Capitation rate-cell error — recoupment / rate certification
Aid Category Conflicts
18,922
Members affected
$34.1M
Estimated exposure
15.1
Avg months at risk
$24.1M–40M
Exposure range
What this is
CBES and MMIS carry different aid categories for the same member and span, so capitation pays from the wrong rate cell. Small dollars per member, huge member counts.
Why single-system review misses this
The category is 'valid' in both systems — just different. Nothing fails a format edit; only a field-level cross-system compare catches it.
One member, two systems
Member CAS-00000518 — the eligibility record and the payment record, on one clock. The hatched window is the seam.
CBES eligibility spanMMIS enrollment spanthe seam — paying from the wrong rate cell
The exposure math, in the open
members × avg monthly rate-cell error × avg months in conflict
18,922members×$119avg per month×15.1avg months≈$34.1Mestimated exposure
Example members:CAS-00000518CAS-00001601CAS-00001741CAS-00002000CAS-00002017