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Eligibility and Enrollment Appeal Response Service

Willis Towers Watson’s enhanced customer service can help alleviate the burden of reviewing eligibility and enrollment appeals.

Reviewing and responding to eligibility and enrollment appeals is an important yet time-consuming task for many plan sponsors. Willis Towers Watson can help alleviate your burden by researching and responding to appeals related to eligibility and enrollment for group health and welfare plans.

While our work in this area varies based on each employer’s needs and the other vendors involved, our services are summarized below.

Eligibility and enrollment appeal response servicing

Willis Towers Watson’s Eligibility and Enrollment Appeal Response Service is designed to conduct research and process determinations for Level 1 and 2 appeals concerning eligibility and enrollment issues related to your group health plans. Our service includes:

  • Collaborating with you to define criteria and clear decision rules, and scenarios for which inquiries can be automatically approved or denied
  • Providing your participants with responses to their group health and welfare eligibility and enrollment appeals, based on guidelines established and provided by your plans*
  • In certain cases, escalating guidance inquiries to you that fall outside of the guidelines we initially established
  • Assisting you with participant eligibility inquiries received in writing by providing all correspondence, contact recordings, system information and other data relevant to the eligibility inquiry

Activity tracked for reference and workflow management

All activity from start to finish is tracked inside our case management system, giving our team and you a real-time view of the eligibility inquiry and all steps leading to resolution. In order to ensure a coordinated and streamlined process, we incorporate the following into our standard operating model:

  • Scan and store all eligibility inquiry correspondence and documentation to provide real-time online access to all relevant information
  • Provide you with quarterly reports of activity for trend analysis
  • Recommend corrective/proactive action to resolve issues and identify process improvements

Eligibility and enrollment appeal response service summary

Eligibility and enrollment appeal response service summary
Activity Standard service Appeal response service
Educate your participants on the business rules you established for eligibility and enrollment inquiries for Willis Towers Watson-administered health and welfare plans
Process transactions that you designate as approved
Provide detailed instructions for completing an appeal in the event one of your participants’ challenges your business rules
Work with you to define automatically approved scenarios that don’t require an appeal
Work with you to define all scenarios that can be automatically approved or denied, and respond directly to your participants
Provide you with data relevant to eligibility appeal upon request
Provide your participants with responses to eligibility and enrollment appeals that have been escalated to you for review
House all eligibility and enrollment appeal correspondence and documentation in Willis Towers Watson’s administration system
Answer your participant’s questions throughout the appeal process
Track activity in case management system
Provide you with quarterly reporting of activity for trend analysis
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Eligibility and Enrollment Appeal PDF .4 MB
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