With the busy season right around the corner, are you prepared for a flood of insurance eligibility requests? Employers often need help processing their employees’ eligibility requests in an efficient manner. GRA’s Eligibility Team handles all eligibility requests for our 1Team and 1Enroll clients, simplifying the process and eliminating costly errors. To make sure you’re ready to hit the ground running, let us walk you through the key steps.

What is eligibility and why does it matter?

In the insurance world, there are a few different types of eligibility:

  • Enrolling an employee in benefits, such as new hires, during the employer’s open enrollment or as a result of qualifying life events
  • Terminating coverage, whether as a result of employee termination or if an employee opts out of coverage
  • Updating an employee’s contract; for instance, adding or deleting a dependent, or updating an address

Eligibility is the foundation of an employee’s coverage, across all stages of an employee’s benefits, from actively employed to COBRA, and all coverages from medical, life, ancillary coverages, and beyond Given this broad application, eligibility can be extremely time-consuming, especially if there are any errors. . When information is incomplete or incorrectly keyed, the employee may be refused by a provider or have claim issues. More and more, employers count on their agent or processing teams, like those furnished by GRA, to ensure eligibility requests are completed correctly the first time.

Additional factors to consider with employee’s eligibility include:

  • When is an employee eligible for coverage?
  • When does an employer have to remove terminated employees from coverage?
  • What information/documentation is required?
  • Where do I submit eligibility requests?

For answers to these important questions, you’ve come to the right place. Our benefits and eligibility experts are here to walk you through what information and/or documentation is required when submitting insurance eligibility requests, as well as what kind of information needs to be completed correctly, so that you can be sure that your eligibility requests are processed properly.

How to submit eligibility

  1. Review the type of eligibility being submitted.
    1. Removing an employee due to termination of employment
    2. Enrolling a new hire?
    3. Adding a new dependent? 
  2. Complete the appropriate documentation for the request. Confirm that the forms are being submitted for the correct location and to the right carrier.
    – Unless you use a benefits administration system, it is likely that any eligibility requests will require a form. 
  3. Verify that the enrollment, termination, or change form is completed correctly. Is all the employee’s information legible? Be sure that the following crucial information is completed both clearly and accurately:
    1. Employees first and last name
    2. Dependent’s first and last name(s), if applicable
    3. Date of birth (for everyone on the contract)
    4. Social Security Numbers (for everyone on the contract)
    5. Employee’s Address (for enrollments or address changes)
    6. Employee’s Provider information (if enrolling in an HMO)

    ** If eligibility is processed through an online benefits system, double-check that the employee’s information is entered correctly.

  4. Important! The effective date of the request must be listed.
    –Note: follow the established qualifications when confirming the timeframes that an employee is eligible or ineligible for coverage: new hire waiting period, the company’s open enrollment period, or qualifying event change. Always check policies for any additional rules when adding, changing, or removing coverages. 
  5. Once all the information is validated and required documentation is complete, submit the request to be processed.
    1. Do you submit to a servicing staff?
    2. Directly to the carrier?
      – Or do you skip these steps and submit changes directly through an online benefits administration system? Using an online benefits administration system can save time and reduce errors. When you’re ready, GRA can help get your group set up for success.
  6. After submitting the eligibility request, a receipt of confirmation should be received from the carrier. If one is not received, request one.
  7. A good rule of thumb: ALWAYS verify carrier invoices to make sure enrollments, terminations, and/or changes are completed and are correctly reflected on invoices. If a carrier invoice cannot be verified, reach out to the processor to confirm completion or request confirmation of completion.

    Does this sound like a lot? That’s what we’re here for! Simplifying eligibility is why GRA has a dedicated Eligibility Team for our 1Team and 1Enroll Clients. We are here to handle all eligibility requests and leave you worry-free.

Quick tips for submitting eligibility

  • Contact your agent’s office, or refer to your online benefits administration system, to confirm the eligibility guidelines, clarify what documentation is required, and note information that must be included in the eligibility request.
  • Make sure the correct information is printed clearly on the form or entered into the administration system.
  • Follow-up by reviewing the carrier invoice and requesting a confirmation of completion if there are delays in processing.

Eligibility is an integral part of employee benefits. We like to think of it as the sail that moves the ship and it’s important to be sure that your ship is heading in the right direction. That’s why it’s paramount that submitted documentation be not only accurate, but also legible, if submitted by paper form. When reviewing enrollment forms, remember to confirm the employee’s name, date of birth and social security number (SSN), along with any dependent information is clearly printed. When an employee is enrolled with either an incorrect SSN or date of birth, it causes claim issues and/or impacts coverage – not to mention headaches for everyone. Following up to confirm that eligibility is complete is also critical, as it saves on time spent correcting items and retroactive adjustments.

If this process seems overwhelming or just more than you care to deal with, we understand. At GRA Benefits, we have knowledgeable staff who can efficiently process eligibility requests, are familiar with the carriers, are available to answer questions, and best of all, are ready to handle any and all of your eligibility needs.

Contact GRA Benefits Group if you would like more information.