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Reliable Group

For dual-eligible special needs plans

When dual status drifts, revenue and members drift too.

A fixed-fee discovery measures one eligibility, encounter or appeals queue; then we rebuild and run it as your AI operating partner.

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Table of where money and risk sit in a D-SNP. Payment accuracy: dual status mismatches found late today, every MMR and state file compared once rebuilt. Risk adjustment: encounters stuck in two reject queues, then pre-checked against both edit sets. Member retention: Medicaid loss spotted after the fact, then deeming and outreach start on the loss. Audit exposure: appeal clocks in workbooks, then every clock and notice dated. Cost to serve: coordinators on paperwork today, then coordinators on members with the paperwork automated.
A pattern across D-SNP operations, not a client result; each rule is sourced below.

Where money and members slip

  • Revenue resting on a dual status nobody reconciled.

    The MMR, CMS's monthly membership report, drifts from the state file, and dual status sets the risk score segment.

  • Encounters rejected by two sets of edits.

    Rejected encounters mean diagnoses CMS does not see and state data failing review. Automation pre-checks both edit sets; people fix the rest.

  • Members lost at renewal.

    Deeming tracked from the Medicaid loss, required notices sent and renewal outreach logged, so your team works the reinstatements.

  • Coordinators chasing HRAs, not members.

    HRA outreach, ICT scheduling, care plan mailings and, for coordination-only plans, state admission notices done by hand. Automation takes them; coordinators keep clinical work.

Before and after of one dual status change. Today, twelve steps by hand: pull the MMR and CMS reply files, open the state file, compare dual codes, check the state system and CMS records, fix the cost share tier and LIS level, start the deeming clock, mail the notice, reprocess claims, refund or recover. Once rebuilt, the same steps, mostly automated: files matched and mismatches researched; cost share, LIS and notices updated; claims, refunds and recoveries queued; authorized staff approve the fix.

What we do, and what we leave alone

Payment and cost share ride on two files that disagree

When CMS dual status drifts from the state file, payment and cost share land on the wrong payer or the member. Automation flags each mismatch; authorized staff approve the fix.

  • We take: status mismatches, encounter rejects, deeming and appeal clocks
  • We leave: model of care, coverage and appeal decisions
Flow of a Medicaid loss from file to audit trail, every step by hand today. Once rebuilt, automation spots the loss in the state file, dates the deeming period and issues the required notice from a template; AI sorts returned mail and faxes; your people decide reinstatement or disenrollment; automation leaves the dates ready for a universe pull.

What we build and run

Rules first, your team on judgment

Deeming clocks, encounter pre-checks and appeal deadlines go to automation first, each step dated for a CMS audit universe. AI reads mail and faxes. People we manage work exceptions.

Medicare distribution, anonymized

Healthcare services

Commissions, HR and onboarding rebuilt while the business grew

A field marketing organization placing Medicare plans for 225,000+ lives through roughly 1,500 agents. Reliable Group rebuilt commissions, HR and onboarding around automation and AI, and gave agents a voice assistant for plan comparison and compliance. Sales capacity held and the business grew through the year, while the corporate team went from about 450 to under 200.

Grew, capacity held

One year: the business grew and sales capacity held. The corporate team went from about 450 to under 200.

anonymized realized

No D-SNP case is published yet; this one shows the operating model only.

  • Growth and sales capacityanonymized realized

What transfers: Dated, rules-driven enrollment steps run automation first, people on disputes: the pattern behind deeming work.

See the measured results

Questions D-SNPs ask

  • Automation compares the MMR to the state file. We research each mismatch in the state system and MARx, including changes not yet sent to CMS in the MMA file. Your authorized enrollment staff approve each correction, and the Part D LIS level follows it.

  • A fixed fee, agreed first, for a six to eight week discovery of one department. We suggest enrollment, where the MMR and state file meet. No savings figure before measuring. You leave with a workflow map and a fixed-price proposal for the first build.

  • From 2027, certain D-SNPs limit enrollment to members of their affiliated Medicaid plan, and more materials and appeals become integrated. So Medicare and Medicaid records have to match. We take the reconciliation and clock tracking; plan design and state contracting stay with you.

  • The tracking, yes: flagging Medicaid loss, starting the deeming period your plan elected, sending required notices and logging renewal outreach. Your enrollment staff decide reinstatement or disenrollment. For SNPs, federal rules allow 30 days to six months; some states set longer minimums.

  • Yes, as administrative work: pre-checking 837-I and 837-P files against CMS and state edits, working 999, 277CA, MAO-002 and state rejects, sending replacements and voids, and reconciling MAO-004 risk adjustment status. Diagnosis coding stays with your coders.

  • We track integrated reconsideration clocks, continuation of benefits requests, IRE forwarding of adverse Medicare decisions and the state fair hearing window, and assemble case files and acknowledgment letters. Coverage decisions stay with your reviewers. Stricter state contract timeframes govern where they apply.

Sources for the rules and deadlines on this pagechecked November 1, 2026

Rules change and vary by program, state and contract. Your compliance team confirms what applies to you.

How we handle regulated data

Design posture, not certification

Request documentation
BAA
Where a department handles protected health information, we execute a business associate agreement before Trace is installed or any data is accessed.
HIPAA
We execute a Business Associate Agreement before any engagement that touches PHI, and PHI is accessed only inside client-controlled systems by named individuals. Our first healthcare engagement under BAA is in progress.
Posture
Ready and aligned describe design posture, not certification. Reliable Group does not currently hold SOC 2 or ISO 27001 certification; our teams operate inside client-certified environments under client controls.
Notice
We deploy Trace only after your organization has given team members the written notice required in your state; we provide the notice template.

Your client-specific workflows, data and documentation are yours. Trace is Reliable Group software, licensed under the engagement; third-party tools keep their own license terms.

Last reviewed October 2026

Next step

Stop guessing how your operation works.

Tell us which department eats the most hours. We will say candidly whether measuring it is worth it.

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