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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.

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Cye 09 prospective offeror technical overview1
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 overview2
CYE ’09 Prospective Offeror Technical Overview

INTRODUCTION

Provide all potential offerors with an overview of AHCCCS technical environment and data interface and standards.



Cye 09 prospective offeror technical overview4
CYE ’09 Prospective Offeror Technical Overview

PSTN

Telephone

PBX

VPN

Firewall

Internet

Contractor

Frame Relay

HTTPS Server

Mainframe

AHCCCS Network Connectivity

All information presented on this page is confidential.



Cye 09 prospective offeror technical overview6
CYE ’09 Prospective Offeror Technical Overview

  • Interfaces

  • Recipient/Health Plan

  • Eligibility

  • Enrollment

  • Capitation

  • Processing

  • Data Exchange

  • Provider/Provider Affiliation

  • Reference

  • Encounters

  • Reinsurance




Cye 09 prospective offeror technical overview9

DES

SSA

ACE

OTHER

CYE ’09 Prospective Offeror Technical Overview

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 overview10

DES

CYE ’09 Prospective Offeror Technical Overview

  • 1931

  • S.O.B.R.A.

  • TITLE 19 WAIVER

  • HIFA PARENTS

  • FEDERAL EMERGENCY SERVICES


Cye 09 prospective offeror technical overview11

DES

SSA

CYE ’09 Prospective Offeror Technical Overview

  • SSI CASH


Cye 09 prospective offeror technical overview12

DES

SSA

ACE

CYE ’09 Prospective Offeror Technical Overview

  • ALTCS (ARIZONA LONG TERM CARE)

  • SSI MAO

  • FREEDOM TO WORK

  • BCCTP

  • MEDICARE COST SHARING

  • KIDSCARE/HIFA PARENTS

  • SSDI/TMC


Cye 09 prospective offeror technical overview13

DES

SSA

ACE

OTHER

CYE ’09 Prospective Offeror Technical Overview

  • BEHAVORIAL HEALTH SERVICES

  • CHILDRENS REHABILITATIVE SERVICES

  • DES SPECIAL NEEDS (DDD)

  • MEDICARE

  • MEDICARE BUY IN

  • MEDICARE HMO

  • MEDICARE PART D

  • VITAL STATISTIC (DOD)



Cye 09 prospective offeror technical overview15
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 overview16
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 overview17
CYE ’09 Prospective Offeror Technical Overview

ENROLLMENT DATES

Usually effective the day AHCCCS updates action

EXCEPTIONS:

System

Unavailable at

Notification

Can be retroactive

(Month End)

Prospective

Enrollments

As of the 1st

of the next month

(The Last Daily)

Administrative

Actions

Can be any day

in the past

(Any Daily)


Cye 09 prospective offeror technical overview18
CYE ’09 Prospective Offeror Technical Overview

DISENROLLMENT DATES

For loss of eligibility, disenrollment is last day of month

Normally effective the day prior to update

EXCEPTIONS:

Incarceration

Institutional

(Normal or

Retroactive)

Linking /

Duplicate

Enrollment

(Normal or

Retroactive)

Date of

Death

(Retroactive)

Administrative

(Normal or

Retroactive)

Voluntary

Withdrawal

(Normal)

CMDP

(Foster Care)

(Normal)


Cye 09 prospective offeror technical overview19
CYE ’09 Prospective Offeror Technical Overview

COUNTY MOVES

County to county move

  • Moves to a county which is served by current Contractor

  • Disenroll from current county effective day before and

enroll with same contractor in new county

County move with choice

  • Moves to a county which is NOT served by Contractor

  • Remain with contractor until end of month

  • Or until member chooses new Contractor

  • Member is AA if no choice is made by end of month


Cye 09 prospective offeror technical overview20
CYE ’09 Prospective Offeror Technical Overview

ENROLLMENT RULES

  • Newborns

  • Less than 30 days of eligibility

  • 90 day re-enrollment

  • Enrollment choice

  • Family continuity

  • Native American on reservation zip code

  • Auto assignment


Cye 09 prospective offeror technical overview21
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 Contractor

Identifies all Contractor’s members who have opportunity to make a Contractor choice

File placed on VPN server with name of ccyymm.MWC

  • Member makes choice

  • Potential Transitional Listing

Identifies all members who have made an AEC choice of the Contractor

File placed on VPN server with name of mmddyy.PTL


Cye 09 prospective offeror technical overview22
CYE ’09 Prospective Offeror Technical Overview

OPEN ENROLLMENT

  • Special process when needed

Contractor termination

New Contractor

  • Auto Assign population

  • Generate letter with AA Contractor with choice

    material

  • Member makes choice (optional)

  • Potential Transitional Listing

Identified all member who will be enrolled into gaining contractor and those who will be leaving the losing contractor

File placed on VPN server with name of mmddyy.PTL


Cye 09 prospective offeror technical overview23
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 overview25
CYE ’09 Prospective Offeror Technical Overview

CAPITATION

  • Contractors receive weekly payments

  • Contractors receive payment notification via

    weekly 820 files

  • Activity based on enrollment actions

  • Capitation calculated on

  • Contractor

  • GSA

  • Contract Type

  • Rate Code

  • Capitation calculated on per diem basis

  • Rate  Days in the month  days of enrollment thru end of month


Cye 09 prospective offeror technical overview26
CYE ’09 Prospective Offeror Technical Overview

CAPITATION

  • Recoupments are subtracted from Contractor’s

    weekly payments

  • Contractors receive payment notification via

    weekly 820 files

  • Recoupment calculated on per diem basis

  • Rate  Days in the month  days of

    disenrollment thru end of month


Cye 09 prospective offeror technical overview27
CYE ’09 Prospective Offeror Technical Overview

SPECIAL PAYMENTS

Delivery Supplemental

  • Paid when Contractor notifies AHCCCS of birth

  • Mother was enrolled with Contractor on DOB

  • Mother was not in PPC period on DOB

  • One Delivery Supplemental paid per delivery

Multiple births are considered one delivery

Payment made on Mother’s record


Cye 09 prospective offeror technical overview28
CYE ’09 Prospective Offeror Technical Overview

MASS ADJUSTMENTS

  • Ability 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 overview29
CYE ’09 Prospective Offeror Technical Overview

MANUAL PAYMENTS

  • Error in record prevents enrollment/disenrollment

    action from appearing on daily 834 file

  • Manual capitation correction on an individual record

  • Payments will appear on the weekly 820 file

  • Activity will also appear on Manual Payment file

  • When no capitation is involved

Manual notification to Contractor



Cye 09 prospective offeror technical overview31
CYE ’09 Prospective Offeror Technical Overview

UPDATES

  • Online 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 overview32
CYE ’09 Prospective Offeror Technical Overview

DAILY BATCH PROCESSING CYCLE

  • Start at 6pm every evening

  • 834 files available to Contractors no later than 7am

  • Email notification if files will be delayed

  • Enrollment activity includes

  • Enrollments

  • Retroactive enrollment blocks

  • Disenrollments

  • Disenrollment blocks

  • Demographic changes


Cye 09 prospective offeror technical overview33
CYE ’09 Prospective Offeror Technical Overview

‘LAST DAILY’ PROCESSING CYCLE

  • Third day before the 1st of the next month

1/29/08, 2/27/08, 3/29/08, 4/28/08, etc


Cye 09 prospective offeror technical overview34

MARCH 2008

SUN

MON

TUES

WED

THUR

FRI

SAT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

LAST DAILY

30

31

CYE ’09 Prospective Offeror Technical Overview


Cye 09 prospective offeror technical overview35
CYE ’09 Prospective Offeror Technical Overview

‘LAST DAILY’ PROCESSING CYCLE

  • Third day before the 1st of the next month

  • 1/29/08, 2/27/08, 03/29/08, 04/28/08, etc

  • Starts at noon if on weekdays, 2am on weekends

  • Monthly process schedule available on AHCCCS

    Web site

  • ftp://ftp.azahcccs.gov/content/notice/hplan/hplan.htm#downtime

  • Activity includes

Enrollments, Retroactive enrollment blocks

Disenrollments, Disenrollment blocks

Demographic changes

Rate Code Changes


Cye 09 prospective offeror technical overview36
CYE ’09 Prospective Offeror Technical Overview

MONTHLY PROCESSING CYCLE

  • Occurs immediately after Last Daily Cycle

  • Monthly 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


Cye 09 prospective offeror technical overview37
CYE ’09 Prospective Offeror Technical Overview

‘NEXT DAILY’ PROCESSING CYCLE

  • Starts at 6pm after completion of Monthly Cycle

  • Output files available to Contractors by 7am

  • Includes all enrollment activity since last daily

  • Enrollments & Retroactive enrollment blocks

  • Disenrollments

Will recoup prospective capitation already paid

  • Disenrollment blocks

  • Demographic changes

  • These must be processed after Last Daily and

    Monthly Enrollment Notifications


Cye 09 prospective offeror technical overview38

MARCH 2008

SUN

MON

TUES

WED

THUR

FRI

SAT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

LAST DAILY

30

31

NEXT DAILY

NEXT DAILY

CYE ’09 Prospective Offeror Technical Overview



Cye 09 prospective offeror technical overview40
CYE ’09 Prospective Offeror Technical Overview

VERIFICATION

  • Obtain Eligibility, Enrollment, Medicare and

    TPL Coverage

  • Single date of service

  • Range of days

  • Automated processes available to AHCCCS

    registered providers

  • IVR

  • MEVS

  • WEB

  • Contractors are encouraged to have their providers use the

    automated verification processes

  • Communications Center available to AHCCCS member and

    providers


Cye 09 prospective offeror technical overview41
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 overview42
CYE ’09 Prospective Offeror Technical Overview

VERIFICATION

Medicaid Eligibility Verification System (MEVS)

  • PC or POS based verifications

  • Available 24/7

  • Hardware/software provided by

    contracted vendors

  • Contracted vendors charge providers

  • Ability to print information

  • Requires input of AHCCCS ID or SSN

    or key demographic information

  • Real Time inquiry

  • Single or batch request


Cye 09 prospective offeror technical overview43
CYE ’09 Prospective Offeror Technical Overview

VERIFICATION

WEB Based Verification

  • Internet based verifications

  • Available 24/7

  • No cost to providers

  • Requires advance registration

  • Ability to print information

  • Requires input of AHCCCS ID or SSN

    or key demographic information

  • Real Time inquiry


Cye 09 prospective offeror technical overview44
CYE ’09 Prospective Offeror Technical Overview

VERIFICATION

Communications Center

  • Staffed by Customer Service Representatives

  • Limited to business hours availability

  • Not available weekends

  • No cost to providers

  • Provides service to members and providers

  • Accepts Newborn notifications from Contractors

  • Problem research and resolution

  • Real Time inquiry


Cye 09 prospective offeror technical overview45
CYE ’09 Prospective Offeror Technical Overview

DATA EXCHANGE

  • From AHCCCS to Contractors

  • Daily Files

  • Enrollment Notification (834)

  • yymmdd.DLR

  • Manual Payment file

  • yymmdd.MPR

  • Rate Code Summary

  • yymmdd.DRC

  • Third Party Liability File (in addition to 834)

  • yymmdd.TPL

  • Active Care File

  • yymmdd.ACR

  • Prior Plan File

  • yymmdd.PPL


Cye 09 prospective offeror technical overview46
CYE ’09 Prospective Offeror Technical Overview

DATA EXCHANGE

  • From AHCCCS to Contractors

  • Weekly Files

  • Capitation Notification (820)

  • yymmdd.820


Cye 09 prospective offeror technical overview47
CYE ’09 Prospective Offeror Technical Overview

DATA EXCHANGE

  • From AHCCCS to Contractors

  • Monthly Files

  • Enrollment Notification (834)

  • FYI data is included in 834

  • ccyymm.MTR

  • Rate Code Summary

  • ccyymm.SUM

  • Members with Choice file

  • ccyymm.MWC

  • Potential Transitional Listing

  • yymmdd.PTL

  • Management Summary Reports

  • http://www.azahcccs.gov/Statistics/


Cye 09 prospective offeror technical overview48
CYE ’09 Prospective Offeror Technical Overview

DATA EXCHANGE

  • From AHCCCS to Contractors

  • Unscheduled Files / As needed

  • Open Enrollment

  • Potential Transitional Listing

  • Mass Adjustment

  • Capitation Notification (820)


Cye 09 prospective offeror technical overview49
CYE ’09 Prospective Offeror Technical Overview

DATA EXCHANGE

  • From Contractors to AHCCCS

  • Third Party Liability Updates

  • Electronic file

  • Newborn Notifications

  • Phone call

  • Real Time entry/update


Cye 09 prospective offeror technical overview50
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 overview52
CYE ’09 Prospective Offeror Technical Overview

WHAT IS PROVIDER?

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.


Cye 09 prospective offeror technical overview53
CYE ’09 Prospective Offeror Technical Overview

PROVIDER INTERFACE

  • Consists of two files found in the VPN ShareINFO folder

  • Provider Profile

  • Provider Includes all provider types, service

    codes, and categories of service

  • Name: PROFILE.ZIP

  • Provider Record

  • Includes all AHCCCS registered providers

  • Includes active, terminated and suspended

    providers

  • Name: PROVIDER.ZIP

  • Produced weekly

  • Created every Wednesday

  • Available to Contractors Thursday


Cye 09 prospective offeror technical overview54
CYE ’09 Prospective Offeror Technical Overview

PROVIDER INTERFACE

  • Data included

  • Demographic data

  • Provider status

  • Categories of service

  • Service rates

  • Licenses/certifications

  • Specialties

  • Medicare coverage

  • Restrictions

  • Service/billing addresses



Cye 09 prospective offeror technical overview56
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 overview57
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 acceptance

  • Each 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 overview58
CYE ’09 Prospective Offeror Technical Overview

PROVIDER AFFILIATION TRANSMISSION

  • AHCCCS conducts verification procedures

    to monitor accuracy of data submitted

  • 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


Cye 09 prospective offeror technical overview59
CYE ’09 Prospective Offeror Technical Overview

PROVIDER AFFILIATION TRANSMISSION

Reports

Transmission Validation Report

  • Found on VPN server under LGmmddyy.TXT

  • 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


Cye 09 prospective offeror technical overview60
CYE ’09 Prospective Offeror Technical Overview

PROVIDER AFFILIATION TRANSMISSION

Reports

PAT Comparison-Exception by Provider

  • Found on VPN server under EPmmddyy.TXT

  • Provides a list of all exception errors that

    occurred during the PAT load process

  • Sorted by Provider ID

  • Aids the Contractor in error correction

  • All exception errors must be corrected

    prior to next submission


Cye 09 prospective offeror technical overview61
CYE ’09 Prospective Offeror Technical Overview

PROVIDER AFFILIATION TRANSMISSION

Reports

PAT Comparison-Exception by Field

  • Found on VPN server under EFmmddyy.TXT

  • Provides a list of all exception errors that

    occurred during the PAT load process

  • Sorted by field in error

  • Aids the Contractor in error correction

  • All exception errors must be corrected

    prior to next submission


Cye 09 prospective offeror technical overview62
CYE ’09 Prospective Offeror Technical Overview

PROVIDER AFFILIATION TRANSMISSION

Reports

PAT Comparison-Detail Report

  • Found on VPN server under LDmmddyy.TXT

  • Provides a complete list of all PAT data

    loaded

  • Sorted by Provider ID


Cye 09 prospective offeror technical overview63
CYE ’09 Prospective Offeror Technical Overview

PROVIDER AFFILIATION TRANSMISSION

Reports

Summary Totals Report

  • Found on VPN server under ‘STmmddyy.TXT

  • Provides summarized information about the

    providers listed on the PAT

  • Includes totals of

  • PCPs

  • PCPs with EPSDT services

  • PCPs with OB services

  • OB providers

  • BH providers



Cye 09 prospective offeror technical overview65
CYE ’09 Prospective Offeror Technical Overview

REFERENCE

  • Recipient produces one reference file

  • Master Carrier ID file

  • Complete file of TPL Carrier ID number

  • Produced every Friday

  • Placed in the ShareINFO folder as

    ‘RFCARIDmmddyy.TXT’


Cye 09 prospective offeror technical overview66
CYE ’09 Prospective Offeror Technical Overview

REFERENCE

  • Three Encounter Reference files produced

  • Internal Field Information

  • Provides mapping of Field name on a specific Form to

    an Internal table and Field name/number

  • Found in ShareINFO folder on VPN with name of ECFLD.TXT

  • Error to Internal Field relationship

  • Provides mapping for each Error Code on a

    specific Form and which Fields are used

  • Found in ShareINFO folder on VPN with name of ECERRFLD.TXT

  • Error Codes and Descriptions

  • Provides each Error Code and description

  • Found in ShareINFO folder on VPN with name of ECERR.TXT


Cye 09 prospective offeror technical overview67
CYE ’09 Prospective Offeror Technical Overview

REFERENCE

  • Four service code related Reference files are produced

  • Procedure Tables

  • Provides Procedures, Maximum Allowable

    Charge, Categories of Service, Revenue to

    Bill Types and Revenue to Procedure Code

    information

  • Found in ShareINFO folder on VPN with name of

    REFER01.ZIP

  • Procedure Modifiers

  • Provides valid Modifiers for Procedure Codes

  • Found in ShareINFO folder on VPN with name of

    REFER02.ZIP


Cye 09 prospective offeror technical overview68
CYE ’09 Prospective Offeror Technical Overview

REFERENCE

  • Outpatient Fee Schedules

  • 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

  • Found in ShareINFO folder on VPN with name of

    REFER03.ZIP

  • ASC Group Reference

  • Provides valid ASC Group Bundled Service

    codes

  • Found in ShareINFO folder on VPN with name of

    REFER04.ZIP



Cye 09 prospective offeror technical overview70
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 overview71
CYE ’09 Prospective Offeror Technical Overview

ENCOUNTER SUBMISSION

  • 837 FILES

  • Submitted by Contractor

  • 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 overview72
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 overview73
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 overview74
CYE ’09 Prospective Offeror Technical Overview

TECHNICAL ASSISTANCE

  • The 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 overview75
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 overview76
CYE ’09 Prospective Offeror Technical Overview

PROCESSING CYCLE

  • Encounters 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 overview77
CYE ’09 Prospective Offeror Technical Overview

PROCESSING CYCLE

  • Both Cycles include:

  • CRN Assignment

  • Edits and Audits

  • File and Report generation


Cye 09 prospective offeror technical overview78
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

    product

  • Acknowledgements (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 overview79
CYE ’09 Prospective Offeror Technical Overview

Community

Manager

Internet

Contractors

Transaction

Insight

Good and Bad

Transactions

837 (P,I,D)

NCPDP

Transactions

Modified

Transactions

Mainframe

FTP

Server

Valid

Transactions

Translated

Transactions

Acknowledgement Return

(997, 824, TA1)

Validation

Translation

Pend and 277U Response files


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CYE ’09 Prospective Offeror Technical Overview

TESTING

  • New 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)

  • A training session for the Contractor and/or

    designated subcontractor is scheduled during

    which the testing process will be reviewed.

  • 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.


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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



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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

  • All members (with limited exceptions) enrolled with a

    Contractor that meet the deductible limits are eligible for

    reinsurance

  • Services covered under reinsurance are detailed in

    contract and in the Reinsurance Processing Manual. Not all

    AHCCCS covered services are covered under reinsurance.


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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.

  • 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

  • Upon the creation of a RI case the Encounters are

    processed through the RI edits/audits.

  • The RI system generates the following monthly reports:

    • Reinsurance Case Initiation

    • Reinsurance Reconciliation

    • Reinsurance Case Summary

    • Reinsurance Remittance Advice


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CYE ’09 Prospective Offeror Technical Overview

PROCESSING

  • The Contractors can change the RI Encounters using the

    Reinsurance Correction Process via the PMMIS on-line system.

  • 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 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.


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CYE ’09 Prospective Offeror Technical Overview

CATASTROPHIC REINSURANCE

  • Provided 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


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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.


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CYE ’09 Prospective Offeror Technical Overview

REPORTING

REINSURANCE CASE INITIATION

  • Recipient’s Name, AHCCCS ID and Case Type

  • Case Initiation Date

  • Associated Encounters in case by CRN

REINSURANCE CASE RECONCILIATION

  • Shows 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


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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



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CYE ’09 Prospective Offeror Technical Overview

HIPAA

  • HIPAA 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

  • Currently all 837s and NCPDP5.1 files are processed through the Validator

  • Next phase (2008) outbound 820s, 834s, 277Us will be processed through the Validator

  • During this contract period 2008 – 2012, HIPAA transactions will be upgraded from the 4010A1 to the 5010 versions



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