plan year renewal date.
    • Failure to complete open enrollment prior to the carrier renewal date risks interruption to the scheduled weekly delivery of your carrier EDI file. Please always plan to have your open enrollment period end at least two weeks prior to the renewal effective date.

Other Items to Note

  • All EDI files run on a set, scheduled day of the week that is generally dependent on the carrier. Please be aware of the specific day of the week their carrier file runs as this can affect the timeframe in which open enrollment needs to be completed.
    • For example, if your file runs on Mondays and your renewal date is 1/1/2018, we will target the Monday that is at least two weeks before 1/1/2018 to send your renewal file.
    • This means open enrollment should ideally be completed and processed prior to Monday, 12/18/2017. If you’re not sure what day of the week your file runs, please reach out to your broker.
  • Be aware that any employees with open enrollment end dates that extend beyond the date that the renewal file is sent (such as new hires) will not be included on the renewal file. Once those employees exit their open enrollment, they will be picked up on subsequent EDI enrollment files.
  • In order for new members to receive their ID cards, most carriers recommend that the renewal file be sent at least two weeks before the renewal date. This means that at least two weeks before the renewal date of your EDI-enabled plans, employees must complete their open enrollment elections and renewal products must be processed.
  • Do not extend open enrollment dates once the renewal file has been sent. Any changes requiring an extension of open enrollment should be managed on a per-employee basis.
Was this article helpful?
2 out of 2 found this helpful