Standard Operating Procedure
OPS-SOP-003 — Monthly Premium Invoice Reconciliation (Allied Auto ACH)
1. Purpose
This SOP establishes the monthly procedure for receiving, validating, and reconciling the Allied TPA monthly premium invoice, which is collected via automatic ACH debit. It ensures the premium amount is accurate, contract-compliant, and fully documented prior to ACH collection.
2. Scope
Applies to the monthly Allied premium invoice and associated auto-ACH debit for each participating employer plan under the Unity Care Member Plan Master Trust. Covers invoice receipt through monthly GL reconciliation. Excludes weekly medical claims (OPS-SOP-001) and PBM invoices (OPS-SOP-002).
3. Roles & Responsibilities
| Role | Responsibility |
|---|
| Operations | Primary owner. Log receipt, validate invoice fields and math, coordinate enrollment summary, prepare payment record. |
| Nuwell HR | Provide current lives and tiers enrollment summary to support validation. |
| Finance | Validate rates, fees, credits vs. contract. Sign payment record. GL posting and monthly reconciliation. |
| Compliance | Run QA/QC attestation (SUB-003), verify controls met before ACH debit date. |
| Allied TPA | Send monthly premium invoice. Initiate auto-ACH on scheduled date. Issue corrections on request. |
4. Procedure
Subprocess reference: SUB-006 (master flow), SUB-003 (Compliance QA/QC)
1. Receive Invoice: Allied sends the monthly premium invoice by [TBD] of each month. Operations logs receipt with date/time in the Invoice Log [TBD]. If invoice is not received by [TBD], Operations contacts Allied.
2. Validate Invoice Fields and Math: Operations reviews the invoice for:
- Correct billing period and coverage month
- Required fields present (plan name, group number, billing date)
- Math: line-item totals sum correctly to invoice total
3. HR Enrollment Summary: Operations requests current lives and tiers enrollment summary from Nuwell HR. Nuwell HR provides the summary within [TBD] business days.
4. Finance Rate Validation: Finance validates:
- Per-member, per-month rates match contracted schedule
- Administrative fees are within contracted limits
- Any credits or adjustments are documented and contract-allowed
- Invoice total is consistent with enrollment counts
5. Discrepancy Handling: If discrepancies are found, Operations works with Finance to resolve with Allied. All communications are documented. Outcome recorded in Invoice Log [TBD]. If unresolved, log dispute per OPS-SOP-004 and return to Step 4 with corrected invoice.
6. Compliance QA/QC (SUB-003): Compliance runs the QA/QC attestation subprocess. Verifies validation steps complete, controls met, no PHI in payment record, approvals present, retention locations recorded. If controls fail, packet returns to Operations.
7. Create Payment Record: Operations creates the payment record using the new vendor form or contract approval form. Record signed by Finance and Compliance. Contains: billing period, validated amount, enrollment summary reference, compliance attestation — no PHI.
8. Auto ACH Debit: Allied initiates auto-ACH debit on the scheduled date per contract. Operations confirms ACH date with Allied prior to debit.
9. Bank Confirmation: Operations captures and timestamps bank confirmation of ACH debit. Stored in evidence retention location [TBD].
10. GL Posting & Monthly Reconciliation: Finance posts payment to GL and completes monthly reconciliation within [TBD] business days. Any discrepancies trigger dispute per OPS-SOP-004.
5. Controls
| Control | Description | Owner | Frequency |
|---|
| Invoice Math Validation | All line items and totals verified before acceptance | Operations | Monthly |
| Enrollment Reconciliation | Invoice lives/tiers reconciled against HR enrollment summary | Finance, Nuwell HR | Monthly |
| Contract Rate Check | Per-member rates validated against contract schedule | Finance | Monthly |
| Dual Sign-Off | Finance and Compliance sign payment record | Finance, Compliance | Monthly |
| Compliance Attestation | SUB-003 attestation issued before ACH debit date | Compliance | Monthly |
| Bank Confirmation Capture | ACH confirmation timestamped and retained | Operations | Monthly |
| GL Reconciliation | Payment posted and reconciled within [TBD] days | Finance | Monthly |
6. Evidence Retention
| Document | Location | Retention Period |
|---|
| Monthly premium invoice (original) | Ops shared drive [TBD] | 6 years (ERISA) |
| HR enrollment summary | Ops/HR shared location [TBD] | 6 years (ERISA) |
| Finance validation checklist | Finance records [TBD] | 6 years (ERISA) |
| Dispute log (if applicable) | Dispute log [TBD] | 6 years (ERISA) |
| Compliance attestation | Compliance records [TBD] | 6 years (ERISA) |
| Signed payment record | 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 |
|---|
| Invoice not received by [TBD] | Contact Allied; escalate to Finance if unresolved by [TBD] | Operations |
| Rate discrepancy vs. contract | Log dispute; request correction from Allied; escalate to Legal if unresolved | Finance |
| Enrollment count mismatch | Reconcile with Nuwell HR; notify Allied; correct before ACH date | Operations |
| Compliance QA/QC fails | Return to Operations; do not allow ACH to proceed | Compliance |
| ACH debit incorrect amount | Notify Allied and Finance immediately; log dispute; request credit/refund | Operations |
⚠️ Open Items — Tracking Tools To Be Built
- Invoice Receipt Log: Timestamped monthly log of premium invoice receipt and processing [TBD format]
- HR Enrollment Summary Template: Standardized lives/tiers summary provided by Nuwell HR each month [TBD format]
- Finance Validation Checklist: Rate and fee validation checklist template [TBD format]
- Dispute Log: Shared case tracking for invoice discrepancies — shared with OPS-SOP-004 [TBD format]
- Payment Record Template (Contract Approval Form): Standardized record signed by Finance and Compliance [TBD]
- ACH Calendar / Debit Schedule: Forward-looking schedule of Allied auto-debit dates [TBD format]
- Evidence Retention Index: Monthly index of retained documents [TBD format]
OPS-SOP-003 | Unity Care Solutions, LLC — Internal / Confidential
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