EXIGEN · CAPITATION RECONCILIATION

Confirm the coverage. Reconcile the payment.

Continuously review eligibility, contract scope, and capitation payment records so an account is adjusted only when the evidence supports it—not simply because the patient was once listed as capitated.

Validate coverage for the date of service.

Compare service dates with effective eligibility and enrollment periods. Revisit accounts when retroactive terminations, reinstatements, or other changes arrive, and identify adjustments that may need correction.

Apply the actual agreement.

Confirm that the service, provider, and member fall within the capitated arrangement. Identify carve-outs, exclusions, and services payable separately. Do not assume every charge on an account belongs under capitation.

Reconcile the health plan’s payment.

Match member-month enrollment and payment rosters with received capitation payments, contract rates, and relevant service periods. Capitation is generally paid for covered members and periods rather than separately for each claim; verify the arrangement and payment evidence before approving an adjustment.

Reopen the right work.

When retroactive changes invalidate an assumption, flag the affected account, review prior adjustments, and determine the next action under the agreement. Route eligible fee-for-service claims, payment discrepancies, or unresolved coverage questions to the appropriate team.

Exigen | Capitation ReconciliationILLUSTRATIVE WORKSPACE · SYNTHETIC DATA

Service dateEligibility historyContract scopePayment reconciliation

ACME account · Initial reviewMember shown as eligible for April. Covered services and member-month payment require reconciliation before a capitation adjustment is approved.

New information · Retroactive terminationA May update changes the termination date to March 31. April services are flagged for review; an earlier capitation adjustment is no longer assumed valid.

Resolution queueReview coverage and responsibility, assess whether a reversal is needed, and pursue the contract-appropriate billing or payer follow-up path.

Required check	Example result
Eligible on date of service?	Retroactive change — review
Service included in agreement?	Check coverage and carve-outs
Member-month payment reconciled?	Compare roster and received cash
Adjustment supported?	Hold pending resolution

Why the entire account is not automatically written off

A capitation designation is one input. Eligibility dates, contract inclusions, exclusions, payment reconciliation, and subsequent changes all affect the decision. Each applicable service must follow the agreement and the organization’s approved adjustment process.

ACME demonstration only. Illustrative data and workflows; no live accounts, bank files, or payments are processed on this page.

Continuous eligibility review

Surface retroactive changes that affect previously reviewed accounts.

Contract-aware adjustments

Distinguish covered services from carve-outs and separately payable items.

Payment accountability

Reconcile roster expectations to received capitation and route unexplained differences.