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CYE ’09 Prospective
Offeror Technical Overview
CYE ’09 Prospective Offeror Technical Overview
Introduction Technical Environment Interfaces
Recipient/Health Plan Provider Provider Affiliation Reference Encounters Reinsurance HIPAA
Questions
CYE ’09 Prospective Offeror Technical Overview
Provide all potential offerors with an overview of AHCCCS technical environment and data interface and standards.
INTRODUCTION
CYE ’09 Prospective Offeror Technical Overview
CYE ’09 Prospective Offeror Technical Overview
PSTN
Internet
Frame Relay
Telephone
Contractor
Firewall
HTTPS Server
Mainframe
PBX
VPN
AHCCCS Network Connectivity All information presented on this page is confidential.
CYE ’09 Prospective Offeror Technical Overview
CYE ’09 Prospective Offeror Technical Overview
•Interfaces•Recipient/Health Plan
•Encounters
•Provider/Provider Affiliation
•Reinsurance
•Reference
•Eligibility•Enrollment•Capitation•Processing•Data Exchange
CYE ’09 Prospective Offeror Technical Overview
CYE ’09 Prospective Offeror Technical Overview
CYE ’09 Prospective Offeror Technical Overview
DES
SSA
ACE
OTHER
ELIGIBILITY ADDS
DISCONTINUANCE
CHANGE TO
DEMOGRAPHICS
NAME
GENDER
DATE OF BIRTH
CHANGE IN ADDRESS
CONTRACTOR CHOICE
THIRD PARTY LIABILITY LEADS
CYE ’09 Prospective Offeror Technical Overview
DES
•1931
•S.O.B.R.A.
•TITLE 19 WAIVER
•HIFA PARENTS
•FEDERAL EMERGENCY SERVICES
CYE ’09 Prospective Offeror Technical Overview
DES
•SSI CASHSSA
CYE ’09 Prospective Offeror Technical Overview
DES
•ALTCS (ARIZONA LONG TERM CARE)
•SSI MAO
•FREEDOM TO WORK
•BCCTP
•MEDICARE COST SHARING
•KIDSCARE/HIFA PARENTS
•SSDI/TMC
SSA
ACE
CYE ’09 Prospective Offeror Technical Overview
DES• BEHAVORIAL HEALTH SERVICES
• CHILDRENS REHABILITATIVE SERVICES
• DES SPECIAL NEEDS (DDD)
• MEDICARE
• MEDICARE BUY IN
• MEDICARE HMO
• MEDICARE PART D
• VITAL STATISTIC (DOD)
SSA
ACE
OTHER
CYE ’09 Prospective Offeror Technical Overview
CYE ’09 Prospective Offeror Technical Overview
PRE-ENROLLMENT
Eligibility site provides Contractor availability information
Some eligibility sources will collect and send enrollment choice information or
Member may call Communication Center with choice
Member is enrolled in choice Contractor
CYE ’09 Prospective Offeror Technical Overview
BABY ARIZONA
Pregnant woman screened by Doctor
Application completed in Doctor’s office and sent to DES
Woman calls Communication Center from Doctor’s office with her choice of contractor
Member is enrolled in choice Contractor
CYE ’09 Prospective Offeror Technical Overview
ENROLLMENT DATES
Usually effective the day AHCCCS updates action
ProspectiveEnrollments
As of the 1st
of the next month(The Last Daily)
AdministrativeActions
Can be any day in the past
(Any Daily)
SystemUnavailable at
NotificationCan be retroactive
(Month End)
EXCEPTIONS:
CYE ’09 Prospective Offeror Technical Overview
DISENROLLMENT DATES
Normally effective the day prior to update
Date ofDeath
(Retroactive)
IncarcerationInstitutional
(Normal orRetroactive)
Linking / Duplicate
Enrollment
(Normal orRetroactive)
Administrative
(Normal orRetroactive)
For loss of eligibility, disenrollment is last day of month
VoluntaryWithdrawal
(Normal)
EXCEPTIONS:
CMDP(Foster Care)
(Normal)
CYE ’09 Prospective Offeror Technical Overview
COUNTY MOVES
Disenroll from current county effective day before and
Moves to a county which is served by current Contractor
enroll with same contractor in new county
Remain with contractor until end of month
Moves to a county which is NOT served by Contractor
Or until member chooses new Contractor
Member is AA if no choice is made by end of month
County to county move
County move with choice
CYE ’09 Prospective Offeror Technical Overview
ENROLLMENT RULES
90 day re-enrollment
Newborns
Family continuity
Enrollment choice
Native American on reservation zip code
Auto assignment
Less than 30 days of eligibility
CYE ’09 Prospective Offeror Technical Overview
ANNUAL ENROLLMENT CHOICE (AEC)
Each member case is assigned an anniversary month
AEC letter generated two months in advance
Members with Choice file generated to ContractorIdentifies all Contractor’s members who have opportunity to make a Contractor choice
Member makes choice
Potential Transitional ListingIdentifies all members who have made an AEC choice of the ContractorFile placed on VPN server with name of mmddyy.PTL
File placed on VPN server with name of ccyymm.MWC
CYE ’09 Prospective Offeror Technical Overview
OPEN ENROLLMENT
Special process when neededContractor terminationNew Contractor
Auto Assign population
Member makes choice (optional)
Potential Transitional ListingIdentified all member who will be enrolled into gaining contractor and those who will be leaving the losing contractor
Generate letter with AA Contractor with choice material
File placed on VPN server with name of mmddyy.PTL
CYE ’09 Prospective Offeror Technical Overview
ID CARDS
A file generated daily to vendor
Cards created for
Initial enrollment
Change of Contractors
On request to Communications Center
Lost / damaged / never received
When a new card is issued the old card is inactivated
Not a guarantee of eligibility or enrollment
CYE ’09 Prospective Offeror Technical Overview
CYE ’09 Prospective Offeror Technical Overview
CAPITATIONContractors receive weekly payments
Activity based on enrollment actionsCapitation calculated on
Contractor
GSA
Contract Type
Rate Code
Capitation calculated on per diem basisRate Days in the month days of enrollment thru end of month
Contractors receive payment notification via weekly 820 files
CYE ’09 Prospective Offeror Technical Overview
CAPITATIONRecoupments are subtracted from Contractor’s
weekly payments
Rate Days in the month days of disenrollment thru end of month
Recoupment calculated on per diem basis
Contractors receive payment notification via
weekly 820 files
CYE ’09 Prospective Offeror Technical Overview
SPECIAL PAYMENTS
Delivery SupplementalPaid when Contractor notifies AHCCCS of birthMother was enrolled with Contractor on DOBMother was not in PPC period on DOBOne Delivery Supplemental paid per delivery
Multiple births are considered one delivery
Payment made on Mother’s record
CYE ’09 Prospective Offeror Technical Overview
MASS ADJUSTMENTSAbility to change capitation payment for a population (Risk Group)
Payments which were paid in the past
Contractors receives notification via 820 file
No enrollment activity
Only reflect changes of payment due to change in payment rate
CYE ’09 Prospective Offeror Technical Overview
MANUAL PAYMENTS
Error in record prevents enrollment/disenrollment action from appearing on daily 834 fileManual capitation correction on an individual record
Activity will also appear on Manual Payment file
When no capitation is involved
Manual notification to Contractor
Payments will appear on the weekly 820 file
CYE ’09 Prospective Offeror Technical Overview
CYE ’09 Prospective Offeror Technical Overview
UPDATESOnline eligibility and enrollment updates to PMMIS occur between 6 am and 6 pm daily
Eligibility data created by AHCCCS by 5 pm will be process the same day
Eligibility data received from DES or SSA after 5pm will be updated to PMMIS the next day
In the event a member needs services and the Contractor has not received the daily 834 file, enrollment for the member can be verified using one of the automated verification processes.
CYE ’09 Prospective Offeror Technical Overview
DAILY BATCH PROCESSING CYCLE
Start at 6pm every evening
834 files available to Contractors no later than 7am
Enrollment activity includesEnrollmentsRetroactive enrollment blocksDisenrollments
Disenrollment blocksDemographic changes
Email notification if files will be delayed
CYE ’09 Prospective Offeror Technical Overview
‘LAST DAILY’ PROCESSING CYCLEThird day before the 1st of the next month
1/29/08, 2/27/08, 3/29/08, 4/28/08, etc
LAST DAILY
29
3130
282726252423
22212019181716
1514131211109
8765432
1SATFRITHURWEDTUESMONSUN
MARCH 2008
CYE ’09 Prospective Offeror Technical Overview
CYE ’09 Prospective Offeror Technical Overview
Starts at noon if on weekdays, 2am on weekendsMonthly process schedule available on AHCCCS Web site
Activity includesEnrollments, Retroactive enrollment blocks
Disenrollments, Disenrollment blocks
Demographic changes
Rate Code Changes
‘LAST DAILY’ PROCESSING CYCLE
ftp://ftp.azahcccs.gov/content/notice/hplan/hplan.htm#downtime
Third day before the 1st of the next month1/29/08, 2/27/08, 03/29/08, 04/28/08, etc
CYE ’09 Prospective Offeror Technical Overview
Occurs immediately after Last Daily CycleMonthly Enrollment Notification
Full file of all members enrolled in Contractor as of the 1st of the month
Basis for prospective capitation payment
File to be used to validate Contractor’s data
Discrepancies in Contractor’s data to be reported to DHCM
Management Reports
MONTHLY PROCESSING CYCLE
CYE ’09 Prospective Offeror Technical Overview
Starts at 6pm after completion of Monthly CycleOutput files available to Contractors by 7amIncludes all enrollment activity since last daily
Enrollments & Retroactive enrollment blocksDisenrollments
Will recoup prospective capitation already paidDisenrollment blocksDemographic changes
These must be processed after Last Daily and Monthly Enrollment Notifications
‘NEXT DAILY’ PROCESSING CYCLE
CYE ’09 Prospective Offeror Technical Overview
LAST DAILY
29282726252423
22212019181716
1514131211109
8765432
1SATFRITHURWEDTUESMONSUN
MARCH 2008
30 31NEXT DAILY
NEXT DAILY
CYE ’09 Prospective Offeror Technical Overview
CYE ’09 Prospective Offeror Technical Overview
VERIFICATIONObtain Eligibility, Enrollment, Medicare and TPL Coverage
•Single date of service•Range of days
•IVR
Automated processes available to AHCCCS registered providers
•MEVS•WEB
Communications Center available to AHCCCS member and providers
Contractors are encouraged to have their providers use the automated verification processes
CYE ’09 Prospective Offeror Technical Overview
VERIFICATION
Integrated Voice Response (IVR)
Telephone based verifications Available 24/7 No cost to providers Information faxed back to local area providers
Requires input of AHCCCS ID or SSN Real Time inquiry
Single Request
CYE ’09 Prospective Offeror Technical Overview
VERIFICATIONMedicaid Eligibility Verification System (MEVS)
PC or POS based verifications Available 24/7 Hardware/software provided by contracted vendors Contracted vendors charge providers
Requires input of AHCCCS ID or SSN or key demographic information Real Time inquiry Single or batch request
Ability to print information
CYE ’09 Prospective Offeror Technical Overview
VERIFICATION
WEB Based Verification
Internet based verifications Available 24/7
No cost to providers
Requires advance registration
Requires input of AHCCCS ID or SSN or key demographic information Real Time inquiry
Ability to print information
CYE ’09 Prospective Offeror Technical Overview
VERIFICATIONCommunications Center
Staffed by Customer Service Representatives Limited to business hours availability
No cost to providers Provides service to members and providers
Problem research and resolution Real Time inquiry
Accepts Newborn notifications from Contractors
Not available weekends
CYE ’09 Prospective Offeror Technical Overview
DATA EXCHANGEFrom AHCCCS to Contractors
Daily FilesEnrollment Notification (834)
Rate Code Summary
Manual Payment file
Third Party Liability File (in addition to 834)
Active Care File
Prior Plan File
yymmdd.DLR
yymmdd.MPR
yymmdd.DRC
yymmdd.TPL
yymmdd.ACR
yymmdd.PPL
CYE ’09 Prospective Offeror Technical Overview
DATA EXCHANGEFrom AHCCCS to Contractors
Weekly Files
Capitation Notification (820)yymmdd.820
CYE ’09 Prospective Offeror Technical Overview
DATA EXCHANGEFrom AHCCCS to Contractors
Monthly FilesEnrollment Notification (834)
Rate Code Summary
FYI data is included in 834
Members with Choice file
Potential Transitional Listing
Management Summary Reports
ccyymm.MTR
ccyymm.SUM
ccyymm.MWC
yymmdd.PTL
http://www.azahcccs.gov/Statistics/
CYE ’09 Prospective Offeror Technical Overview
DATA EXCHANGEFrom AHCCCS to Contractors
Unscheduled Files / As needed
Open Enrollment
Potential Transitional Listing
Mass Adjustment
Capitation Notification (820)
CYE ’09 Prospective Offeror Technical Overview
DATA EXCHANGEFrom Contractors to AHCCCS
Third Party Liability Updates
Electronic file
Newborn Notifications
Phone call Real Time entry/update
CYE ’09 Prospective Offeror Technical Overview
TESTING
Testing must be completed prior to:
Production implementation of a new Contractor
Change in software vendor or version upgrade
Change by AHCCCS resulting in an impact to any data exchange
Must be completed prior to any implementation
CYE ’09 Prospective Offeror Technical Overview
CYE ’09 Prospective Offeror Technical Overview
AHCCCS has contracts and agreements with Contractors, the AHCCCS Pharmacy Benefit Manager and other AHCCCS contractors to deliver medically necessary services to members.
AHCCCS requires that all providers utilized by Contractors to provide these services be registered with AHCCCS.
WHAT IS PROVIDER?
CYE ’09 Prospective Offeror Technical Overview
PROVIDER INTERFACEConsists of two files found in the VPN ShareINFO folder
Provider Profile
Provider Record
Produced weeklyCreated every WednesdayAvailable to Contractors Thursday
Provider Includes all provider types, service codes, and categories of service
Includes all AHCCCS registered providersIncludes active, terminated and suspended providers
Name: PROFILE.ZIP
Name: PROVIDER.ZIP
CYE ’09 Prospective Offeror Technical Overview
PROVIDER INTERFACEData included
Demographic dataProvider statusCategories of serviceService ratesLicenses/certificationsSpecialties
Medicare coverageRestrictionsService/billing addresses
CYE ’09 Prospective Offeror Technical Overview
CYE ’09 Prospective Offeror Technical Overview
PROVIDER AFFILIATION TRANSMISSION
The Provider Affiliation Transmission (PAT) is an integral part of the monitoring process in the Division of Health Care Management (DHCM) to ensure that Contractor’s provider networks are adequate and meet the minimum contractual requirements to deliver medically necessary services to members. This information is also used for reporting to CMS, legislature and other entities.
These requirements are presented in the AHCCCS Provider Affiliation Transmission User Manual.
CYE ’09 Prospective Offeror Technical Overview
PROVIDER AFFILIATION TRANSMISSION
Submitted quarterly Includes information about each individual provider within the Contractor’s network
Each PAT must represent the Contractor’s entire provider network
Contractor is responsible for submitting true and valid information Certain fields of the PAT are not systematically edited prior to acceptanceEach PAT must have an error rate of less than 3.0% for the fields that are edited prior to acceptance
CYE ’09 Prospective Offeror Technical Overview
PROVIDER AFFILIATION TRANSMISSION
If incorrect, Contractor may be considered to be noncompliant with obligation to submit an accurate PAT
Contractor may be required to make corrections immediately, submit a corrective action plan and subject to sanctions
AHCCCS conducts verification procedures to monitor accuracy of data submitted
CYE ’09 Prospective Offeror Technical Overview
PROVIDER AFFILIATION TRANSMISSIONReports
Transmission Validation Report
Provides information about the status of PAT
If all conditions are met, the transmission passes and is accepted for loading
If transmission fails, the transmission is rejected and returned to the Contractor for correction and resubmission
Found on VPN server under LGmmddyy.TXT
CYE ’09 Prospective Offeror Technical Overview
PROVIDER AFFILIATION TRANSMISSION
Reports
PAT Comparison-Exception by Provider
Provides a list of all exception errors that occurred during the PAT load process
All exception errors must be corrected prior to next submission
Sorted by Provider ID
Aids the Contractor in error correction
Found on VPN server under EPmmddyy.TXT
CYE ’09 Prospective Offeror Technical Overview
PROVIDER AFFILIATION TRANSMISSION
Reports
PAT Comparison-Exception by Field
Provides a list of all exception errors that occurred during the PAT load process
All exception errors must be corrected prior to next submission
Sorted by field in error
Aids the Contractor in error correction
Found on VPN server under EFmmddyy.TXT
CYE ’09 Prospective Offeror Technical Overview
PROVIDER AFFILIATION TRANSMISSION
Reports
PAT Comparison-Detail Report
Provides a complete list of all PAT data loadedSorted by Provider ID
Found on VPN server under LDmmddyy.TXT
CYE ’09 Prospective Offeror Technical Overview
PROVIDER AFFILIATION TRANSMISSION
Reports
Summary Totals Report
Provides summarized information about the providers listed on the PATIncludes totals of
PCPsPCPs with EPSDT servicesPCPs with OB servicesOB providersBH providers
Found on VPN server under ‘STmmddyy.TXT
CYE ’09 Prospective Offeror Technical Overview
CYE ’09 Prospective Offeror Technical Overview
REFERENCE
Recipient produces one reference fileMaster Carrier ID file
Complete file of TPL Carrier ID numberProduced every FridayPlaced in the ShareINFO folder as ‘RFCARIDmmddyy.TXT’
CYE ’09 Prospective Offeror Technical Overview
Three Encounter Reference files producedInternal Field Information
Error to Internal Field relationship
Error Codes and Descriptions
Provides mapping of Field name on a specific Form to an Internal table and Field name/number
Provides mapping for each Error Code on a specific Form and which Fields are used
Provides each Error Code and description
REFERENCE
Found in ShareINFO folder on VPN with name of ECFLD.TXT
Found in ShareINFO folder on VPN with name of ECERRFLD.TXT
Found in ShareINFO folder on VPN with name of ECERR.TXT
CYE ’09 Prospective Offeror Technical Overview
REFERENCE
Four service code related Reference files are produced
Procedure Tables
Procedure Modifiers
Provides Procedures, Maximum Allowable Charge, Categories of Service, Revenue to Bill Types and Revenue to Procedure Code information
Provides valid Modifiers for Procedure Codes
Found in ShareINFO folder on VPN with name of REFER01.ZIP
Found in ShareINFO folder on VPN with name of REFER02.ZIP
CYE ’09 Prospective Offeror Technical Overview
REFERENCEOutpatient Fee Schedules
ASC Group Reference
Provides OPFS Procedures Indicators and Values, Bundled Rate Driver Codes, Bundled Revenue codes, CCI Codes, Multiple Surgery Exception Codes, Limit Override Modifiers, Override Modifier Action Codes, Valid OPFS Procedure Modifiers and Limit Override Procedures
Provides valid ASC Group Bundled Service codes
Found in ShareINFO folder on VPN with name of REFER03.ZIP
Found in ShareINFO folder on VPN with name of REFER04.ZIP
CYE ’09 Prospective Offeror Technical Overview
CYE ’09 Prospective Offeror Technical Overview
AHCCCS ENCOUNTERS
The contents of an encounter record must meet the requirements prescribed by the Centers for Medicare and Medicaid Services (CMS) and accepted by AHCCCSA.
These requirements are presented in the AHCCCS Encounter Reporting User Manual.
CYE ’09 Prospective Offeror Technical Overview
ENCOUNTER SUBMISSION
Submitted by Contractor
837 FILES
HIPAA 837P (Professional)
HIPAA 837I (Institutional)
HIPAA 837D (Dental)
NCPDP V5.1 (Pharmacy)
Further details can be found in the Implementation Guides and AHCCCS Companion Documents
CYE ’09 Prospective Offeror Technical Overview
SUBMISSIONS
Submission standards are defined in the Encounter Reporting User Manual
AHCCCSA defines the receipt date for encounters as the date the encounter is received on the AHCCCS FTP server
CYE ’09 Prospective Offeror Technical Overview
SUBMISSIONS
Encounter data is loaded daily to a mainframe staging area where the encounter is held until loaded for processing
A copy of the encounter in its received form is maintained in a staging area
Contractors may submit as often as they deem necessary as each file is date and time stamped on the server
CYE ’09 Prospective Offeror Technical Overview
TECHNICAL ASSISTANCEThe Encounter Operations Technical Assistance staff are available Monday through Friday (excluding State holidays) to assist Contractors in resolving encounter errors or to research specific encounter issues.
Contractors are notified of the name and telephone number of their assigned Technical Assistant, who is their main point of contact for encounter related issues.
Encounter Operations Unit offers training on how to correctly submit encounters
•This training is mandatory for new Contractors and is available to existing Contractors as requested.
CYE ’09 Prospective Offeror Technical Overview
SET UP
Before a Contractor may submit encounter data, AHCCCS requires the completion of certain agreements, authorizations and control documents. These documents are as follows:
Form 1:Contractor Encounter Submission Notification and Transmission Submitter Number (TSN) Application
Form 2:Electronic Data Interchange Agreement Form
CYE ’09 Prospective Offeror Technical Overview
PROCESSING CYCLEEncounters now process twice monthly beginning at 5:00 P.M. on the 1st Friday after the 1st Wednesday of the month and on the 3rd Friday of the month
The 1st cycle of the month is a complete process to include Reinsurance Case Creation and processing
The 2nd cycle processing is equal to the 1st cycle except is does not include Reinsurance Case Creation and processing, and only includes Voids/ Replacements not associated with RI Cases
CYE ’09 Prospective Offeror Technical Overview
PROCESSING CYCLEBoth Cycles include:
CRN Assignment
Edits and Audits
File and Report generation
CYE ’09 Prospective Offeror Technical Overview
PROCESSING CYCLE
Encounters are processed through Validation
Submitted data can be viewed / modified in Transaction Insight. This is a web based productAcknowledgements (997,824,TA1) are returned
Data is translated for the adjudication system
Pend Files and 277U transactions returned after cycle
CYE ’09 Prospective Offeror Technical Overview
FTP Server
Mainframe
Internet
Contractors
CommunityManager
TransactionInsight
Validation Translation
Good and Bad
Transactions
ModifiedTransactions
837 (P,I,D) NCPDP
Transactions
Acknowledgement Return
(997, 824, TA1)
ValidTransactions
Pend and 277U Response files
TranslatedTransactions
CYE ’09 Prospective Offeror Technical Overview
TESTINGNew Contractors must go through a testing phase before submitting official encounter data to AHCCCSA.
Prior to beginning the testing phase, Contractors must have provided all necessary control documents to the AHCCCS Encounter Manager, and has been assigned a Transmission Submitter Number (TSN)
Technical assistance is available from Encounter Operations Unit staff during the testing period.
When AHCCCSA verifies that a Contractor has successfully completed the testing process, the Contractor will be allowed to begin submitting encounters.
A training session for the Contractor and/or designated subcontractor is scheduled during which the testing process will be reviewed.
CYE ’09 Prospective Offeror Technical Overview
TESTING (cont’d)
Initial Testing begins with Community Manager. This product validates Encounter transactions against our Implementation Guide. This product is web based
Next set of testing involves submitting Encounters to the FTP server for processing
CYE ’09 Prospective Offeror Technical Overview
CYE ’09 Prospective Offeror Technical Overview
WHAT IS REINSURANCE?Reinsurance is a method of partially reimbursing Contractors when the cost of care for a member for reinsurance covered services exceeds a deductible amount within a Contract Year.
The deductible is based on the number of statewide members enrolled with a Contractor at the beginning of a Contract Year
Services covered under reinsurance are detailed in contract and in the Reinsurance Processing Manual. Not all AHCCCS covered services are covered under reinsurance.
All members (with limited exceptions) enrolled with a Contractor that meet the deductible limits are eligible for reinsurance
CYE ’09 Prospective Offeror Technical Overview
WHAT IS REINSURANCE?AHCCCS also provides for reconciliation and adjustment of RI payments as needed in which Encounters used in RI payment calculation are replaced or voided.
The RI system generates the following monthly reports:Reinsurance Case InitiationReinsurance ReconciliationReinsurance Case SummaryReinsurance Remittance Advice
Upon the creation of a RI case the Encounters are processed through the RI edits/audits.
AHCCCS established RI cases using a monthly process that scans the Encounters database for approved, historical Encounters for each Contractor’s members.
The monthly RI Case Creation cycle runs after the 1st
monthly Encounter cycle
CYE ’09 Prospective Offeror Technical Overview
PROCESSING
RI cases are generated automatically by AHCCCS based on Encounter data (with limited exceptions). An on-line interface allows the Contractor to view RI data.
After an RI Encounter passes edits/audits and is approved, the RI payment process calculates the amount due the Contractor.
The Contractors can change the RI Encounters using the Reinsurance Correction Process via the PMMIS on-line system.
The Reinsurance Remittance Advice is then processed by the Finance system for payment to the Contractor. Contractors are required to notify AHCCCS of any third party coverage identified in a Reinsurance case.
CYE ’09 Prospective Offeror Technical Overview
CATASTROPHIC REINSURANCEProvided to partially reimburse Contractor for the cost of care for a member who meet the criteria and requirements for Catastrophic Reinsurance.
Contractor is responsible for identifying members and submitting written notification to the Division of Health Care Management (DHCM), Medical Management Unit.
Supporting medical documentation must accompany request. Details are include in the Reinsurance Processing Manual
CYE ’09 Prospective Offeror Technical Overview
TRANSPLANT REINSURANCE
Provided to partially reimburse Contractor for the cost of care for a member who meet the criteria and requirements for Transplant Reinsurance.
Covers members eligible to received AHCCCS covered solid organ or tissue transplants
Contractor is responsible for identifying members and submitting written notification to the Division of Health Care Management (DHCM), Medical Management Unit.
CYE ’09 Prospective Offeror Technical Overview
REPORTINGREINSURANCE CASE INITIATION
Recipient’s Name, AHCCCS ID and Case Type
Case Initiation Date
Associated Encounters in case by CRN
REINSURANCE CASE RECONCILIATIONShows Encounters that could be associated to an existing Reinsurance case when the Encounter Pend is cleared.
Case Type, Recipient AHCCCS ID and Reinsurance Case Number
CRN number of pended Encounter
CYE ’09 Prospective Offeror Technical Overview
REPORTING
REINSURANCE CASE SUMMARY
Shows members by Contractor with RI cases.
Recipient’s Name, AHCCCS ID and Case Type
CRN (Claim Reference Number)
Coinsurance percentage and status
Total Case Value
Deductible
Total Paid
CYE ’09 Prospective Offeror Technical Overview
CYE ’09 Prospective Offeror Technical Overview
HIPAAHIPAA Implementation Guides can be purchased at
http://wpc-edi.com/
AHCCCS Companion Documents can be found on our website or bidder’s library with additional information
http://www.azahcccs.gov/commercial/EDIresources/EDIresources.aspx
Next phase (2008) outbound 820s, 834s, 277Us will be processed through the Validator
Currently all 837s and NCPDP5.1 files are processed through the Validator
During this contract period 2008 – 2012, HIPAA transactions will be upgraded from the 4010A1 to the 5010 versions
CYE ’09 Prospective Offeror Technical Overview
QUESTIONS
Recommended