Benefits Carrier Reconciliation
Who you enrolled against who the insurance carrier actually covers and bills, with what the gap costs every month.
Reads .xlsx and .csv inside your browser. Nothing is uploaded, and any nine-digit ID is shown as its last four digits only.
Who HR says is enrolled
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The enrollment export from your HR or benefits system for one line of cover, such as medical: one row per enrolled employee, with plan and tier.
The carrier's file
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The insurer's eligibility or billing file for the same cover. Dependents on their own rows, sharing the subscriber's ID, are fine.
The carrier bills from its own list
Every month the insurer invoices for the people on its file, not the people in your HR system, and the two drift apart one missed form at a time. Somebody who left in July and is still on the carrier’s file is a premium paid every month for nobody. Where the carrier’s file has premiums, the tool adds them up: the monthly total for everybody covered whom your file does not show as enrolled, and what has been billed for leavers since their cover should have stopped. Most carriers limit how far back they will refund, so the second figure only grows.
The other direction hurts a person
Somebody enrolled in your system and missing from the carrier’s file believes they are insured, and finds out at the pharmacy. It costs the company nothing this month, which is why a report built around cost tends to leave it out. Here it sits in the headline beside the money.
The tier is what gets billed
Family cover in one file and employee only in the other is a wrong premium, and possibly a child who is not covered. The two files spell tiers differently, EE+FAM, Family, EF, so both are read into plain tiers before they are compared. Where the carrier lists dependents on their own rows, the people it actually covers are checked against the tier it bills: a spouse covered under an employee-only premium is worth a question.
The plan names will not match either
“Gold PPO” in your system is “MED-PPO” at the carrier. Rather than calling everybody a mismatch, each of your plans is matched to the carrier plan most of its people are in, and only the people who break that pattern are reported.
Continuation cover, and when cover stops
A leaver on continuation coverage, COBRA in the US, belongs on the carrier’s file. Where the carrier marks it, the person is listed as expected and left out of the cost. When cover stops after somebody leaves, on the day or at the end of that month, is your plan’s rule, so you set it.
What this does not do
It compares two files. It does not decide who is eligible for coverage, whether continuation coverage applies to anybody, or what notices are owed; those depend on the plan documents and the law, and are questions for your benefits advisers. It works on one line of cover at a time, so run medical, dental and vision separately. For headcount rather than coverage, the Headcount Reconciliation does the same kind of job between your HR system, payroll and finance.