834 Supplemental Eligibility Guide › 5010 Companion Guides › NEW 834... · 2020-03-11 ·...

Supplemental 834 Eligibility Guide State of Idaho MMIS

Date of Publication: 02/17/2020 Document Number: TL636 Version: 2.0

Idaho MMIS Supplemental 834 Eligibility Guide

Last Updated: 02/17/2020 Page ii

Revision History

Version Date Author Action/Summary of Changes 1.0 8/5/2019 Chad Steinhauser Initial Draft for CCF 10839B1. Will

replace previous Supplemental Guide. 1.1 8/21/2019 Flo Clarke Reviewed. Approved.

1.2 8/21/2019 Myranda Payne Infomal approval provided by DHW on 8/21/2019. Accept changes, and PDF for vendor use.

1.3 9/16/2019 Chad Steinhauser Added the concatentation of +SEC and +COB to the non-medicare identification code in 2320 COB02. Medicare records already have MED_A and MED_B concatenated.

1.4 9/19/2019 Chad Steinhauser Updated external COB to say Third Party Liability for COB records that will be concatenated with +COB.

1.5 9/23/2019 Flo Clarke Reviewed. Informally approved. 1.6 12/19/2019 B Oliverez Reviewed for formatting and

standards. 2.0 02/17/2020 TQD Finalized per DHW approved via

UB02219. 2018-2019 DXC Technology Company. All rights reserved. - http://www.dxc.technology/legal

http://www.dxc.technology/legal


Last Updated: 02/17/2020 Page iii

Table of Contents 1. Base-to-Vendor 834 Eligibility File Data .................................................................. 1

1.1. Reference Items and Locations ........................................................................ 1 1.2. Overview ...................................................................................................... 1 1.3. Open Construction Items ................................................................................ 1 1.4. Acronyms and Definitions ................................................................................ 1 1.5. Selection Criteria ........................................................................................... 2

1.5.2. Operational Information ............................................................................ 4 Appendix A. ............................................................................................................... 5

Interface Synopsis –Base-to-Vendor 834 Eligibility File Data ......................................... 5 Interface Mapping –Base-to-Vendor 834 Eligibility File Data Layout ............................... 6

Table of Figures

Figure 1-1: Reference Items ........................................................................................ 1 Figure 1-2: Open Construction Items ............................................................................ 1 Figure 1-3: Acronyms and Definitions ........................................................................... 1 Figure 1-4: 834 Data File ............................................................................................ 5 Figure 1-5: 834 Data File Layout .................................................................................. 6


Last Updated: 02/17/2020 Page 1 of 42

1. Base-to-Vendor 834 Eligibility File Data

1.1. Reference Items and Locations Figure 1-1: Reference Items

Document Title/File Location Version Publication Date

1.2. Overview This document defines the technical specifications and narrative for interfacing the -HIPAA compliant generic X-12 834 Base-to-Vendor Eligibility File Data to corresponding Idaho Department of Health & Welfare (DHW) Health PAS solution system tables. This interface will supply demographic, eligibility, provider COB and member condition information to the vendor.

1.3. Open Construction Items Figure 1-2 below provides a list (if applicable) of the open construction items. These will need to be resolved before build and unit testing can be completed.

Figure 1-2: Open Construction Items

Open Construction Items Status

N/A

1.4. Acronyms and Definitions Figure 1-3 provide a list of acronyms and definitions for the Base-to-Vendor 834 Eligibility File Data. Figure 1-3: Acronyms and Definitions

Acronym Definition

ADD Addition AUD Audit BA Business Associate COB Coordination of Benefits DDI Design, Development, and Implementation DEL Deletion or Voided DHW Department of Health and Welfare EDI Electronic Data Interchange FDS Family Directed Services HIPAA Health Insurance Portability and Accountability Act of 1996 HIPP Health Insurance Premium Payment IBES Idaho Benefits Eligibility System JAD Joint Application Development, term used for requirements validation



Acronym Definition

MMCP Medicare/Medicaid Coordinated Plan MMIS Medicaid Management Information System sFTP Secure File Transfer Protocol SOC Share of Cost SQL Standard Query Language UPD Update X12 Accredited Standards Committee X12N Insurance Subcommittee

1.5. Selection Criteria The selection criteria will vary between the daily, monthly and initial based on the data included in those files. The filtering criteria is identified in the next section and will be the same for the daily, monthly and initial file. The monthly file will only use the member, eligibility and MMCP MemberPCP filtering criteria for the vendor to identify which members to include even though eligibility and MemberPCP data is not included in the outbound file. The filtering criteria for COB, conditions and non MMCP MemberPCP data will not be used to generate the monthly file.

Daily: The daily file will contain the changed data of all members that are part of the vendors population based on the vendors specific filtering criteria and will include eligibility, COB, demographic, provider or member condition updates since the interface last run date.

Monthly: The monthly will be executed on the last working day of every month and after the IBIS monthly file has been executed. It will contain all members that are part of the vendor’s population that match the vendor’s specific filtering criteria for members that are active. Active will be considered as having primary Medicaid eligibility with a term date greater than today’s date. The file will only contain member demographic information and will not contain rate code eligibility, COB, provider or condition data. Eligibility and MemberPCP data will only be used to allow filtering criteria to be applied.

Initial: The initial file will contain all members that are part of the vendor’s population with all of their current active demographic, eligibility, COB, provider and condition data that match the vendor’s specific filtering criteria. Active will be considered eligibility, COB, provider and conditions with a term date greater than today’s date. Only records with a term date greater than today’s date will be included in the initial. The initial run will be scheduled as part of the go live for a vendor or on an as needed basis.

1.5.1.1. Filtering Criteria Each vendor file can be customized to use a filtering parameter. Filtering criteria can utilize “AND” logic but not “OR” logic. For example filtering parameter requested requires a specific plan id “AND” a specific set of rate codes, then the eligibility record must include both the rate code “AND” the plan for the record to be returned in the data set. The customization of the selection criteria is subject to approval by DHW management.



The filtering criteria by parameter listed: Parameter Description

MEM_834_PLANID A vendor can be configured to allow specific plans to be selected.

MEM_834_ALLRATECODES A vendor can be configured to allow all rate codes to be selected. If all rate codes are allowed then specific rate codes cannot be defined.

MEM_834_RATECODE A vendor can be configured to only allow specific rate codes.

MEM_834_COVERAGECODE A vendor can be configured to only allow specific coverage codes. Coverage codes are not but they are used to ensure the correct eligibility segments are included due to secondary coverages that utilize the same rate codes.

MEM_834_EXCLUDENINED A vendor can be configured to exclude members that have been nined by placing a “9” in front of their last name.

MEM_834_MEMBERPCP_NONSPECIFIC

A vendor can be configured to include all MMCP data regardless of the network or affiliate it is associated with.

MEM_834_MEMBERPCP_ATYPICALID

A vendor can be configured to further filter MMCP data based on an atypical id.

MEM_834_CONDITION A vendor can be configured to include Condition data based on the inclusion of a condition_id.



1.5.2. Operational Information This file can be processed as a daily, monthly or initial to be transmitted to the EDI gateway for 834 formatting and placed on the Trading partners mailbox.

1.5.2.1. Maintenance Type Codes 001 – Change

• DXC Technology Medicaid refers to change records as updates (UPD) internally. • Reasons a UPD record would be sent:

o Update(s) to rate code eligibility date span, specifically end dates. o Updates to member demographic information such as address(es) and

name(s). 021 – Addition

• DXC Technology Medicaid refers to addition records as (ADD) internally. • ADDs are for new members or new Medicaid eligibility never sent previously. ADDs in

the eligibility loop can occur in conjuction with a retro termination of eligibility in which case the existing eligibility records will receive a DEL and the eligibility with the retro term date will appear as an ADD.

024 – Cancelation or Termination • DXC Technology Medicaid refers to cancelation records as deletes (DEL) internally. • Only used to void eligibility for members that were in prior eligibility file(s). • An eligibility cancelation is often preceded by an eligibility ADD; however, there are

times that a cancelation does not have an accompanying ADD record. • A cancelation may contain eligibility not previously sent if multiple eligibility

segments are associated with the EnrollID on the source system and only the latest active eligibility was sent through the Initial file. In this case VOID all eligibility associated with the EnrollID regardless of the EnrollCoverageID included.

030 – Audit or Compare • DXC Technology Medicaid refers to audit records as (AUD) internally. • They are to be used by the receiver for reconciliation purposes. • Reasons as to why a AUD record would be sent:

o A member has COB data that is active when a member’s eligibility has termed. o During the time the member is not eligible, the COB segment is ended.

This will not be sent. o When the member becomes active again, we will send the eligibility segment

and they are expected to term all sub-entity data such as COB/SOC/PCP because of omission.

o To support the sending of child loops. For example, when sending a change to eligibility loop 834: 2300 with no change to demographic information the demographic loop 834: 2000 will be sent as an AUD 030. This is accurate for all parent child relationships including demographic(834: 2000)/headofhouse(834: 2100F), demographic(834: 2000)/condition(834: 2750), demographic(834: 2000)/eligibility(834: 2300), eligibility(834: 2300)/provider(834: 2310), and eligibility(834: 2300)/COB(834: 2320).

Additional processing rules for maintenance codes • Identical ADDs, UPDs, DELs or AUDs may be sent in the same file due to a variety of

conditions including but not limited to maximum entries for a child loop reached. The identical records, regardless of loop only need to be processed a single time.



Appendix A.

Interface Synopsis –Base-to-Vendor 834 Eligibility File Data Figure 1-4: 834 Data File

Base-to-Vendor 834 Eligibility File Data

To Be:

Description: Daily: Send a delta file containing all members with Medicaid updates since the interface last run date. Monthly: Send a file of all active members that match the vendor’s specific filtering criteria on the last working day of the month. Initial: Send a file containing all active data of members that match the vendors specific filtering criteria during vendor go live or on an as needed basis.

File Name: int_exp_eligibility_XXXXX_Z_CCYYMMDD where XXXXX is the roster number of the specific vendor and Z is either D, I, or M for daily, initial or monthly

File Layout: XML Estimated

Number of Records:

# of Rec Types/Layouts:

1

Import/Export: Export Media: EDIGateway Frequency: Initial, Daily and Monthly Full/Incremental Incremental/Full Selection Criteria: Please see Selection Criteria listed above for Initial, Daily and

Monthly extract State DDI Contact

Information: MSST (Medicaid Support System Team)

State BA/Technical Contact Information:

MSST (Medicaid Support System Team)

Source: BASE MMIS

Source Vendor Contact Information:

DXC Technology Vendor Liaison

Target: Vendor Target Vendor

Contact Information:

JAD: N/A Error Type and

Action: Record Level



Interface Mapping –Base-to-Vendor 834 Eligibility File Data Layout The XSD contains the location of the field name or attribute within the XML file.

Figure 1-5: 834 Data File Layout

Base-to-Vendor 834 Eligibility File Data Layout

Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type

Source Valid Values/Range

Transformation Rule

Comments

<output_file />

The root element of the output file. There can only be one.

<output_file filetype=”” />

I = Initial D = Daily M = Monthly

I|D|M 834: HEADER BGN08

<output_file vendor=”” />

Roster number XXXXX-{Short Description}

834: HEADER BGN08

<demo />

The demographic data can be filtered on whether or not to include members that have been nined.

The main element that will act as the container for all data sent for a member. This element will always be included in the Daily, Monthly and Initial files.




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

<demo memberactionind=”” />

NA NA 4 Alphanumeric If member.createdate or entity.createdate> last run date then ‘ADD’ Else If member.updatedate or entity.updatedate > last run date then ‘UPD’ Else ‘AUD’ An ADD identifies a new member that the vendor has previously not received, UPD identifies a change to that members demographic data and an AUD indicates no changes to the demographic data. 834: 2000 INS03

<demo secondaryid=”” />

Member.secondaryid

member 15 Alphanumeric 834: 2000 REF02




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

<demo lastname=”” />

Lastname entity 60 Alphanumeric Member’s last name 834: 2100A NM103

<demo firstname=”” />

Firstname entity 35 Varchar Member’s first name 834: 2100A NM104

<demo middleinitial=”” />

Middlename entity 30 Alphanumeric Left(member,middlename,1)

Member’s middle initial 834: 2100A NM105

<demo ssn=”” />

SSN Member 15 Alphanumeric SSN 834: 2100A, NM109 where NM108 = ‘34’

<demo dob=”” />

dob member Datetime CCYY-MM-DD HH:MM:SS

Entity.entid=member.entityid -> member.dob reformat to CCYYMMDD

Member’s date of birth in format CCYYMMDD 834: 2100A DMG02

<demo deathdate=”” />

Deathdate Member Datetime CCYY-MM-DD HH:MM:SS

Entity.entid=member.entityid -> member.deathdate reformat to CCYYMMDD

Member’s date of death in format CCYYMMDD 834: 2000 INS12




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

<demo sex=”” />

Sex member 1 Alphanumeric M – Male F - Female

Entity.entid=member.entityid -> member.sex

Member’s gender 834: 2100A DMG03

<demo ethnicity=”” />

Ethnicid Member 15 Character Qnxt values C00307910 – Other ETHN0001 – Caucasian ETHN0002 – Hispanic ETHN0003 – African American ETHN0004 – Asian/Pacific ETHN0005 – Alaskan/Amer Indian ETHN0006 – Filipino ETHN0007 – Unknown ETHN0008 – Amerasian

E Other race or ethnicity = C00307910 O White non-hispanic = ETHN0001 H Hispanic = ETHN0002 – Hispanic B Black = ETHN0003 A Asian or Pacific Islander = ETHN0004 I American Indian or Alaskan Native = ETHN0005 P Pacific Islander = ETHN0006

834: 2100A DMG05-1




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

ETHN0009 – CHINESE ETHN0010 – Cambodian ETHN0011 – Japanese ETHN0012 – Korean ETHN0013 – Samoan ETHN0014 – Asian Indian ETHN0015 – Hawaiian ETHN0016 – Guamanian ETHN0017 – Laotian ETHN0018 - Vietnamese

7 Not Provided = ETHN0007 D Subcontinent Asian = ETHN0008 U Asian = ETHN0009 U Asian = ETHN0010 U Asian = ETHN0011 U Asian = ETHN0012 V Native Hawaiian or Other Pacific Islander = ETHN0013 D Subcontinent Asian American = ETHN0014 J Native Hawaiian = ETHN0015




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

P Pacific Islander = ETHN0016 F Asian Pacific American = ETHN0017 – Laotian U Asian = ETHN0018 Handled by the MEM_834_ETHNICITY_TRANSLATION parameter.

<demo mailingaddress1 =”” />

Addr1 entity 60 Alphanumeric ONLY 0-9 & A-Z, replace all ascii or other characters (example, colons) w/a space Required

Member’s first address line 834: 2100C N301

<demo mailingaddress2=”” />

Addr2 entity 60 Alphanumeric ONLY 0-9 & A-Z, replace all ascii or other characters (example, colons) w/a space

Member’s second address line 834: 2100C N302




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

<demo mailingcity=”” />

City entity 30 Alphanumeric If city is less than 2 characters and all other address values are present (state/zip etc.) then city should be ‘UNK’ Required field If city is less than 2 characters and all other address values are not present then city along with all address values should be null

Member’s city 834: 2100C N401

<demo mailingstate=”” />

State entity 2 Alphanumeric Must pass valid 2 character state abbreviation required

Member’s state 834: 2100C N402




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

<demo mailingzip=”” />

Zip entity 9 Alphanumeric left(entity.zip,5), If all other address field are not empty, and if zip contains a non-numeric character or is less than 5 digits, default to “99999”. Remove trailing spaces Require

Member’s zip code 834: 2100C N403

<demo physicaladdress1=”” />

phyAddr1 entity 60 Alphanumeric ONLY 0-9 & A-Z, replace all ascii or other characters (example, colons) w/a space Required If no physical address and all other address fields are blank default to 450 W. State Street

Member’s first address line 834: 2100A N301

<demo physicaladdress2=”” />

phyAddr2 entity 60 Alphanumeric ONLY 0-9 & A-Z, replace all ascii or other characters (example, colons) w/a space

Member’s second address line 834: 2100A N302




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

<demo physicalcity=”” />

phyCity entity 30 Alphanumeric If city is less than 2 characters and all other address values are present (state/zip etc.) then city should be ‘UNK’ If city is less than 2 characters and all other address values are not present then default city to Boise

Member’s city 834: 2100A N401

<demo physicalstate=”” />

phyState entity 2 Alphanumeric Must pass valid 2 character state abbreviation Required Default to ID if blank and all other address fields are blank

Member’s state 834: 2100A N402




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

<demo physicalzip=”” />

phyZip entity 9 Alphanumeric left(entity.zip,5), If all other address field are not empty, and if zip contains a non numeric character or is less than 5 digits, default to “99999”. Remove trailing spaces Required If blank and all other addresses are blank, default to 83720

Member’s zip code 834: 2100A N403

<demo phone=”” />

Phone entity 15 Alphanumeric Format: No dashes

Member’s phone number 834: 2100A PER04




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

<demo primarylanguage=”” />

languageid language 15 Alphanumeric ARA,Arabic CHI,Chinese ENG,English FRE,French GER,German HAT,Haitian HIN,Hindi JPN,Japanese KUR,Kurdish LAO,Laotian POR,Portuguese RUM,Rumanian RUS,Russian SCC,Serbo-Croation SPA,Spanish= THA,Thai VIE,Vietnamese UND,Null

ARA=LAN0004 CHI=LAN0011 ENG=LAN0086 FRE=LAN0023 GER=LAN0025 HAT=C00307210 HIN=LAN0029 JPN=LAN0040 KUR=C00307211 LAO=LAN0046 POR=LAN0059 RUM=LAN0062 RUS=LAN0063 SCC=LAN0065 SPA=LAN0072 THA=LAN0076 VIE=LAN0082 else, UND Handled by MEM_834_LANGUAGE_TRANSLATION parameter

Primary language of the member 834: 2100A LUI02




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

<headofhouse />

The headofhouse element will act as the container for all headofhouse data sent for a member. This element will be included in the daily only if headofhouse information is changed. This element will not be included in the monthly file. This element will always be included in the initial file.




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

<headofhouse memberactionind=”” />

If member.createdate or entity.createdae> last run date then ‘ADD’ Else If member.updatedate or entity.updatedate > last run date then ‘UPD’ Else ‘AUD’ This field is not included in the outbound 834 but has been identified to aid in research.




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

<headofhouse secondaryid=”” />

HeadofHouse

member 15 Alphanumeric Headofhouse SecondaryID (State Identifiers not supported in the 834) This field is not included in the outbound 834 but has been identified to aid in research.

<headofhouse firstname=”” />

Firstname entity 35 Varchar Headofhouse first name 834: 2100F NM104

<headofhouse lastname=”” />

Lastname entity 60 Alphanumeric Headofhouse last name 834: 2100F NM103




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

<headofhouse ssn=”” />

SSN Member 15 Alphanumeric When a Head of House first name and last name is found and the SSN is less than 9 digits the SSN will be set to 000000000 otherwise if a first name and last name is not found and the SSN is empty or less than 9 digits it will be set to blank.

Headofhouse SSN 834: 2100F NM109 where NM108 = ‘34’

<headofhouse mailingaddress1=”” />

Addr1 entity 60 Alphanumeric ONLY 0-9 & A-Z, replace all ascii or other characters (example, colons) with a space Not required

First address line 834: 2100F N301

<headofhouse mailingaddress2=”” />

Addr2 entity 60 Alphanumeric ONLY 0-9 & A-Z, replace all ascii or other characters (example, colons) with a space

Second address line 834: 2100F N302




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

<headofhouse mailingcity=”” />

City entity 30 Alphanumeric If city is less than 2 characters and all other address values are present (state/zip etc.) then city should be ‘UNK’ If city is less than 2 characters and all other address values are not present then city along with all address values should be null

City 834: 2100F N401

<headofhouse mailingstate=”” />

State entity 2 Alphanumeric Must pass valid 2 character state abbreviation

State 834: 2100F N402




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

<headofhouse mailingzip=”” />

Zip entity 9 Alphanumeric left(entity.zip,5), If all other address field are not empty, and if zip contains a non numeric character or is less than 5 digits, default to “99999”. Remove trailing spaces

Zip code 834: 2100F N403

<eligibility />

The eligibility elements will include Medicaid records for both primary and secondary rate codes that match the identified filtering criteria for a vendor based on planid, ratecode, and coveragecodes. For MMCP records they may be further filtered through the use of atypicalid’s to

The eligibility element will act as the container for all eligibility information. The daily file will only include this element if there was a change to the eligibility information or to provider or COB information that is stored in a sub-loop under eligibility.




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

specify a specific vendors MMCP data.

The monthly file will never include the eligibility element. The initial file will include the latest active eligibility information.

<eligibility healthcoverageactionind=”” />

NA NA 4 Alphanumeric If enrollkeys.lastupdate > last run date and enrollkeys.segtype voided then ‘DEL’ Else If enrollcoverage.createdate > last run date then ‘ADD’ Else If enrollcoverage.updatedate > last run date ‘UPD’ Else ‘AUD’ If the record is from enrollcoverage_audit it will be a ‘DEL’




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

An ADD indicates this is a record that the vendor has never received or is being sent to replace voided eligibility with similar information. A DEL indicates a voided record that should have never existed or was voided and a new eligibility record was sent as an ADD to replace it. An UPD indicates eligibility that has changed. An AUD is an eligibility record that has no changes but is being sent to support other information in the 834.




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

834: 2300 HD01

<eligibility enrollid=”” />

Enrollid

Enrollcoverage

30 Alphanumeric The EnrollID is the parent ID that will reference one of more EnrollCoverageID’s and should be used by the vendor to expedite the processing of voids. An EnrollID identified as a Void will Void any associated EnrollCoverageID. 834: 2300 REF02 (REF01 set to X9)




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

<eligibility enrollcoverageid

Enrollcoverageid

Enrollcoverage

30 Alphanumeric The EnrollCoverageID is a child ID of EnrollID and represents individual eligibility records. When an ADD or UPD is processed action should be taken against the current eligibility record in the vendors system with that EnrollCoverageID record. 834: 2300 REF02 (REF01 set to X9)

<eligibility ratecode=”” />

Ratecode Enrollcoverage

30 Alphanumeric Two-digit Medicaid aid category code that identifies what a member is covered under. 834: 2300 REF02 (REF01 set to RB)




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

<eligibility effdate=”” />

For Eligibility: Effdate For Share of Cost: If Aid Category Code = 14,15,17 then soc_startdate If Aid Category = 43 then effdate

For Eligibility: enrollcoverage For Share of Cost: If Aid Category Code = 14,15,17 then Healthpas_Common..CS_PrimaryShareOfCost If Aid Category = 43 then memberattribute

8 Smalldatetime

CCYY-MM-DD HH:MM:SS

Reformat in CCYYMMDD format

Medicaid eligibility effective date Format CCYYMMDD 834: 2300 DTP03 where DTP01 = ‘348’ Contains SOC eff date if there is a value in SOC AMT.




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

<eligibility termdate=”” />

For Eligibility: termdate For Share of Cost: If Aid Category Code = 14,15,17 then soc_enddate If Aid Category = 43 then termdate

For Eligibility: enrollcoverage For Share of Cost: If Aid Category Code = 14,15,17 then Healthpas_Common..CS_PrimaryShareOfCost If Aid Category = 43 then memberattribute

8 Smalldatetime

CCYY-MM-DD HH:MM:SS

Reformat in CCYYMMDD format

Medicaid eligibility term date Format CCYYMMDD 834: 2300 DTP03 where DTP01 = ‘349’ Contains SOC term date if there is a value in SOC AMT. Magellan will not be receiving SOC information.




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

<eligibility socamt=”” />

If Aid Category Code = 14,15,17 then socamount If Aid Category = 43 then thevalue

If Aid Category Code = 14,15,17 then memshareofcost If Aid Category = 43 then memberattribute

If Aid Category Code = 14,15,17 then zmoney If Aid Category = 43 then 60

If Aid Category Code = 14,15,17 then zmoney If Aid Category = 43 then varchar

Share of Cost Amount 834: 2300 AMT02 where AMT01 = ‘C1’ Blank if the record is associated with Eligibility and not SOC.

<eligibility mmcprecordtype=”” />

case when ec.termdate <> '2078-12-31' and m.deathdate is not null and ek.segtype in ('INT') and ec.coveragecodeid = 'MMCP' and ek.lastupdate >

834: 2300 REF02 (REF01 set to CE)




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

@lastrundate and ec.lastupdate > @lastrundate and ec.coveragecodeid = 'MMCP' then 'V' when ec.coveragecodeid in ('ENHANCED') then 'P' when ek.segtype = 'INT' and ec.termdate <> '2078-12-31' and ec.coveragecodeid = 'MMCP' then 'T' when ek.segtype = 'INT' and ek.termdate = '2078-12-31' and ec.coveragecodeid = 'MMCP' then 'A'




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

when ek.segtype = 'DEL' then 'V' when ek.termdate <> '2078-12-31' then 'T' else '' end

<condition />

The condition element will act as the container for all condition data. This element will only be included in the daily file if data has changed. This element will never be included in the monthly file. This element will be included in the initial if there is an active condition.




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

<condition condition=”” />

ConditionID MemberCondition

60 Alphanumeric This is handled by the Translation parameter MEM_834_CONDITION_TRANSLATION which presently contains the following translations QMXCD00175 = PREGNANCY CND00005 = YES

Pregnancy/YES Indicator 834: 2750 N102 = ‘PREGNANCY’ or ‘YES’

<condition effdate=”” />

effdate MemberCondition

8 Numeric YYYMMDD member.memid= membercondition.memid -> membercondition.effdate If the condition_effdate > condition_termdate, then set condition_effdate = condition_termdate and load.

Effective date of the condition. Format YYYYMMDD. 834: 2750 DTP03 where DTP01 = 007




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

<condition termdate=”” />

ReconsiderDate TermDate

MemberCondition

8 Numeric YYYYMMDD This is handled by the Translation parameter MEM_834_CONDITION_TERMDATE_TRANSLATION which presently contains the following translations QMXCD00175 = RECONSIDERDATE CND00005 = TERMDATE

Termdate of the condition. 834: 2750 DTP03 where DTP01 = 007




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

<PCP /> The PCP element will act as a container for all MemberPCP data of PCPType = PCP sent for a member. This element will be included in the daily only if MemberPCP information has changed. This element will never be included in the monthly file. This element will always be included in the initial file for active MemberPCP records with a PCPType = PCP.




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

<PCP providerid=”” />

Provid NPI

provider 10 char If NPI = ’’ then ProvID else NPI

834: 2310 NM109

<pcp effdate=”” />

8 Smalldatetime

834: 2310 PLA03

<pcp termdate=”” />

8 smalldatetime

(No 834 available) If the record included is from MemberPCP_Audit then this date will be equal to PCP Effective Date indicating it is a void. The 834 transformation for this scenario will store a 22 in 2310 PLA05 otherwise it will remain AI.

<pcp lastname=”” />

Lastname Entity 60 character 834: 2310 NM103

<PCP firstname=”” />

Firstname Entity 35 varchar 834: 2310 NM104




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

<PCP mailingaddress1=”” />

Addr1 entity 60 Alphanumeric 834: 2310 N301

<PCP mailingaddress2=”” />

Addr2 Entity 60 Alphanumeric 834: 2310 N302

<PCP mailingcity=”” />

City Entity 30 Alphanumeric 834: 2310 N401

<PCP mailingstate=”” />

State Entity 2 Alphanumeric 834: 2310 N402

<PCP mailingzip=”” />

Zip Entity 9 Alphanumeric 834: 2310 N403

<PCP phone=”” />

Phone Entity 15 Alphanumeric 834: 2310 PER04

<COB /> The maximum number of COB records that can be included in a loop are five. If there are more than five COB records they need to be split up and

The COB element will act as the container for all COB data sent for a member. This element will be included in the daily only if the COB information has changed.




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

associated with a parent eligibility record. COB records are not filtered and all BP0002, BP0003, COB01, COB02, and COB04 plans are included. COB records will also include MemberPCP records with a PCPType = SEC.

This element will not be included in the monthly file. This element will always be included in the initial file for active COB information.

<COB cobactionind=”” />

Createdate Lastupdate Changetype Time_of_change Createdate Lastupdate Changetype Time_of_change

Enrollcoverage Enrollcoverage_audit MemberPCP MemberPCP_Audit

If enrollkeys.lastupdate > last run date and enrollkeys.segtype voided then ‘DEL’ Else If enrollcoverage.createdate > last run date then ‘ADD’ Else If enrollcoverage.up




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

datedate > last run date ‘UPD’ Else ‘AUD’ If the record is from enrollcoverage_audit it will be a ‘DEL’ Iff memberpcp.createdate > last run date then ‘ADD’ Else If memberpcp.updatedate > last run date ‘UPD’ Else ‘AUD’ If the record is from memberpcp_audit it will be a ‘DEL’ An ADD indicates a record the vendor has not previously received. An UPD indicates there




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

was a change to the record that the vendor needs to update. A DEL indicates the record should be removed. The AUD indicator identifies that there was no change to this record. 834: 2320 REF02

<COB identificationcode=”” />

Enrollid Hic Ratecode NPI or ProvID

Enrollkeys Latest membercmshic Enrollcoverage Provider

50 Alphanumberic

For MED_A and MED_B concatenate enrollid, hic and ratecode using a ”+” to separate the values. ---------- For Third Party Liability concatenate enrollid, CarrierMemID, coverage_code and the value

834: 2320 COB02




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

’COB’ using a ”+” to separate the values. ---------- For MemberPCP records of PCPTYPE=SEC concatenate NPI or if NPI is empty use PROVID and the value ’SEC’ using a ”+” to separate the values.

<COB effdate />

Effdate Effdate

Enrollcoverage MemberPCP

8 Smalldatetime

834: 2320 DTP03 where DTP01 = ‘344’

<COB termdate=”” />

Termdate Termdate

Enrollcoverage MemberPCP

8 smalldatetime

834: 2320 DTP03 where DTP01 = ‘345’




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

<COB primarystatus=”” />

Primarystatus

Enrollstatus

1 character When COBACTIONIND = ‘DEL’ then ‘U’ otherwise use PrimaryStatus value When PCPType=SEC then ’S’

834: 2320 COB01

<COB fullname=”” />

Fullname Fullname

Carrier Provider

If networkid = ‘PRZ000000067721’ then prepend IMP+ to COB fullname 834: 2330 NM103

<COB mailingaddress1=”” />


<COB mailingaddress2=”” />


<COB mailingcity=”” />

City Entity 30 Alphanumeric 834: 2330 N401




Field Name

Source Column Name

Source Table Name

Source Field

Length

Source Field Type


Transformation Rule

Comments

<COB mailingstate=”” />

State Entity 2 Alphanumeric 834: 2330 N402

<COB mailingzip=”” />

Zip entity 9 Alphanumeric left(entity.zip,5), If all other address field are not empty, and if zip contains a non numeric character or is less than 5 digits, default to “99999”. Remove trailing spaces

834: 2330 N403

<COB phone=”” />

Phone entity 15 Alphanumeric Format: No dashes

834: 2330 PER04

834 Supplemental Eligibility Guide › 5010 Companion Guides › NEW 834... · 2020-03-11 ·...

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