Standard Operating Procedure
OPS-SOP-001 — Weekly Medical Claims Funding (Allied TPA)
1. Purpose
This SOP establishes the weekly procedure for receiving, validating, approving, and funding medical claims through the Allied Third Party Administrator (TPA) for each participating employer plan under the Unity Care Member Plan Master Trust. It ensures all claim payments are accurate, compliant, and properly documented before funds are released.
2. Scope
Applies to all weekly medical claim funding cycles for the each participating employer plan under the Unity Care Member Plan Master Trust. Covers receipt through bank confirmation and GL reconciliation. Excludes Rx (ProAct — see OPS-SOP-002) and premium invoices (see OPS-SOP-003).
3. Roles & Responsibilities
| Role | Responsibility |
|---|
| Operations | Primary owner. Log receipt, redact file, coordinate QC subprocesses, prepare payment packet, trigger approval workflow. |
| Nuwell HR | Provide eligibility roster, validate eligibility exceptions, confirm coverage status. |
| Compliance | Run QA/QC attestation (SUB-003), verify redaction, verify controls met before funds move. |
| Finance | Sign off on payment packet. GL posting and monthly reconciliation. |
| Primary Approver | Review and approve funding amount. Authorize fund movement. |
| Backup Approver | Approves and moves funds when Primary Approver is unavailable. |
| Allied TPA | Send weekly claims register. Initiate same-day ACH pull upon approval. |
4. Procedure
Subprocess reference: SUB-004 (master flow), SUB-001 (Eligibility QC), SUB-002 (Funding QC), SUB-003 (Compliance QA/QC)
1. Receive Register: Allied sends the weekly claims register by [TBD] AM on [TBD] day. Operations logs receipt with date/time in the Claims Log [TBD]. If register is not received by [TBD], Operations contacts Allied.
2. Secure PHI Storage: Operations stores the unredacted register in the designated PHI-secure location [TBD]. Access restricted to authorized roles only.
3. Create Redacted Working Copy: Operations creates a redacted version of the register removing all member names and direct identifiers. Only member IDs and plan identifiers are retained. Redacted copy is used for all downstream QC steps.
4. Run Eligibility QC (SUB-001): Nuwell HR runs the eligibility QC subprocess. Matches register members against current eligibility roster. Checks active status, enrolled status, and coverage window. Any failures produce an exceptions list (no PHI). Exceptions sent to Operations.
5. Run Funding QC (SUB-002): Operations runs the funding reasonableness and volatility QC subprocess. Checks file completeness, totals, duplicates, trailing average comparison, high-dollar items, provider concentration, and clustering. Any anomalies are logged (no PHI) and sent to triage.
6. Triage Flags & Exceptions: If flags or exceptions exist, Operations, Nuwell HR, and Compliance triage. Decision: proceed today or pause.
- If pause: Operations requests clarification/correction from Allied. Logs dispute per OPS-SOP-004. Returns to Step 1 on receipt of corrected register.
- If proceed with documented exceptions: move to Step 7.
7. Compliance QA/QC (SUB-003): Compliance runs QA/QC attestation subprocess. Verifies eligibility QC complete, funding QC complete, exceptions handled or documented, redaction verified, approvals present, retention locations recorded. If any controls fail, packet returns to Operations for correction.
8. Prepare Payment Packet: Operations prepares the payment packet using the payment request form (signed by Primary Approver). Packet contains: funding amount, QC attestations, compliance sign-off, no PHI. Packet is signed by Finance and Compliance before submission.
9. Approver Review & Authorization: Payment packet submitted to Primary Approver for review and authorization of funding amount.
- If Primary Approver available: Primary Approver reviews and moves funds.
- If Primary Approver unavailable: Backup Approver is notified and moves funds. Absence is documented.
10. ACH Pull: Allied initiates same-day ACH pull per approved amount. Operations confirms ACH initiation with Allied.
11. Bank Confirmation: Operations captures and timestamps the bank confirmation of ACH debit. Stored in the evidence retention location [TBD].
12. GL Posting & Reconciliation: Finance posts the payment to the general ledger. Reconciliation completed within [TBD] business days. Any discrepancies trigger dispute per OPS-SOP-004.
5. Controls
| Control | Description | Owner | Frequency |
|---|
| PHI Redaction | No PHI in working packet or downstream documents | Operations | Every cycle |
| Eligibility Match | All register members confirmed active and enrolled | Nuwell HR | Every cycle |
| Funding Reasonableness | Totals validated against trailing average and contract | Operations | Every cycle |
| Dual Sign-Off | Finance and Compliance sign payment packet | Finance, Compliance | Every cycle |
| Approver Authorization | Primary or documented Backup Approver must authorize | Operations | Every cycle |
| Compliance Attestation | SUB-003 attestation issued before funds move | Compliance | Every cycle |
| Bank Confirmation Capture | ACH confirmation timestamped and retained | Operations | Every cycle |
| GL Reconciliation | Payment posted and reconciled within [TBD] days | Finance | Every cycle |
6. Evidence Retention
| Document | Location | Retention Period |
|---|
| Unredacted claims register (PHI) | PHI-secure location [TBD] | 6 years (ERISA) |
| Redacted working copy | Ops shared drive [TBD] | 6 years (ERISA) |
| Eligibility QC exception log | QC log [TBD] | 6 years (ERISA) |
| Funding QC log | QC log [TBD] | 6 years (ERISA) |
| Compliance attestation | Compliance records [TBD] | 6 years (ERISA) |
| Signed payment packet | Finance records [TBD] | 6 years (ERISA) |
| Bank confirmation | Finance records [TBD] | 6 years (ERISA) |
| GL reconciliation record | Finance records [TBD] | 6 years (ERISA) |
7. Escalation
| Trigger | Action | Escalation Owner |
|---|
| Register not received by [TBD] | Contact Allied; escalate to Compliance if not resolved by [TBD] | Operations |
| Eligibility exception cannot be resolved | Escalate to Nuwell HR Director and Compliance | Operations |
| Funding anomaly exceeds [TBD]% | Pause funding; escalate to Finance and Compliance | Operations |
| Compliance QA/QC fails | Return packet to Operations; do not move funds | Compliance |
| Primary and Backup Approver both unavailable | Escalate to Legal; do not move funds without authorization | Operations |
| ACH error or bank rejection | Notify Allied and Finance immediately; log and investigate | Operations |
⚠️ Open Items — Tracking Tools To Be Built
- Claims Receipt Log: Timestamped log of register receipt and processing steps [TBD format]
- PHI-Secure Storage Location: Designated secure folder or system for unredacted registers [TBD]
- Eligibility QC Log: Structured log for exceptions from SUB-001, no PHI [TBD format]
- Funding QC Log: Structured log for anomalies from SUB-002, no PHI [TBD format]
- Dispute Log: Case tracking system for disputes from this or any QC subprocess [TBD format]
- Evidence Retention Index: Master index of retained documents per cycle [TBD format]
- Payment Packet Template: Standardized payment request form (signed by Primary Approver) signed by Finance and Compliance [TBD]
- Approver Availability Protocol: Documented process for Primary/Backup designation [TBD]
OPS-SOP-001 | Unity Care Solutions, LLC — Internal / Confidential
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