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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 Overview


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    1. CYE ’09 Prospective Offeror Technical Overview

    2. CYE ’09 Prospective Offeror Technical Overview • Introduction • Technical Environment • Interfaces • Recipient/Health Plan • Provider • Provider Affiliation • Reference • Encounters • Reinsurance • HIPAA • Questions

    3. CYE ’09 Prospective Offeror Technical Overview INTRODUCTION Provide all potential offerors with an overview of AHCCCS technical environment and data interface and standards.

    4. CYE ’09 Prospective Offeror Technical Overview TECHNICAL ENVIRONMENT

    5. 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.

    6. CYE ’09 Prospective Offeror Technical Overview INTERFACES

    7. CYE ’09 Prospective Offeror Technical Overview • Interfaces • Recipient/Health Plan • Eligibility • Enrollment • Capitation • Processing • Data Exchange • Provider/Provider Affiliation • Reference • Encounters • Reinsurance

    8. CYE ’09 Prospective Offeror Technical Overview RECIPIENT / HEALTH PLAN

    9. CYE ’09 Prospective Offeror Technical Overview ELIGIBILITY

    10. 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

    11. DES CYE ’09 Prospective Offeror Technical Overview • 1931 • S.O.B.R.A. • TITLE 19 WAIVER • HIFA PARENTS • FEDERAL EMERGENCY SERVICES

    12. DES SSA CYE ’09 Prospective Offeror Technical Overview • SSI CASH

    13. 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

    14. 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)

    15. CYE ’09 Prospective Offeror Technical Overview ENROLLMENT

    16. 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

    17. 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

    18. 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)

    19. 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)

    20. 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

    21. 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

    22. 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

    23. 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

    24. 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

    25. CYE ’09 Prospective Offeror Technical Overview CAPITATION

    26. 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

    27. 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

    28. 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

    29. 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

    30. 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

    31. CYE ’09 Prospective Offeror Technical Overview PROCESSING

    32. 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.

    33. 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

    34. 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

    35. 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

    36. 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

    37. 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

    38. 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

    39. 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

    40. CYE ’09 Prospective Offeror Technical Overview VERIFICATION

    41. 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

    42. 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

    43. 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

    44. 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

    45. 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

    46. 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

    47. CYE ’09 Prospective Offeror Technical Overview DATA EXCHANGE • From AHCCCS to Contractors • Weekly Files • Capitation Notification (820) • yymmdd.820

    48. 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/

    49. 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)

    50. 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