AEP 2025: Why Claims Accuracy & Denial Prevention Matter Most for Member Trust

Denials happen every day in healthcare, but AEP amplifies them; especially for plans still running on manual or legacy systems that can’t keep pace with enrollment surges. These denial triggers aren’t abstract “bad data” issues; they directly impact onboarding and member trust. 

1. Eligibility mismatches during onboarding

A new enrollee may show as active in your system but hasn’t yet been fully processed in CMS databases. Their first claim bounces, and the member receives a denial notice. The implications are serious: the provider isn’t paid on time, the member loses confidence in their new plan, and often logs a complaint with CMS. That single complaint, during AEP, counts more heavily toward Star Ratings and can snowball into grievances and early disenrollment. 

2. Improper coding due to rushed submissions

Claims departments under AEP volume pressure may overlook coding validation. Errors inevitably slip through. A routine denial for incorrect coding translates to unnecessary care delays.  

3. Coordination of benefits confusion

During enrollment, members often switch from employer plans or Medicaid to Medicare Advantage. If secondary payer rules aren’t easily adjudicated, denials spike. Again, hurting onboarding momentum.  

Unlike billing failures (which may hit months later), these denial drivers strike immediately, breaking trust from day one. And that’s why accurate claims adjudication isn’t just an AEP tactic; it’s the foundation for retaining members, safeguarding CMS Stars, and protecting long‑term plan reputation. 

The Cost of Inaccurate Claims During AEP 

Most health plans still underestimate the downstream costs of inaccurate claims. They see denials as an “operations headache,” but don’t fully connect them to AEP outcomes. The truth is: national CMS data already shows the scale of the problem and it grows sharper during AEP. 

• Improper payments add up: In FY2024, Medicare Advantage (Part C) had an improper payment rate of 5.61% -  representing $19 billion in errors, with eligibility and diagnosis mismatches among the biggest drivers.¹ Most plans don’t realize how directly these national figures map onto AEP’s surge, where onboarding errors flood first-claim denials.  

• Denials trigger complaints: A denied first claim isn’t “just reprocessed.” It often escalates into a formal complaint or grievance, and for 2025 CMS has doubled the weight of member experience measures in Star Ratings.²  

• Denials weaken loyalty. CMS disenrollment data shows that coverage issues remain a top driver of early disenrollments, often linked back to denied first claims.³  

The bottom line: During AEP, denial prevention is not “nice-to-have efficiency.” It directly translates into: 

• Fewer CMS complaints and grievances (protecting Stars). 

• Lower rework and admin costs. 

• Stronger member retention in the first 90 days. 

Put simply; denial prevention is the frontline of financial, compliance, and reputational success for Medicare Advantage plans. 

3 AEP‑Ready Claims Adjudication Practices You Should Adopt Before October 15

If you’re questioning whether your current systems can withstand AEP, these are the mission‑critical practices to operationalize right now. For Mirra clients, these aren’t add‑ons; they’re built into the platform. 

1. Real‑Time Eligibility Verification 
    Ensure onboarding mismatches don’t derail first claims. With direct CMS eligibility integrations, plans can guarantee members’ first claims are payable. 

2. Automated Coding Accuracy Checks 
    High submission volumes create coding shortcuts. Automated pre‑adjudication checks prevent costly denials and audit triggers.  

3. Denial Trend Monitoring Dashboards 
    Daily denial tracking gives visibility into sudden spikes (e.g., COB confusion, new provider contracts) so plans can act in days, not months. 

Together, these practices transform adjudication from reactive cleanup to proactive trust protection. 

 Looking for ways to protect your enrollment and Star Ratings? Read our blog post on Premium Billing System: Protect Your Star Ratings in AEP 2025 

How Can Technology Strengthen Claims Adjudication and Prevent Denials During AEP?

For health plans still relying on manual or piecemeal legacy systems, the AEP surge magnifies every weakness. From eligibility mismatches to coding errors. Technology changes the equation: 

• Automation at scale: AI‑driven flagging of coding errors before submission. 

• Denial prediction models: Machine learning alerts on high‑risk claims. 

• Actionable metrics: Real‑time dashboards that tie denial causes back to CMS‑critical satisfaction and complaint measures. 

• Faster first‑claim processing: Members receive uninterrupted care, reducing complaints and keeping retention intact. 

The shift is decisive: modern claims adjudication prevents errors upstream instead of drowning teams in denials downstream. 

Why Mirra Healthcare is Built for AEP Claims Success

At Mirra Healthcare, our claims adjudication solution is designed to handle the surge and complexity of AEP with precision, speed, and compliance.  

Here’s how Mirra strengthens claims adjudication for health plans:  

• High Auto-Adjudication Rates – Mirra’s ClaiMaster® engine is built for CMS‑mandated EDI claims, achieving a high level of automation and timeliness in processing. This ensures faster onboarding and smoother claims flow during AEP surges.  

• Customizable & Configurable Rules – Plans can configure benefits flexibly, ensuring accurate adjudication across HMO, PPO, Dental, Vision, and other plan types, without breaking under AEP volume pressure.  

• Built‑In CMS Edits & Quality Checks – With more than 40 million built‑in edits (including CMS NCCI edits), Mirra flags eligibility mismatches, coding inaccuracies, and potential fraud/waste/abuse before they become denials.  

• Integrated Eligibility & Pricing – The platform integrates with utilization management and built‑in pricers (Inpatient, Outpatient, PDPM), preventing costly coordination errors during member onboarding and claims.  

• Automation Across Claim Types – Mirra auto‑processes professional, institutional, and dental claims, while also generating EOBs, EOPs, overpayment letters, and denial notices to maintain full CMS compliance.  

• Actionable Dashboards & Reports – With SSRS and Power BI analytics, plans can monitor claims flow and denial trends in real time. This is vital for identifying AEP‑specific spikes before they escalate.  

• Proven Scalability During AEP – Purpose‑built to support both electronic and paper claims (via ClaimsLite® for paper entry), Mirra ensures plans don’t crack under enrollment surges.   

Most importantly, Mirra’s claims adjudication solution protects member trust. By ensuring accuracy, transparency, and compliance at scale, we help plans prevent denials, accelerate payments, minimize grievances, and safeguard CMS Star Ratings during AEP and beyond.  

Beyond claims, Mirra’s end‑to‑end Medicare Advantage in a Box solution helps health plans simplify enrollment, billing, and compliance giving you a single, integrated system. 

Read on to know How to Prevent Healthcare Billing Farud with Mirra 

Conclusion

Your AEP strategy can’t stop at enrollment campaigns or even at premium billing. The very first claim is the moment of truth. Inaccurate adjudication during AEP creates denial spikes, member frustration, CMS complaints, and long‑term losses.  

Accurate claims adjudication, powered by the right partner, is the true foundation of AEP success in 2025.  

October 15 is coming fast. One denied first claim can cascade into complaints, Star rating damage, and member churn. Don’t let outdated systems put your AEP at risk. Mirra’s claims adjudication platform is AEP‑ready today. Book your AEP readiness session with Mirra Healthcare now. 

For more expert perspectives on Medicare Advantage operations and AEP readiness, explore Mirra’s latest Insights. 

References:

1. CMS. Fiscal Year 2024, Improper Payments Fact Sheet 

2. CMS. Contract Year 2025 Medicare Advantage and Part D Final Rule   

3. CMS. Medicare Advantage/Part D Contract and Enrollment Data