Member-Centric Operations

Members Who Stay and Engage

Member satisfaction is a competitive priority — low satisfaction scores drive disenrollment, poor Star ratings, and reduced CMS revenue. Hetasalvation helps health plans deliver exceptional member experiences at every touchpoint: enrollment, benefits queries, appeals, and care access.

From accurate enrollment processing and eligibility management to member portal development and call center support, we build the operational infrastructure that makes members feel valued and well-served.

Improve Member Experience →

Member Operations

Member Services Solutions

📝

Enrollment Processing

Accurate, timely enrollment processing — individual, group, Medicare Advantage, and Medicaid enrollment handled with precision and compliance.

834 EDI enrollment processing
CMS enrollment file processing
SEP / OEP enrollment management
Group enrollment & billing
COBRA administration

✅

Eligibility Management

Real-time eligibility maintenance — timely updates, 270/271 transaction processing, and coordination with CMS and state agencies.

270/271 eligibility transactions
Real-time eligibility verification
CMS MARx / MMSEA file processing
Medicaid eligibility verification
Retroactive eligibility adjustments

📞

Member Call Center Support

Trained member services representatives who handle benefits inquiries, claims questions, PCP changes, and access issues — efficiently and empathetically.

Inbound member service calls
Benefits explanation & guidance
Claims inquiry support
PCP / specialist change processing
Member grievance intake

⚖️

Grievance & Appeals

CMS-compliant member grievance and appeal management — timely processing, clinical review coordination, and member communication that meets regulatory requirements.

Member grievance processing
Pre-service & post-service appeals
IRO referral coordination
CMS timeframe compliance
Grievance & appeal reporting

💊

Benefits Administration

Accurate benefits configuration, ID card production, and EOB generation — ensuring members understand and can access their covered benefits.

Benefits plan configuration
ID card production & mailing
SBC / SOB document generation
EOB statement generation
Formulary management support

⭐

Star Rating Improvement

Targeted programs to improve Medicare Advantage and Part D Star ratings — CAHPS, HOS, HEDIS measure improvement, and member outreach campaigns.

Star rating gap analysis
CAHPS improvement strategies
HEDIS care gap closure programs
Member outreach campaigns
Medication adherence programs

Member Services & Enrollment