Electronic Eligibility Management System (EEMS) … · Web viewManagement System (EEMS) Electronic Eligibility Guide September 26, 2013 Table of Contents Introduction 3 - 4 Role of

Electronic Eligibility Management System

(EEMS)

Electronic EligibilityGuide

September 26, 2013

Electronic Eligibility Guide Page 2 of 28

Table of ContentsIntroduction.................................................................................................3 - 4

Role of Your Electronic Eligibility Analyst....................................................5Questionnaire .................................................................................................. 5

File Specifications...........................................................................................6Acceptable File Formats ........................................................................6Acceptable File Transmission methods .................................................7

Eligibility File Processing...............................................................................7File testing .............................................................................................7Your First Production File.......................................................................8Changes only versus Full Population Files.......................................8 - 9Sending Files on a Schedule................................................................10Enrollments/Changes....................................................................10 - 11Mapping RX from Medical Coverage....................................................12Terminations/Cancellations...........................................................12 - 13Reinstatements....................................................................................13Retroactive Processing Policy..............................................................14Alternate Identification Numbers..........................................................15Social Security Number (SSN).............................................................15Address processing..............................................................................15Qualified medical Child Support Order (QMCSO).........................16 - 17Survivor and Dependent Only Coverage..............................................18Phone Number.....................................................................................18COBRA Coverage................................................................................19Suspected Duplicate Processing..........................................................19No Reset Logic.....................................................................................20Retiree Processing...............................................................................20Medicare and Coordination of Benefits................................................21Primary Physician & Primary Care Dentist Information.................21 - 22

Employer eServices Information..................................................................23Training Tutorials..................................................................................23Online Customer File Processing Reports....................................23 - 25 Processing Statistics Add Transactions (New Enrollments) Change Transactions Customer Corrections Required

Summary of Errors and Warnings No Change Transactions Terms Submitted/Auto Cancel

Transactions

Additional Contact Information for Member Updates................................25ID Cards.......................................................................................................... 25

Overview..............................................................................................25When ID cards are generated.......................................................25 - 26

Open Enrollment............................................................................................26


Introduction

We are pleased to present this guide to utilizing the Employer eServices Electronic Eligibility Management System. It has been designed to help our customers understand exactly what information needs to be transmitted in order for us to process eligibility updates in the most timely and accurate manner possible, thus enabling us to provide the highest level of service to you and your members. Please review this Guide and retain for reference.

Using input and requirements from valued customers like you, the system has been designed to provide Human Resource (HR) benefits staff a user-friendly, intuitive, self-service application to verify eligibility transactions. Based on the philosophy of using well-defined "standards" to drive efficiency and accuracy, the system minimizes the time lag from when an eligibility update is made to an employer’s HR system to when that update is reflected in our systems. The shorter this delay, the lower the chances exist for service issues to adversely affect your employees and their families.

This guide outlines the processing rules that the system is based upon, and explain in detail how your electronic eligibility file submissions need to reflect additions, terminations, changes, etc. that are made to your HR system.

The Employer eServices Electronic Eligibility System can accept updates using the following file formats: Gateway Standard Format (GSF) HIPAA 834 (ASC X12N 834) file format

What is the Employer eServices Electronic Eligibility System?

The Employer eServices Electronic Eligibility System is a Business to Business (B2B) web application that allows us to receive and apply eligibility updates in a fully automated manner. Electronic eligibility files are transmitted from a customer’s HR system directly into our eligibility system with virtually no human involvement. As a result of this automation, eligibility updates are reflected in our eligibility system generally within 24 hours of the file being received. Following each production file application, an automatic email is sent to designated individuals advising that the file has been applied, at which point the customer can immediately view their file transaction results and any potential transaction errors by going online, to www.employereservices.com.

Continued on next page


http://www.employereservices.com/

Introduction, Continued

Why is it important that eligibility files meet the processing rules and file format standards as defined by the Employer eServices Electronic Eligibility System?

The use of standards to define processing rules and file format is what differentiates the Employer eServices Electronic Eligibility System from traditional eligibility update methods. Historically, eligibility staff members had the ability to manipulate, derive or translate a wide variety of information that was transmitted from customers. While it allowed customers the flexibility to transmit information in whatever manner they chose, that flexibility came at a severe cost. That cost came in the form of frequent data misinterpretations, errors and delays that ultimately led to service issues and member dissatisfaction.

By eliminating the need to manipulate and translate customer data, the overall quality of the transactions is greatly improved. So while the Employer eServices Electronic Eligibility System provides a quantum leap in service by leveraging technology and using automation, it is highly dependent on receiving your data via the use of predefined standards.

We hope you find this guide helpful as you position your organization to take advantage of the industry-leading technology that the Employer eServices Electronic Eligibility System provides.


The Role of Your Electronic Eligibility Analyst (EEA)

Your Electronic Eligibility Analyst will work closely with you to make sure you understand the processing logic and file format requirements for using the Employer eServices Electronic Eligibility System. He/she will also be responsible for applying your test files and providing feedback on any potential format issues during the implementation phase. In addition, an electronic eligibility analyst’s duties include the following:

Help you understand UnitedHealthcare’s eligibility system in order to ensure a successful transfer and an accurate load of your eligibility data.

Explain eligibility processing, potential processing issues and available online diagnostic reports.

Assist you with establishing a file transmission connection (i.e.: SFTP or FTP w/ PGP Encryption setup) for transmitting eligibility files to us.

Assist you in understanding any processing errors that occur when files are applied.

Coordinate file testing and provide recommendations surrounding open enrollment timelines and procedures.

Electronic Eligibility Questionnaire

In order to facilitate the implementation of your group into the Electronic Eligibility Management System, please complete the attached questionnaire and return this form to your electronic eligibility analyst. Set up of your electronic file process cannot begin until this form has been fully completed and returned to your EEA.

File Specifications


The following formats are currently acceptable for use with the Employer eServices Electronic Eligibility System.

Gateway Standard Format (GSF)

The Gateway Standard Format (GSF) is a proprietary flat file format that contains all of the fields stored on our eligibility system. Although the format allows for a maximum of 5699 bytes, this is a variable length layout. It also contains a number of filler fields that may be used as needed for your company’s specific reporting and claim requirements, if needed.

The Gateway Standard Format (GSF) was created to standardize the processing of electronic eligibility information as it passes through the Employer eServices Electronic Eligibility System. Please note that this format is UnitedHealthcare’s own proprietary layout and is not a HIPAA compliant layout.

Click on the icon below to review the Gateway Standard Format (GSF) file specifications.

HIPAA 834 (ASC X12N 834) File Format

UnitedHealthcare will also accept the HIPAA 834 (ASC X12N 834) file format. All customers wishing to utilize this layout must also follow the requirements of the UnitedHealthcare companion document. Click on the icon below to review a copy of the UnitedHealthcare Companion Guide to the X12N 834 (005010X095) Benefit Enrollment & Maintenance Transaction.

You must use this companion guide in conjunction with the government’s X12N834 file format specifications.

Acceptable File Transmission Methods

UnitedHealthcare currently utilizes the below transmission methods for receiving files:


SFTP Internet FTP w/PGP encryption HTTPS

Eligibility File Processing File Testing

UnitedHealthcare requires a lead-time of 10-15 weeks to set up your electronic process. This will allow time to review and complete the eligibility questionnaire, review file layout questions, determine a file testing schedule, set up a file transmission method, complete testing, load your production file, and issue ID cards.

We recommend that you provide at least one test file with the sample scenarios on the enclosed spreadsheet. Please complete and return the enclosed spreadsheet prior to sending your test file (EE ID and effective date columns). Your electronic eligibility analyst would then review the test data with you to ensure your file transmitted the members with those scenarios accurately.

Test files that process successfully will have results posted to our testing website which can be accessed with your eServices user ID. Files that are unsuccessful may require more intensive testing to determine the cause of the file failure and could take up to 5 business days to obtain results. Files that fail validation will require changes made and a new file to be submitted to our test region – Always notify your EEA prior to transmitting a test file. Any files submitted for testing MUST complete processing in our test region, and the test system re-synced with the ‘live’ production region prior to a new test file being sent. Even if you immediately know the wrong file was sent , you must still wait to get the okay from your electronic eligibility analyst prior to sending another test file.

NOTE: Every test file needs to contain a full population of valid membership - not "dummy” data.

Your First Production File

The first production file sent to UnitedHealthcare will initially be run through our test system – this ensures that no unexpected changes were made after the last test file was tested.


The results of the production file running through the test system will be shared with you, available through the eServices reporting system. Please Note: Regardless of whether you choose to send Changes Only files or Full Population files for ongoing file submissions, the first file sent to UnitedHealthcare must be a Full Population file. This file is used to establish your group's membership on the UnitedHealthcare System. More information on Changes Only or Full Population files is included below.

IMPORTANT: Test results will require sign-off prior to our having the ability to run a file in our ‘live’ production system. In order to produce timely results please confirm with your electronic eligibility analyst all contact names who will be reviewing the results. We also need the name & email of one person who will be available during testing and is authorized to give the final go-ahead to run the file into production.

The person to provide sign-off and approval must:1) Provide the confirmation to apply the electronic eligibility file(s) into our Production

environment; or2) Request the electronic eligibility file(s) be placed on Hold for further investigation; or3) Request the electronic eligibility file(s) be discarded and confirm when a new Test file

will be submitted. In order for your electronic eligibility file(s) to be loaded into our Production environment in a timely manner, we require a response to the test results and Quality Reports within 24 hours.

NOTE: Prior to running into production, your test files must run in our test region and complete within certain thresholds. Your electronic eligibility analyst will have a discussion with you about what would need to happen prior to our being able to use your file in our ‘live’ production region if there are any concerns about your file being ready. Concerns could include something like a high number of errors, missing SSNs, missing coverage types, incomplete data, etc. and what would need to happen prior to our being able to use the file in ‘live’ production.

Changes Only Files Versus Full Population Files

UnitedHealthcare prefers to receive a weekly Changes-Only file, with a monthly Full Population reconciliation file from you. However, an acceptable alternative is to send Full Population files on a bi-weekly basis or monthly basis. Below is a description of each of the options and the benefits or disadvantages associated with each option.

Changes Only Files Versus Full Population Files, continued

Changes Only Files


A Changes Only file should consist of any subscriber or family that were newly enrolled, terminated, reinstated or had a change to any field that is transmitted on your file. Whenever a member of a family has a change in any field, you must transmit the complete records for that family member AND for the subscriber, even though the subscriber’s record might not contain any change. For example, if a dependent is terminating coverage, your file must first contain the subscriber’s record, and then the terming dependent’s record.

Advantages : Records in UnitedHealthcare's eligibility system will not be inadvertently overlaid with any old data on your file. Also, a Changes Only file may significantly reduce the amount of time it takes to transmit the file, since each file will have fewer records.

Disadvantages : The sequencing of Changes Only files is more critical than that of Full Population files. If a problem occurs during processing, that problem must be resolved before subsequent files are applied. Since the data on a Changes Only file contains changes that occurred during a given time period, it is imperative that all changes reported on the file be applied, since this same information will not be included on future files. Another disadvantage is that the membership is not fully reconciled with each file application. Finally, if a change is inadvertently omitted from your file this omission may not be apparent until the full file reconciliation is applied or a manual correction is made.

If you choose to provide UnitedHealthcare with Changes Only files, it is required that a Full Population file containing all covered members be submitted to UnitedHealthcare either on a Monthly or Quarterly basis (monthly reconciliation files are preferred). This Full Population file will be used to compare your current data against the data on UnitedHealthcare’s system, and make any necessary updates to the membership.

Full Population FilesThe entire population covered by UnitedHealthcare is transmitted on each file.

Advantages : Full Population files reconcile your file with UnitedHealthcare’s eligibility system each time the file applies. Members are continuously updated with the information on your file. Members who do not appear on your file but who have active coverage in our system will be automatically terminated and reported to you. As a result, any membership issues can be immediately noted and resolved.

Disadvantages : If your file contains obsolete eligibility information, this method may hinder UnitedHealthcare’s ability to maintain an up-to-date database. For example, if an individual’s record is manually updated on UnitedHealthcare’s eligibility system without the file being updated, the next eligibility file will update this individual’s record with the obsolete data from the file. This will negate the change that was manually completed. To avoid this situation, please make sure all changes that are sent to UnitedHealthcare for manual updating or made on the eServices website are included on all future eligibility files. Also, larger files are generally placed into a separate queue for processing because of their size. Full population files are also more limited in the processing frequency – we cannot accept more than one full population file per week.


Sending Files on a Schedule

Once you decide whether you will send both Changes Only files and Full Population files, or only Full Population files, the next step is determining a file submission schedule.

It is extremely helpful if you determine which day(s) of the week or month the file will be sent, as well as what time of day, and then adhere to that schedule. It is definitely an advantage to know when the file will process, and when the results can typically be expected. If in the future you decide a different schedule would work better inform your electronic eligibility analyst in advance and he or she will work with you to help make the necessary changes.

NOTES: In the event your file cannot be sent on schedule, or if there is an urgent need to send an

additional ‘off-schedule’ file, inform your electronic eligibility analyst as soon as possible. It is especially important that we are informed of any additional files being sent, as well as the reason for them, PRIOR to your sending the file.

If both Full and Changes files will be sent, the usual schedule is a Weekly Changes file, with a Full Population file sent once a month or once per quarter. When the full population file is sent we prefer it is not sent on the same day the changes file is processing. For example: you could set up a changes-only file to be sent weekly – every Wednesday a.m. – and a full population file to be sent on the first Monday of every month.

We do have the ability to accept Changes files as frequently as daily if it is necessary due to the amount of member updates being made, however we ask that no files be sent on weekends. Full Population Files can only be sent as frequent as once per week.

It is important that two files for your group are not sent to process at the same time – running two files at once generates member errors and usually causes both files to fail processing. If there is a need to send more than one file on the same day please coordinate the timing of the files with your electronic eligibility analyst.

Enrollments/ChangesTo enroll a new member or to change an existing member, the entire record for that member must be included on your file submission. In addition, if that member is a dependent, then the entire subscriber’s record must also be sent on the same file.

If any errors occur which would prevent the file from updating electronically, or if the member or any of their family member’s records error during processing, the member will not update to our system until the error(s) are resolved.

Enrollments/Changes, continued


IMPORTANT: Please note the following items – A minimum of one coverage type must be selected when transmitting a member on your

file. All coverage types the member is enrolled in must be included on your file (Medical, Pharmacy, Dental, Vision, etc.)

Only one line of current eligibility coverage should be transmitted for each member on your file. Previous lines of eligibility coverage cannot be accepted. Each member should be sent only once, and each coverage type can only be sent once. Sending current and prior data for the same coverage type cannot be accepted.

A coverage start date must be provided on the file for every coverage type the member is enrolling in (Medical, Pharmacy, Dental, etc.) The start date is the effective date that UnitedHealthcare is responsible for paying claims for that member.

Every time a member has a change in one of the following Date Sensitive Fields, we require a new line of eligibility coverage with an effective date for the change. The following fields are date sensitive:

Policy Number (For example 0123456)

Plan Variation/Reporting Code (For example 0001/0001)

Plan Type (TT or VE)

Cancel Reason – Cobra Indicator (For example: TY)

Members Covered Code (Coverage Tier change)


If any of the Date Sensitive Fields are changed on your file, a change date must be provided in the coverage start date field(s). Only send a termination date for a coverage type if that member is dropping that coverage type with UnitedHealthcare. Do not provide termination dates for the previous coverage when only a change is being made. Our system automatically generates a termination date one day less than the new coverage start date on the prior coverage, when the new change and new coverage start date is sent to us on your file.

Medical and Prescription (Rx) Coverage

Medical coverage, unless instructed otherwise by your Electronic Eligibility Analyst (EEA), require both medical and prescription coverage lines to be built in our system. We require both coverage types sent to us on your file rather than us performing any manipulation or derivation of coverage. Your electronic files will be considered the source-of-truth for each coverage type.

Terminations/Cancellations

To terminate coverage for existing members enrolled with us, the entire record for that member and any associated family members must be included on your file submission. A termination date must be provided for each member and coverage type that should be terminated – the termination date must not be less than the original coverage start date, and should only be sent to us once on the file. UnitedHealthcare will read the termination date directly from your eligibility file and unless the member errs, or there is a retro issue or law directing us to do otherwise we will apply that termination date ‘as is’ to our system. If the termination rule for your group is end-of-month or end-of-prior-month we request that you apply that logic to your system so that the correct termination date is sent to us on your file. Once we have processed the termination date from your file the coverage(s) or member(s) terminated should not be sent on subsequent files. If the member has enrolled in multiple coverage types and not all coverage types will be terminating, a coverage end date should only be sent for the coverage that is terminating.

Also, if a dependent's coverage is being terminated, a termination date must be sent for that dependent coverage(s) as well as a new coverage start date for the remaining actively enrolled employee and family. If an employee's coverage is being terminated, and a termination date was not sent on the dependent records, the entire family will be terminated with the employee's termination date.

If any errors occur which would prevent the file from updating electronically, or if the member or any of their family member’s records error during processing, the member will not update to our system until the error(s) are resolved.

IMPORTANT: Coverage End Dates may not be sent more than 30 days in advance of the actual termination date. Once a Coverage End Date has been sent and all coverage types for that member have been terminated, that member should be dropped from the next file.

Special Termination Processing

AUTO-CANCEL Should a member be missing from your full population file, the member's coverage with UnitedHealthcare will be terminated. There are two choices for the generated termination date: Auto-cancel last day of current month. Auto-cancel last day of prior month.

NOTE: During your Open Enrollment period we also have an option to Auto-cancel the day before Open enrollment date. This is useful if your system drops members who do not renew their coverage. If this is something you may be interested in your electronic eligibility analyst can help determine if this will work for you.

DEATH DATE If an employee is in the UnitedHealthcare system with a DOD and your file continues to send the employee and dependents as active with no Xref (Payee) information, a termination date equal to the DOD will be applied to the employee and all dependents.

Reinstatements

To reinstate a member with no lapse or change in coverage, simply remove the termination date on your file. The member record will reinstate during the application of your file into our system. (The only exception to this is if an employee has a Death Date loaded in UnitedHealthcare’s system – see above “Terminations/Cancellations”.) To reinstate a member with a lapse or change in coverage, a new coverage start date for each coverage type must be provided on your file. The coverage start date must be at least one day greater than the termination date in UnitedHealthcare's eligibility system.

NOTE: If an employee was in our system with “Dependent Only” coverage where the dependents were enrolled with coverage in our system under the employee’s ID, if the employee decides to enroll in coverage at a later date he/she must be reinstated manually.

Retroactive Processing PolicyUnitedHealthcare has set guidelines to assist in the administration of its 60-day administrative policy. This 60-day policy applies to fully-insured business when requesting eligibility enrollments, changes, reinstatements, and terminations. The 60-day administrative policy applies to retroactive activity on a member or dependent

level; it does not apply to group level terminations. The following types of changes are not subject to retroactive adjustment terminations:

A member’s death is not subject to retroactive guidelines. COBRA participant enrollments, without a lapse in coverage, are not subject to

retroactive guidelines. COBRA participant terminations are subject to a 60-day administrative policy. Enrollments and reinstatements received after 60 days from the effective date, will not

process, and will result in an error during the file application. This error will appear on your error reports.

Terminations received after the 60 days from the effective date, will be processed effective 60 days prior to our receiving the request.

Changes received after the 60 days from the effective date, will be processed effective 60 days prior to our receiving the request.

There is a specific exception process that must be followed when addressing specific customer situations.

All transactions involving adds, changes or terminations falling within the same timeframe as your eligibility being administered by a prior carrier must be sent to and handled by the prior carrier. UnitedHealthcare cannot accept transactions with any eligibility dates prior to the UnitedHealthcare plan effective date.

A file containing current transactions should be sent to UnitedHealthcare and a separate file containing retro transactions should be sent to your prior carrier if coverage changes are needed to prior to UnitedHealthcare’s effective date. EXAMPLE: Coverage at ABC Dental is effective 01/01/2013 and eligibility files were submitted directly to them. On 06/01/2006 your company elected to have UnitedHealthcare administer the coverage. The earliest effective date that can be submitted to UnitedHealthcare is 06/01/2013. All additions, changes or terminations prior to 06/01/2013 must be submitted to ABC Dental.

NOTE: Retro Terms - Retro terminations received beyond the retro limit can be adjusted as far back as your retro limit will allow. For example, if a 12/31 termination date isn’t sent to us until June 1st and a 60-day retro limit is set up for your policy, we would apply a termination date of 4/2 to our system. Retro Adds, Changes, Reinstates - Unlike retro terms, the effective dates for retro additions, changes or reinstatements cannot be adjusted if it is received beyond the retro limit set for your group. The request cannot be processed and the member cannot be enrolled. Please work with your service account manager if you feel there was an error.

IMPORTANT: Refer to specific state legislation for additional rules regarding retroactive processing on fully insured groups that may supersede the rules listed above. If further clarification is needed surrounding the retroactive policy, please contact your Service Account Manager.

Alternate Identification Numbers

UnitedHealthcare assigns a randomized unique identification number to every employee member enrolled with us. This 9-digit alternate identification number is used in place of the member's social security number on all printed member materials, such as ID cards, Explanation of Benefits (EOBs), and any other correspondence to the member. Should you wish to assign your own alternate identification number, please contact your Account Management Team immediately for approval and discussion prior to implementation of this non-standard process. If you do use your own alternate identification number, that number will be used for any outgoing feeds to vendors, etc.

Social Security Number (SSN)

S.1932, Deficit Reduction Act is a bill which included a number of Medicaid reforms, one purpose is to make providers and commercial carriers assist states in identifying responsible third parties and other payers, with the goal of making Medicaid the payer of last resort.

In order to ensure compliance, states are increasingly passing state level legislation that mandates this data exchange. To perform this task, UnitedHealthcare requires member SSNs to be loaded for each member in our system - this is the key value on the record for Medicaid and Medicare.

The member SSN is required for every person transmitted on the eligibility file.

If you are unable to supply this data to UnitedHealthcare for all members, please discuss this limitation with your sales account executive as well as your assigned electronic eligibility analyst as special permission may be required if there are more than a certain percentage of Social Security Numbers missing

NOTE: TIN (Tax ID Numbers) or ‘Dummy’ SSNs should NOT be used. If a member SSN is not yet available, blanks should be sent until the actual SSN can be added to the file.

Address ProcessingUnitedHealthcare's eligibility system can accept two addresses per member: One permanent and one mailing address. However, please note that only the employee's mailing address feeds to our claim system. Any ID cards, EOBs, or other correspondence is sent to the mailing address on the employee's record. The permanent address is a required field for all members – subscribers and their dependents. The mailing address should be sent only if it is different than the permanent address. If only one address is submitted for the member on your file, we will use that same address for both the permanent and mailing addresses fields for that member in our system.

Occasionally, you may have members that require special handling of their mail. These may be dependents covered under a Qualified Medical Child Support Order (QMCSO) or may be members living in a foreign country, including Canada. If these situations apply, please contact your electronic eligibility analyst to discuss the appropriate method of updating these members.

Dependent Processing

MICHELLE'S LAW:

Michelle’s Law is a federal medical leave that allows a dependent at or over the child maximum age (generally 26) and under the student maximum age (varies by plan/state) to continue coverage for up to one year or to the student maximum age, whichever occurs earlier, without providing verification of full time student status. This federal law is effective on plan years on or after 10/9/09.

Important Next Steps: If you, the customer/Third Party Administrator (TPA) handle the student verification

you will also handle your own Michelle's Law verification. There is no need to report these members any differently on the eligibility file than other child or student dependents.

If UnitedHealthcare handles the student verification then you (the customer/TPA) should continue to send the CH or ST as the dependent’s relationship code. Impacted members will work with their physician to complete and remit the Student Medical Leave Certification Form. Eligibility data entry will extend the member's student verification dates to comply with the federal law.

NOTE: The HC relationship code should not be used for members exercising Michelle’s Law.

Qualified Medical Child Support Order (QMCSO) / Court Ordered Dependents

A Qualified Medical Child Support Order (QMCSO) is an order issued by a court or state administrative agency for dependent children requiring the non-custodial parent to provide insurance coverage for the QMCSO dependent(s). The orders generally require that the custodial parent/legal guardian receive ID cards/correspondence as well as have access to information regarding the QMCSO dependent(s).

In the situation we are describing, the non-custodial parent is the employee on the UnitedHealthcare policy.

UnitedHealthcare Claims has special processing needs for QMCSO dependents, or families with court ordered covered dependents. In order for Claims to meet the processing requirements for QMCSO, any dependent that is identified as a QMCSO dependent must have all correspondence to the members of the family sent to the QMCSO department for re-routing.

The electronic process requires the below mailing address to be in our system as the families mailing address. The address for QMCSO is:

ATTN QMCSOP.O. BOX 30333TAMPA, FL 33630

Qualified Medical Child Support Order (QMCSO) / Court Ordered Dependents, continued

While it is required the mailing address for QMCSO families be the above UnitedHealthcare address, there are three options for accomplishing this:

1. Sending all members within the family with their permanent address loaded as their primary address, and the specific default UnitedHealthcare address [given above] used as the mailing address. This process requires BOTH addresses to be sent on your file.

2. If sending two addresses on the file is not an option, UnitedHealthcare has automated a process which will add the QMCSO address to the mailing address if a relationship code 15 (Ward) is sent for the QMCSO dependent. The relationship code 15 will drive the QMCSO processing, populating the QMCSO address as the mailing address for all members of the family, and populating the member’s individual permanent address into the primary address fields.

3. If neither of the above two options are possible, adding the QMCSO address to UnitedHealthcare’s system must become a manual process. The QMCSO mailing address will need to be manually added to the family, and in order to prevent the QMCSO information from being overlaid by an electronic file you will need to remove the whole family from the file and have their updates processed manually.

Let your electronic eligibility analyst know if you have any questions on this process.

NOTE: Please remember you must still submit the QMCSO implementation form provided to you in your implementation packet. This is the only way that the guardian's address can get populated into the Claims system, and this is used in the re-mailing of ID cards and EOBs. The Implementation form also serves as the method to have an alert placed on a member’s record so that when a call comes into Members Services they can quickly see whether the member is a QMCSO member.

Completing one of the three options above, but failing to remit the QMCSO Implementation Form results in all correspondence being mailed to the QMCSO P.O. Box; however we will not be able to forward any mailings to either the custodial parent, or non-custodial parent due to a lack of address information.

If dependent(s) has not been enrolled already, submit an enrollment form to the paper eligibility processing site along with the QMCSO Implementation Form. Once the form has been submitted, add the dependent(s) to the next electronic feed as outlined above.

Change the address of the employee on the electronic feed to the following address for the Oldsmar production site: Attn: QMCSO, P.O. Box 30333, Tampa, FL 33630

Remove the employee record from the file and manually add and maintain the information via eServices if the address cannot be changed in the customer source system. (This may be because the customer sends eligibility information to other sources in addition to UnitedHealthcare.)

Notify the electronic eligibility analyst of any employee records that are absent from the file for this reason.

Dependent Processing, continued

Survivor and Dependent Only Coverage

Survivor Coverage: UnitedHealthcare requires that surviving spouse and/or surviving dependent coverage continues under the deceased employee’s employee identification number as originally provided to us by you. The coverage under the deceased employee's identification number provides a crucial link to eligibility and claim history for the remaining members of the family.

During the initial enrollment of new groups it is acceptable for any surviving spouses, existing at the time your group becomes effective, to be set up under their own identification number. For any subsequent employee deaths after the initial employee enrollment, the surviving dependent coverage must continue to be transmitted under the deceased employee's coverage record.

All claim checks, explanation of benefit material, and any mailings will use the surviving spouse or payee name and information.

Please refer to the file layout specifications for additional information about sending surviving spouse records to us. How you transmit them is crucial.

NOTE: If an employee was manually entered in the UnitedHealthcare system with a date of death (DOD) and your file continues to send the employee and dependents as active with no Xref (Payee) information, a termination date equal to the DOD will be applied to the employee and all dependents.

Dependent Only Coverage: If an employee has been enrolled with UnitedHealthcare coverage, and drops coverage but needs to continue coverage for his/her dependent(s) the rules are similar to that of Surviving Spouse. If the plan allows it requires that dependents continuing coverage be sent under the employee’s Employee Identification Number (EE ID) as originally provided to us by you. The coverage under the Employee's Identification Number provides a crucial link to eligibility and claim history for the members of the family continuing coverage.

NOTE: If the employee drops coverage, but continues coverage for dependents, and at a later time wants to reinstate coverage the employee’s reinstate MUST be done manually and not via the electronic eligibility file.

Phone Number

Providing the phone number on all files is strongly encouraged. Once the phone number is loaded in our system, it can be used by other areas outside of eligibility, such as Member Services and the United Behavioral Health Nursing Program (Care Coordination).

COBRA Coverage

COBRA (Consolidated Omnibus Budget Reconciliation Act) is a Federal law that requires most employers to offer a continuation of group health care coverage to employees and their dependents in situations where they would otherwise lose coverage under their group plan. While the employer is required to offer this coverage, it is not required that an election by a qualified member be reported on the electronic file for your group. Your electronic eligibility analyst will assist you in determining if you should report the COBRA election to UnitedHealthcare, and if so, the appropriate method of submitting the member(s).

If your electronic file will include members electing COBRA coverage, a COBRA cancel reason code should be included as a part of your layout. Your eligibility analyst will provide this cancel code to you. The COBRA Paid Thru Date (PTD) is an optional field; however, we recommend that it is utilized for all COBRA members. Although there is no negative impact to COBRA enrollment if it is left empty, it does potentially cause issues if the COBRA member uses coverage that hasn’t been paid for. If you do choose to enter a date, you must maintain the date through the entire duration of the employee's COBRA enrollment. All claims submitted after the date appearing in the COBRA paid thru date field will be denied. When the COBRA coverage expires, a coverage stop date must be submitted on your file. Please provide this coverage stop date on your file during the actual month in which the COBRA coverage is expiring. If a coverage stop date is not transmitted, and there is a paid thru date more than 60 days old, the members coverage will be terminated by UnitedHealthcare. Please refer to the file layout supplements for additional information on sending COBRA participants.

Suspected Duplicate Processing

During the processing of your file, any members transmitted under the same employee ID with 1) similar names, 2) relationships, or 3) the same date of birth, those members are flagged for manual verification and enrollment. This process allows us to prevent any inadvertent duplication of membership information into our system. Your electronic eligibility analyst will review and enroll these members after your file processes into our system.

NOTE: If the same member appears on the file more than once the member will error without updating our system, and it could prevent the entire file from completing processing. You must correct your file and remove the duplicate entry.

No Reset Logic

Our system is designed to prevent your file from changing certain fields using “No Reset Logic”. Using this logic will help avoid claim payments from pending or being denied for payment based on an incorrect or missing data being reported on your file. To correct these fields you must submit the changes needed to your Electronic Eligibility analyst. The fields we currently use this logic are:

Handicapped or student relationship codes on a dependent record . We will not change a dependent loaded in our system with a handicap child relationship to a child or student relationship, nor will we change a child dependent loaded in our system with a student relationship back to a child relationship. Any corrections of the relationship code for these two types of dependents must be handled manually.

Middle Initial . If a middle initial is loaded for a member in our system, but the file comes in with the middle initial field blank we will not overlay the initial in our system with the blank from the file. If the middle initial is loaded in our system, but a different middle initial is sent on the file we will correct our system to the new middle initial sent on the file.

Member SSN . If a member SSN is loaded in our system, but your file comes in with blanks (spaces) in that field, we will not overlay the member SSN in our system with the blank from the file. If the member SSN is loaded in our system, but a different member SSN is sent on the file we will correct our system to the new member SSN unless it matches the SSN we already have loaded for another dependent within that family.

Dependent Only Coverage . Employees who waive coverage, but have dependents enrolled under their Employee ID Number cannot be reinstated with coverage with the electronic file – if the employee now elects coverage a Coverage Start Date indicating the effective date of the change must be manually entered to reinstate their coverage.

Retiree Processing

Any members sent as a retiree on your file must have a retirement date transmitted on the file. The retirement date cannot be earlier than the effective date of your group with UnitedHealthcare.

Medicare and Coordination of Benefits (COB)

We are able to process a variety of Medicare and COB information via your electronic eligibility file. Depending on which file format you choose to select to submit this information will determine what fields are required for completion. Available fields include: Medicare Type Medicare Part A Start Date Medicare Part B Start Date Medicare Part D Start Date Medicare Part A Stop Date Medicare Part B Stop Date Medicare Part D Stop Date

Ineligible/Not Enrolled Indicator Entitlement Reason Code COB Indicator COB Start Date COB Stop Date Custody Code

Please consult with your electronic eligibility analyst to determine what data you have available to submit and what fields will be required to be populated within the specific format of your eligibility file.

Primary Physician & Primary Care Dentist Information

Designation of a primary physician or primary dentist is required if the member is enrolled in a gatekeeper medical plan or dental HMO plan. Please contact your UnitedHealthcare account manager if you are uncertain which of your group's plans, if any, require a primary physician or dentist be selected.

Provider directories listing the primary physicians and dentists are included in the enrollment kits. Electronic customers are encouraged to provide the member's primary physician or primary dentist selections on the electronic file along with the member's eligibility information.

MEDICAL PLAN: To indicate a member’s primary physician selection, you will be asked to include the provider’s numeric identification number. Your implementation manager/Sales Account Executive (SAE)/EEA analyst will instruct you on which format(s) are needed to be included on your file.

UnitedHealthcare PCP (primary care physician) Number: This is called the Medical Provider Identification Number (MPIN) and can be found in the provider directory. The MPIN is composed of a seven-digit provider number (preceded by 4 leading zeros) and a 2-digit location code (preceded by 1 leading zero). For example: 00001234567012.

PRIMARY CARE PHYSICIAN: MEDICAL PLAN, continued

NICE HMO System PCP (DEC ID) Number: This is called the ‘PCP ID’ or ‘Provider Number’, and can be found in the provider directory. NICE HMO PCP numbers are between five to eight numbers and consist of a facility number and a PCP number. Leading zeros must be added to the facility and/or PCP number to create a ten byte number as follows:

The first six bytes of the 10-byte ID is the facility number. Add leading zeros to the facility number if it does not equal six bytes.

The last four bytes of the 10-byte ID is the PCP number. Add leading zeros to the PCP number if it does not equal four bytes.

For Example: Conversion and entry of the facility and PCP number for 1027-1 and 16998-208 would be as follows:

Convert PCP number 1027-1 to 0010270001.Convert PCP number 16998-208 to 0169980208

In addition, if you have the ability to provide a "current patient" indicator, the file processing will be able to bypass any "closed panel" edits and enroll that member into the physician of their choice. Please refer to the file layout supplements for more information on how to correctly transmit PCP and Primary Care Dentist (PCD) information within that particular file layout.

DENTAL PLAN: To indicate a member’s primary dentist selection for a Dental HMO plan, you will be asked to include the dentist’s numeric identification number. Your implementation manager/SAE and/or electronic eligibility analyst will instruct you on which format(s) are needed to be included on your file.

UnitedHealthcare Primary Care Dentist (PCD) Number: This is called the PCD and can be found in the provider directory. The PCD code consists of 12 digits; six numeric characters preceded by six zeros (000000). For example: 000000123456.

NOTE: PCP and PCD selections are updated electronically only for new enrollees into a plan. Once a member has a valid PCP in our system, any updates to that selection should be made through member services.

Occasionally, we are unable to update the primary physician or primary care dentist selection into our system electronically. Possible problems include the following: The physician selected by the member is a specialist. The physician selected is not currently in network. The physician is not currently accepting new patients. A clinic was selected instead of a physician. The physician/dentist is no longer with the network. The physician/dentist is not eligible at this time. The physician or dentist's office is closed at the chosen location. The MPIN, PCP ID, or PCD provided on the file is invalid or in the incorrect format.

If for any reason a primary care physician or PCD is not selected or there is invalid information, UnitedHealthcare will default the primary physician or dentist for the member. To change a defaulted Primary Physician or PCD, the member may call the Customer Service 800 number located on the ID card or log onto www.myuhc.com to make the change.

http://www.myuhc.com/

Employer eServices Information

TRAINING TUTORIALS1. Employer eServices has a broad range of on-line training tutorials available. The

Electronic Eligibility Management System Tutorial will walk you through the electronic eligibility reports.To access the tutorials, go to www.employereservices.com and log in with your eservices User ID and Password.

2. At the welcome page click on the Help link at the top of the page3. When the Employer eServices Help page opens click on the Training link from the left

menu. When you click on the Training link you will see two options:a. Site Overview Tutorial: This tutorial is helpful to anyone who is new to using the

eServices website. It provides a high level overview of the Employer eServices site.

b. Tutorials: This selection has multiple tutorials that can be viewed including Enrollment, Invoices (Billing), Reporting, and Electronic Eligibility Management System Tutorials. Please view the Electronic Eligibility Management System Tutorials and contact your Electronic Eligibility Analyst with any questions you still have.

Online Customer File Processing Reports

All file-processing reports are provided online immediately after the file processes in our system. An e-mail notification will be sent to the contact person identified in the questionnaire. Whether you have sent a report to the test region, or the live production region, once the file completes processing the reports are available for viewing or downloading from the eServices Electronic Eligibility website by using one of the following URLs:

Reports for PRODUCTIO: reports are available on the Employer eServices website at www.employereservices.com. Once you sign, in select the Electronic Eligibility Management option from the top menu options.

Reports for TEST/ADOPTION/STAGING: reports are available at https://eems-adoption.uhc.com. Once you sign in you will be brought to the Electronic Eligibility Management System Dashboard and your available group(s) reports will display.

In order to access the sites the contact person will be assigned a User ID and a password that will grant security access to view and download the reports. Reports are available by file processing date and will remain on the system for 30 days. You should print or download any reports you wish to keep, or that you may need for reference at a later date. Please review all of the reports for accuracy and report any discrepancies to your assigned electronic eligibility analyst. It is imperative that you correct any errors in the "Customer Corrections Required" report.

There are multiple levels of access that can be granted within Employer eServices. Your electronic eligibility analyst contact can help with access to view the electronic eligibility reports; all other access must be requested and approved by your client services manager. For other issues or questions regarding your eServices ID, please contact the eServices Customer Service number, 1-800-651-5465.

https://eems-adoption.uhc.com/

https://eems-adoption.uhc.com/

http://www.employereservices.com/

Online Customer File Processing Reports, continued

The following reports are available to be viewed and/or downloaded:

Processing StatisticsThe Processing Statistics report contains an overview of the pertinent data from the processing of your file. It includes the total number of enrollments, changes, cancellations, bypassed, or rejected records that were processed.

Add TransactionsThe Add Transactions report lists the individuals enrolled during the processing of your file. The report is accessed by choosing the “Add Transactions” report from the menu selection page or by clicking on the “ADDS” link within the Processing Statistics page.

Change TransactionsThe Change Transactions report lists the individuals who had updates made to their eligibility. The report is accessed by choosing the “Change Transactions” report from the menu selection page or by clicking on the “CHANGES” link within the Processing Statistics page.NOTE: A more easily-viewable list of changes that occurred when your file applied can be accessed by selecting ‘Field Change Summary’ from the main drop down menu. When the Field Change Summary page opens, notice that the changes are broken down by the type of change. By clicking on the change type you will automatically be shown a list of the members who had that particular change.

Customer Corrections RequiredThe Customer Corrections Required report lists each individual member record where an error occurred as a result of the application of the eligibility file. It is very important that you review this report and determine how to correct the errors. Errors can be corrected during your next file application, or they may be corrected immediately online via Employer eServices. Any changes made via Employer eServices must also be reflected in your next electronic file, in order to prevent the correction from being overlaid with the wrong data. Any errors that are not corrected may result in denied or incorrect claim payment for that member.

There are a variety of errors that may appear on the Customer Corrections Required report. A complete listing the errors can be obtained or accessed by using the “Help” feature on the eServices Web site. You may also contact your electronic eligibility analyst if you would like more specific information about the errors and how to correct them.

Summary of Errors and WarningsThe Summary of Errors and Warnings page summarizes all of the errors and warnings incurred with the file application. This page will assist you in analyzing the errors and warnings, with the available link to all members associated with a particular error.

No Change TransactionsThe No Change Transactions report lists the individuals that were identified as needing no changes made to their eligibility via the electronic file application. The report is accessed by choosing the “No Change Transactions” report from the menu selection page or by clicking on the “NO CHANGES” link within the Processing Statistics page. This is a report you typically will never need to review, but it’s there if you need it.

Terms Submitted/Auto Cancel Transactions This report lists the members and coverage types that were either terminated or had a change in the date of termination with the file application. Each termination is categorized by ‘Term Submitted’ (term date appeared on the file) or ‘Auto-cancel’ (member did not appear on the full population file so was automatically cancelled.) The report is accessed by choosing the Termination/Auto Cancel Transactions report from the menu selection page or by clicking on the Terms link within the Processing Statistics page.

ADDITIONAL CONTACT INFORMATION FOR MEMBER UPDATES:

The eServices Support number is 800-651-5465: This number can be called with any questions about the eServices site, log in issues, or navigation problems.

The Customer Service Unit is 877- 468-0982. You may call this number with urgent manual update request-- be sure to indicate that your request is an EMERGENCY so it will be managed immediately. If not an emergency, the turn-around time is five business days. Remember, you can also use the eServices website for manual updates.

ID Cards

An ID card is used when a member requests services from a provider (i.e., a doctor, hospital, or pharmacy). The ID card shows the plan type, member’s name, employee or alternate identification number, company name, policy number, member services phone number(s), co-pay information, claim office address, and pharmacy coverage, if applicable. If the member is in a gated medical plan, the ID card also includes the member’s primary care physician selection.

When ID Cards Are GeneratedID Cards are generally generated as follows: Initial Production (i.e., Open Enrollment) Daily Production

ID Cards, continued

Initial ProductionID cards are extracted after the entire membership is loaded into our system. The ID cards are extracted five times per week, Monday through Friday, via special processing by our ID card unit. Only records with complete information are extracted from the system.

NOTE: If the open enrollment file is not received four weeks prior to the effective date, ID cards may not be received by the employees prior to the effective date of coverage.

Daily Production

Below is a list of some situations when new ID cards are automatically generated assuming an update has been made via file application or entered manually. Enrollment of a new member. Reinstatement of a non-continuous line of coverage 2 days after current stop date

without other coverage changes. Name change (first name, last name and/or middle initial). Employee identification number change. Product type change (i.e., PPO to POS change). Structure change (if your group selects this option). PCP change (for gated plans only)

ID cards can also be requested through member services or by logging on to https://www.myuhc.com/ to replace a lost card or generate a new ID card that would not automatically be produced (i.e., co-pay change, member services phone number change, etc.). The subscriber can request a temporary ID card from the www.myuhc.com site. Cards are usually mailed within six working days from the request. When a card is automatically generated via file application, there is an additional three-day waiting period.

Open Enrollment

As your Open Enrollment period approaches it will be important that we communicate beforehand each other's needs and expectations for the process. Twelve to fourteen weeks prior to your Open Enrollment we will be sending you an "Open Enrollment Questionnaire". Included is helpful information that will take you through the entire Open Enrollment process with UnitedHealthcare, as well as a series of questions that will enable us to make the necessary preparations for your group. Once completed and returned, a conference call may be set up with your electronic eligibility analyst to review the questionnaire.

http://www.myuhc.com/

https://www.myuhc.com/

Documents

Electronic Eligibility Management System (EEMS) … · Web viewManagement System (EEMS) Electronic Eligibility Guide September 26, 2013 Table of Contents Introduction 3 - 4 Role of