4. ELIGIBILITY AND VERIFICATION A. Eligibility Verification

Transcription

4.
ELIGIBILITY AND VERIFICATION
A.
Eligibility Verification
APPLIES TO:
A.
This policy applies to all IEHP Healthy Kids Members.
POLICY:
A.
Accurate and timely eligibility information is a key concern of all participants in the IEHP
network and is a primary goal of IEHP.
B.
The IEHP ID card does not guarantee eligibility. These cards are issued for Member
convenience and identification purposes only.
C.
Member eligibility should be verified at each visit.
PROCEDURE:
A.
IEHP receives data files including both eligibility and demographic data.
1.
For Healthy Kids Members, data file transfers are received from the IEHP
Enrollment Unit on a daily basis and uploaded weekly.
B.
IEHP processes the eligibility data files received, assigns a PCP and Hospital to each
Member and updates Member demographic information.
C.
Recognizing that the network is comprised of Providers with existing systems employing
varying technologies, IEHP offers a number of methods for distributing eligibility
information to Providers and PCPs.
D.
Providers can receive updated eligibility information on Members through the following
methods:
E.
1.
Eligibility files (refer to Policy 4B1, “Eligibility Verification Methods - Eligibility
Files” for more information).
2.
IEHP’s Interactive Voice Response (IVR) system (888) 440-4340 or (909) 8903800. Refer to Policy 4B2, “Eligibility Verification Methods - Interactive Voice
Response (IVR)” for more information.
3.
IEHP website @ www.iehp.org. Refer to Policy 4B3, “Eligibility Verification
Methods – Online Eligibility Verification System (OEVS).”
These methods offer Providers and PCPs different levels of detail in the information
reported for each Member. The information reported about the Member may contain:
1.
Member Name
2.
IEHP Identification Number
3.
Birth date
IEHP Provider Policy and Procedure Manual
HF / HK
07/13
CO_04A.1
4.
F.
A.
Eligibility Verification
4.
Gender (female or male)
5.
Member Address
6.
Member Phone Number
7.
Language Preference
8.
Status (member is currently active)
9.
Effective date of terminations or transfers
10.
Co-payment Information
11.
Aid Code
12.
County Code
13.
Plan or Program (Healthy Kids and IHSS, etc.)
14.
Assigned PCP
15.
PCP effective date
16.
PCP Phone Numbers
17.
IPA Affiliation
18.
Assigned Hospital
19.
Claims billing address
When a Member visits his/her assigned PCP or Provider, the PCP/Provider should verify
eligibility before rendering services. In addition to verifying eligibility, the PCP/Provider is
encouraged to verify the Member’s identification through a secondary means, such as a
drivers license or state identification with both a picture and signatures.
INLAND EMPIRE HEALTH PLAN
Chief Approval: Signature on file
Original Effective Date:
September 1, 1996
Chief Title: Chief Network Officer
July 1, 2013
Revision Date:
HF / HK
07/13
CO_04A.2
4.
B.
Eligibility Verification Methods
1. Eligibility Files
APPLIES TO:
A.
POLICY:
A.
IEHP processes eligibility data, including assigning a PCP and Hospital to each Member
and updating Member demographics.
B.
Eligibility files created for Providers only contain those Members assigned to the Provider.
C.
IEHP places eligibility files on the IEHP Secure File Transfer Protocol (SFTP) server (See
Attachment, “Eligibility Data File Transmission Schedule” in Section 4).
D.
It is the responsibility of each Provider to retrieve the eligibility files within three days of
file transmission and update their eligibility system.
E.
IEHP requires the Provider to distribute eligibility lists or have the eligibility lists available
online to each of its contracted PCPs by the 5th and 15th of each month for the current
month’s enrollment.
If month end files are not loaded by the first of the month, providers must use alternative
IEHP methods to verify eligibility. Alternative methods include IEHP’s website,
www.iehp.org, and the IVR.
F.
PROCEDURE:
A.
All eligibility files are compressed (to save transmission time), encrypted (for security),
and password protected (additional security).
B.
By the first business day of each month, IEHP places a full eligibility file on the IEHP FTP
server.
C.
1.
IEHP supplies one copy of the decompression and decryption software necessary,
along with a password unique to each Provider, to read the files once retrieved.
2.
Each Provider must retrieve their eligibility files within three days of data file
transmission and upload them into the eligibility system in place at the Provider’s
location.
3.
If month end files are not loaded by the first of the month, providers must use
alternative IEHP methods to verify eligibility. Alternative methods include IEHP’s
website, www.iehp.org, and the IVR.
The eligibility file contains important information about the Member including:

Eligibility status
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4.
B.
1. Eligibility Files

Assigned PCP

Assigned Hospital

Effective date

Termination date (if applicable)

Address

Phone

Language preference

Birth date

Gender

Aid Code

County Code

Co-payment information

Capitation Rate

Race/Ethnicity
(For more detailed information see Attachment “Eligibility Data File Format” in Section 4
or refer to the Provider Eligibility and Encounter File Format Requirements Manual.)
D.
Because Member eligibility changes frequently, IEHP provides periodic file updates.
These file updates contain only changes within the Provider’s network, including any
updated information and new Healthy Kids Members, received since the last file update.
E.
Providers must distribute eligibility lists, or have the eligibility lists available online to their
contracted PCPs by the 5th and 15th of each month for the current month’s enrollment.
F.
Member Rosters are available on the IEHP website at www.IEHP.org
September 1, 1996
July 1, 2013
Revision Date:
HK
07/13
CO_04B1.2
4.
B.
2. Interactive Voice Response (IVR)
APPLIES TO:
A.
POLICY:
A.
IEHP offers the IEHP Interactive Voice Response (IVR) system for convenience in
verifying eligibility.
B.
The IVR is a commonly employed technology that uses a telephone to access Member
eligibility information.
C.
The IVR accesses IEHP’s computer system dynamically and provides the most current
information IEHP has on its Members. It is also helpful in determining if a co-payment is
due.
PROCEDURE:
A.
Member eligibility can be easily checked through the IVR 24 hours a day, seven days a
week by using the following information:
Example

IEHP’s 14-digit Member Identification number
19961105666101

Member social security number
123121234

Member 9-digit pseudo social security, with alpha character
12312123a

Member 9-character Alpha Numeric CIN
12345678A
Note: If the social security number contains an alpha character, refer to Attachment “IVR
Alpha Characters” in Section 4.”
B.
The IVR can be accessed by dialing (888) 440-4340 or (909) 890-3800.
C.
The IVR system searches IEHP’s Member database for a record corresponding to the
number entered by the caller.
D.
When the record is found, the Member’s name, gender and birth date is supplied to verify
this is the Member that the Provider is calling verify eligibility for.
E.
The caller then has the option of verifying current eligibility or historical eligibility based
on the date entered into the phone via the touch-tone keys.
F.
Once the above have been entered, information and benefits about a Member available
through the IVR include:
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07/13
CO_04B2.1
4.
B.









2. Interactive Voice Response (IVR)
Name
Birth date
Gender
Plan or Program (Medi-Cal, Healthy
Families, Healthy Kids, Open Access,
Medicare DualChoice (HMO SNP).
Current Eligibility
Historical Eligibility
County Code
Aid Code
Effective Date




IEHP ID #
PCP
PCP’s telephone number
PCP’s IPA affiliation




Member’s assigned Hospital
Co-Pay Information
Claims Billing Addresses
Verification Code
G.
The IVR provides co-payment information for Healthy Families, and Healthy Kids
Members.
H.
In addition, through the IVR the caller can check multiple dates of service, verify an
unlimited number of Members, check eligibility with identification numbers that have alpha
characters and obtain a verification code as proof of the transaction.
September 1, 1996
July 1, 2013
Revision Date:
HK
07/13
CO_04B2.2
4.
B.
3. Online Eligibility Verification System (OEVS)
APPLIES TO:
A.
POLICY:
A.
IEHP offers the IEHP Web Page for convenience in verifying Member eligibility.
B.
The IEHP Web Page is an efficient alternative source that enables providers to submit
multiple eligibility verification requests at the same time.
C.
The IEHP Eligibility Verification Web Page is a free-transaction service for providers,
which reduces the amount of time spent verifying Member eligibility through the IEHP’s
IVR system or contacting the IEHP Member Services department.
PROCEDURE:
A.
Providers can log onto IEHP’s web page at www.iehp.org.
B.
To access the IEHP Web Page, providers need to contact IEHP Provider Relations Team
at (909) 890-2054 to receive a login ID, and be able to register online to access the
eligibility section of the web page.
C.
IEHP has created an Online Eligibility Verification System Training Manual to provide
instructions for using the online system (See Attachment, “OEVS Training Manual – HK”
in Section 4).
D.
Providers must meet the following system requirements in order to have access to the
IEHP’s WebSite:
1. Computer with an Internet Connection.
2. A browser that supports 128 bit Encryption.
E.
Providers can access Member eligibility information through IEHP’s Web Page, 24 hours
a day, 7 days a week, including holidays.
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07/13
CO_04B3.1
4.
B.
F.
G.
3. Online Eligibility Verification System (OEVS)
The IEHP’s Web Page provides the following Member information:







Name
Social Security Number
Gender
Date of Birth
Assigned PCP
Assigned IPA







Assigned Hospital
Billing Addresses



Effective Date with PCP
Eligibility Status
PCP ID
PCP Phone Number
Plan or Program (Medi-Cal, Healthy Kids,
Open Access, Medicare
DualChoice
IEHP
DualChoice
(HMO
SNP),
(Medicare – Medi-Cal), etc.)
Co-Pay
Aid Code
County Code
Providers can use the following information to verify Member eligibility:
1.
Member Social Security Number (SSN)/Client Index Number (CIN)
2.
IEHP Member Identification Number
3.
Member Last Name and Date of Birth
H.
Providers can check eligibility of up to 10 Members at once.
I.
Providers receive a verification number for every transaction using the Web Page.
J.
Providers can also access the IEHP formulary through the IEHP Web Page.
K.
Providers with any questions regarding the IEHP’s Web Page should call an IEHP
Provider Services Representative at (909) 890-2054.
January 1, 2001
July 1, 2013
Revision Date:
HK
07/13
CO_04B3.2
4.
C.
Member Co-payments
APPLIES TO:
A.
POLICY:
A.
Healthy Kids Members are currently required to pay a $5.00 co-payment..
B.
Healthy Kids Members have a $250 combined medical and pharmacy annual out-ofpocket maximum per family per benefit year (July to June).
C.
It is the Members’ responsibility to keep track of their co-payments paid and to submit
their receipts to IEHP.
D.
Members who demonstrate that their co-payment out-of-pocket maximum has been met
will receive a new IEHP ID card with the co-payment amount listed as $0.
E.
If a Member is unable to pay their co-payment at the time of service, the practitioner may
bill the Member for the co-payment. Practitioners must not waive co-payments.
PROCEDURE:
A.
IEHP Members are issued an IEHP ID card that identifies the co-payment.
1.
Healthy Kids ID cards

ID card is titled “Healthy Kids Health Access”

It includes $5 in the “Co-pays” section at the bottom of the card including
vision services

$0 co-payment for all office visits for children under 24 months of age
B.
Since an IEHP ID card does not guarantee eligibility, practitioners must confirm Member
eligibility before collecting a co-payment (refer to Policy 4A, “Eligibility Verification”
for more information). Additionally, practitioners are encouraged to verify Members’
identification through secondary means, such as a driver’s license or state ID card with
both a picture and signature.
C.
Co-payments apply to the following types of services (these are examples of benefits for
Commercial plan members):

Office Visits (for Members 2 years of age and older)

Urgent Care Visits

Emergency Room Visits

Second Medical Opinions

Outpatient Physical/Occupational/Speech Therapy Visits
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4.
D.
C.
Member Co-payments

Prescription Drugs (excluding contraceptive supplies, Prenatal Vitamins and
Diabetic Supplies)

Outpatient Mental Health/Alcohol/Drug Abuse Visits
Co-payments do not apply to the following types of services:
For Healthy Kids Programs:

Preventive Services, such as:

Periodic Health Exams (including Well Child)

Scheduled Immunizations

Family Planning

Prenatal Care

Vision / Hearing tests or screenings (Exception: Healthy Kids have a $5dollar Copay for Vision tests)

Sexually transmitted disease testing

Health Education

Office Visits (for Member under 2 years of age)

Diagnostic Services (lab and x-ray)

DME and Supplies

Inpatient Services

Home Health Care Visits
E.
A receipt should be given to the Member when a co-payment is collected.
F.
Members who present an IEHP ID card with co-payment amount listed as $0 should not
be charged a co-payment.
1.
Practitioners must confirm whether or not co-payments are required when
verifying eligibility.
2.
If the IEHP Interactive Voice Response (IVR) system states that no co-payments
are required, the practitioner should not collect a co-payment regardless of what
the IEHP ID card indicates.
G.
If a Member is unable to pay their co-payment at the time of service, the practitioner is
encouraged to work with the Member by agreeing to bill the Member for the co-payment.
The practitioner cannot waive the co-payment.
H.
For Healthy Kids - For Vision Benefits Only
1.
In the event that services are not covered under the IEHP Plan or are denied by
IEHP as not being Medically Necessary, for example non-covered cosmetic
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4.
C.
Member Co-payments
contact lenses or non-Medi-Cal benefit frames, the Provider must not charge the
Member unless the Provider has obtained a written waiver from the Member. The
waiver must be obtained in advance of rendering services and must specify those
non-covered services or services IEHP has denied as not being Medically
Necessary and must clearly state that the Member is responsible for payment of
those services.
2.
I.
The form must be signed by both the Member and the Provider and be retained as
part of the Member’s optometric record for a period of seven years. In these
cases, Providers cannot bill IEHP or Medi-Cal for the contact lens materials and
fitting services or for frames purchase.
Discrepancies regarding whether or not a co-payment is due should be directed to IEHP
Member Services (800) 440-4347 while the Member is present.
July 1, 1998
July 1, 2013
HK
Revision date:
07/13
CO_04C.3
4.
Attachments
DESCRIPTION
POLICY CROSS
REFERENCE
4B1
4B1
4B2
4B3
Eligibility Data File Transmission Schedule - HK
Eligibility Data File Format - HK
IVR Alpha Characters
OEVS Training Manual
HK
07/13
CO_04.1
Att – Eligibility Data File Format
#
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
DATA ELEMENT
PCP ID
PCP Name
Current Eligibility Status Code
Effective Date
Termination Date
Group
Aid Code
Subscriber ID #
Last Name
First Name
Middle Initial
Date of Birth
Gender
Race Code
Ethnicity Code
Language Code - Spoken
Language Code – Written
Phone Number
Alternative Phone Number
C/O Address
Street Address
City/State
Zip Code + 4
Mailing C/O Address (Pending)
Mailing Street Address (Pending)
Mailing City/State (Pending)
Mailing Zip Code + 4 (Pending)
Social Security Number
Provider Manual
T
Y
P
E
A
A
A
N
N
A
A
A
A
A
A
N
A
A
A
A
A
N
N
A
A
A
A
A
A
A
A
A
P
O
S
1
8
38
39
47
55
65
67
81
96
106
107
115
116
117
119
120
122
132
142
168
194
220
229
255
281
307
316
B
Y
T
E
S
7
30
1
8
8
10
2
14
15
10
1
8
1
1
2
1
2
10
10
26
26
26
9
26
26
26
9
9
FORMAT
AXX9999
X(30)
X
CCYYMMDD
CCYYMMDD
X(10)
X(2)
CCYYMMX(8)
X(15)
X(10)
X
CCYYMMDD
X
X
X(2)
X
X
X(10)
X(10)
X(26)
X(26)
X(26)
X(9)
X(26)
X(26)
X(26)
X(9)
X(9)
DESCRIPTION
IEHP assigned PCP code. A=IPA, XX=Hospital, 9999=PCP code
Provider Name
Represents status of eligibility (see note # 3)
The effective date the Member was with this PCP (see note # 4)
The date the Member was terminated from this PCP (see note # 5)
The group for this Member (see note # 6)
Identifies Member's aid code. (See note # 7)
The IEHP assigned # for the Member (see note # 8)
Member Last Name
Member First Name
Member Middle Initial
Member date of birth
M= Male or F= Female
Identifies race of Member (see note # 14)
Identifies ethnicity of Member (see note # 15)
Identifies spoken language of Member (see note #16)
Identifies written language of Member (see note # 17)
Identifies Member 10 character phone number. Example 9094302752
Member Alternative Phone Number Example 9094302752 (see note # 19)
Member C/O address
Member Street address
Member City and State
Member Zip Code
Member Mailing C/O address (Field will be passed but may not contain data)
Member Mailing Street address (Field will be passed but may not contain data)
Member Mailing City/State (Field will be passed but may not contain data)
Member Mailing Zip Code (Field will be passed but may not contain data)
This field consists of one of the following: SSN#, PSEUDO# or Blank (see
note # 28)
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Revision Date: 01/01/2013
Page 1 of 13
Att – Eligibility Data File Format
29
Previous Social Security Number
A
325
9
X(9)
30
31
32
33
34
35
36
37
CIN#
Medicare Number
Alternate ID #
Prior Alternate ID #
Part D
Copay
PHP Status Code
Previous PCP code
A
A
A
A
A
A
A
A
334
343
355
369
383
384
385
387
9
12
14
14
1
1
2
7
X(9)
X(12)
CCAAX(10)
CCAAX(10)
X
X
X(2)
AXX9999
38
39
40
Capitation Rate
Previous Subscriber ID #
IEHP PROV ID
N
394
401
415
7
14
9
X(7)
CCYYMMX(8)
AAAXX9999
41
Filler
424
137
X(7)
TOTAL RECORD SIZE
Provider Manual
A
This field consists of the previous SSN# as identified above or blank (see note
#29)
CIN# (see notes#30)
Health Insurance Number (HICN) (See note # 31)
Medicaid # for dual eligible’s (see note # 32)
Medicaid # for dual eligible’s (see note # 33)
Identifies if Member is active with Medicare Part D (see note # 34)
Identifies if copay exists. Y = Yes or N = No (see note # 35)
Health Plan Status Code (See note # 36)
IEHP assigned PCP code. A=IPA, XX=Hospital, 9999=PCP code (See note #
37)
Category (See note#38)
The previous IEHP assigned # for the Member (see note # 39)
Assigned IEHP Provider ID. A=IPA, XX=Hospital, 9999=Sequential ID
number
Spaces from position 393 through 553
561
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Page 2 of 13
NOTES:
Data Element
Element:
Note #3:
3
CURRENT ELIGIBILITY STATUS CODE
This code can be an A, C, T, or N:
A = Active (on weekly and monthly files) identifies existing Members or Members who were part of your organization
last month.
C = Change (on both weekly and monthly updates) identifies Members who have demographic changes or have changed
PCPs, but remain assigned to your organization.
T = Termed (on both weekly and monthly updates) identifies Members who are no longer assigned to your organization.
N = New (on both weekly and monthly updates) identifies Members who are newly assigned to your organization.
NOTE: Members who are not included in the IEHP monthly eligibility file who are active in the health plan’s
membership database are not eligible for the new month and should be disenrolled effective the first day of the current
month.
Element:
Note #4:
4
EFFECTIVE DATE
Effective Date Logic – Applies to both Daily and Monthly Files
1. If the member is active (status “A”), the Effective Date could be any date of the month since the HK members can be
effective any date of the year, including holidays and weekends.
2. If the member is Disenrolled/Termed (status “T”), the Effective Date will show the same date as the “Termination
Date”.
See “Term Date Logic” section below.
3. Effective Date field showing a date prior to the current date is due to demographic and/or Provider Changes.
Members
are still active and new demographic information must be updated in the provider’s member database.
4. HK effective dates might look like 20110115, since HK members can become eligible any day of the month.
Provider Manual
07/13
Page 3 of 13
Element:
Note #5:
5
TERMINATION DATE
Term Date Logic – Applies to both Daily and Monthly Files
1. This field should always be populated with a date.
2. If it is an “Active” record noted with an “A”, the Term date is defaulted to the last day of the month being reported.
For instance, if the Effective date is 20120901 then the Term Date shows 20120930.
3. If it is a disenrollment record noted with a “T”, the Term Date and Effective Date are set to the last day of the month
when the member was active. For instance, if member is disenrolled effective 20121201, then both Effective date
and Term Date fields show 20111130.
4. Once a member is sent as a brand new member in a daily file, in the subsequent monthly file, the member’s effective
date is sent as the 1st of the new month. For instance, if the member was submitted with an active eligibility status
with the effective date of 20121103 in the daily file, the member will be sent in the December 2012 file with the
Effective Date of 20121201.
Element:
Note #6:
6
GROUP
MEDI-CAL
RIVERSIDE
RVC-FAMILY
RVC-ADULT
RVC-AGED
RVC-DISABLED
RVC- NONCVR (*)
RVC-TLICH
HEALTHY FAMILIES
RIVERSIDE
RVC-HFP
RVC-HFI
HEALTHY KIDS
RIVERSIDE
RVC-HKI
RVC-HKC
IEHP DUALCHOICE
RIVERSIDE
RVC-SNPMD**
RVC-SNPMO**
SAN BERNARDINO
SBC-HFP
SBC-HFI
SAN BERNARDINO
SBC-HKI
SBC-HKC
SAN BERNARDINO
SBC-SNPMD**
SBC-SNPMO**
SAN BERNARDINO
SBC-FAMILY
SBC-ADULT
SBC-AGED
SBC-DISABLED
SBC- NONCVR (*)
SBC-TLICH
(**) XXX-SNPMD = IEHP for Medi-Cal and Medicare DualChoice; XXX-SNPMO = IEHP Medicare Only
Provider Manual
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Page 4 of 13
Element:
Note #7:
7
AID CODE
Medi-Cal – The following aid codes are covered by IEHP
Family
Disabled
Aged
Adult
Child
01
3U
0N
10
86
5C
02
3W
14
0M
5D
03
40
16
0P
H1
04
42
1E
0R
H2
08
45
1H
0T
H3
0A
47
0U
H4
30
4A
0W
32
4C
H5
33
34
35
38
39
3A
3C
3E
3G
3H
3L
3M
3N
3P
3R
4F
4G
4K
4M
54
59
5K
5X
72
7A
7J
7X
82
8P
8R
20
24
26
28
2E
36
60
64
66
68
6A
6C
6E
6H
6J
6N
6P
6R
6V
Healthy Family – The following aid codes are covered by IEHP
HC
HI
Healthy Kids – The following aid codes are covered by IEHP
K1
K2
Provider Manual
07/13
Page 5 of 13
K3
K5
K7
K9
KB
KD
K4
K6
K8
KA
KC
KZ
Medicare DualChoice
MD = IEHP Medicare DualChoice and IEHP Medi-Cal
MF = IEHP Medicare DualChoice and Fee For Services Medi-Cal
MN = IEHP Medicare DualChoice and No Medi-Cal
Element:
Note #8:
8
SUBSCRIBER ID #
The Subscriber ID # is the IEHP assigned number for each Member. An example of a Subscriber ID # is 201101000001,
a Medicare Subscriber ID# ends in 00. Ex 20110100000100.
Element:
Note #14:
14
RACE CODE
1 - White
2 - Hispanic
3 - Black
4 - Other Asian or Pacific Islander
5 - Alaskan Native or American Indian
6 - Not a Valid value
7 - Filipino
8 - No Valid Data Reported (MEDS generated)
9 – Not Reported
A – Amerasian
C – Chinese
H – Cambodian
J – Japanese
K – Korean
M – Samoan
N – Asian Indian
P – Hawaiian
R – Guamanian
T – Laotian
U – Unknown
V – Vietnamese
X – Multiple Race
Z – Other
Race code is not a required Healthy Kids Field and may be blank.
Provider Manual
07/13
Page 6 of 13
Element:
Note #15:
15
ETHNICITY CODE
1 - White
2 - Hispanic
3 - Black
4 - Other Asian or Pacific Islander
5 - Alaskan Native or American Indian
6 - Not a Valid value
7 - Filipino
8 - No Valid Data Reported (MEDS generated)
9 – Not Reported
A – Amerasian
AA – African-American
AG – Argentinean
AI – American
AM – Armenian
AR – Arab
BG – Bangladeshi
BZ – Brazilian
C – Chinese
CL – Chilean
CO – Colombian
CR – Costa Rican
CU – Cuban
EE – Eastern European
ET – Ethiopian
EU – Ecuadorian
GT – Guatemalan
H – Cambodian (Khmer)
HM – Hmong
HT – Haitian
ID – Indonesian
IQ – Iraqi
IR – Iranian
J – Japanese
LT – Latino
M – Samoan
MX – Mexican
N – Asian Indian (India)
NC – Nicaraguan
OL – Other Latino
P – Hawaiian
PK – Pakistani
PR – Puerto Rican
PU – Peruvian
R – Guamanian
RS – Russian
SA – South American
SL – Sri Lankan
SV – Salvadoran
T – Laotian
TA – Thai
TN – Trinidadian
TW – Taiwanese (Chinese)
V – Vietnamese
WE – Western European
Z – Other
Ethnicity code is not a required Healthy Kids Field and may be blank.
Provider Manual
07/13
Page 7 of 13
Element:
Note #16:
16
LANGUAGE CODE – SPOKEN
0 - American Sign Language C - Other Chinese Languages
1 – Spanish
D – Cambodian
2 – Cantonese
E – Armenian
3 – Japanese
F – Ilacano
4 – Korean
G – Mien
5 – Tagalog
H – Hmong
6 - Other non-English
I – Lao
7 – English
J – Turkish
8 - No valid data reported
K – Hebrew
9 – No valid data reported
L – French
A - Other Sign Language
B – Mandarin
M – Polish
N – Russian
O - Default to 0 (zero)
P – Portuguese
Q – Italian
R – Arabic
S – Samoan
T – Thai
U – Farsi
V – Vietnamese
Language code - Spoken is not a required Healthy Kids Field and may be blank.
Provider Manual
07/13
Page 8 of 13
Element:
Note #17:
17
LANGUAGE CODE – WRITTEN
7S – English Standard
7B – English Braille
7C – English Audio - Cassette
7D – English Audio – CD
7E – English Electronic
7L – English Large Print
1S – Spanish Standard
1B – Spanish Braille
1C – Spanish Audio – Cassette
1D – Spanish Audio – CD
1E – Spanish Electronic
1L - Spanish Braille
Language code - Written is not a required Healthy Kids Field and may be blank.
Element:
Note #19:
19
ALERNATIVE PHONE NUMBER
This field may be blank.
Element:
Note
#24-27:
24-27
Element:
Note #28:
MEMBER MAILING ADDRESS
This data will be provided at a later date. IEHP will be adding mailing address information at a later date.
28
SOCIAL SECURITY NUMBER
This field is not required and may be blank.
For Medi-Cal and or Medicare Members, this field consists of one:
1. SSN- Member SSN or
2. PSEUDO- This number appears in this field if no SSN is available as provided by Medical. First digit
Provider Manual
07/13
Page 9 of 13
begins with the number "8 or 9" and ends with a letter.
3. May be blank
For Healthy Families Members, this field consists of one of the following:
SSN – Member SSN or
PSEUDO- This number appears in this field if no SSN is available as provided by FAME. First digit begins
with the number "8 or 9" and ends with a letter or
For Healthy Kid members, this field will be blank.
SSN is not a required Healthy Kid field.
Element:
Note #29:
29
PREVIOUS SOCIAL SECURITY NUMBER
Previous SSN - Member previous SSN if available or may be blank.
Element
Note #30:
30
CIN #
The Member ID # is a 9 digit alphanumeric Client Index Number (CIN #).
For Healthy Kids, the Member ID# is a 9-digit number in the format HK####### (IEHP ID number). First two
digits begin with “HK”.
For Medicare members this field may be blank.
Element:
Note #31:
31
MEDICARE NUMBER
Members who are eligible for DualChoice for the current month have the HICN displayed in this field.
Element:
Note #32:
32
ALTERNATE ID #
Medi-Cal and Medicare Members: The Member ID # is a 14 digit Medi-Cal # in the format of CC = County Code,
AA = Aid Code, X = “9” + SSN or X = Case #, Family Budget Unit, and Person #.
Healthy Family Members: The Alternate ID # is a 11 digit alphanumeric Family ID number.
Provider Manual
07/13
Page 10 of 13
Element:
Note #33:
33
PRIOR ALTERNATE ID #
Medicare Members: The Member ID # is a 14 digit Medi-Cal # in the format of CC = County Code, AA = Aid Code,
X = “9” + SSN or X = Case #, Family Budget Unit, and Person #.
Member ID # may be blank.
Healthy Family Members: The Alternate ID # is a 11 digit alphanumeric Family ID number.
Member ID # may be blank.
Element:
Note #34:
34
PART D
If Member is active with Medicare Part D, it is indicated with a “D”. If Healthy Families or Healthy Kids member
this field will be blank.
Element:
Note #35:
35
COPAY
COPAY is presented as a Y or N. Y = Copay due from Member. N = No copay due from Member.
Element:
Note #36:
36
PHP STATUS CODE
MEDI-CAL
01 –Active Enrollment
S1 – Active Enrollment– Activated from hold Retroactive
51 - Active Enrollment – Activated from hold
05 - Enrollment Held – Due to Medi-Cal hold
55 - Enrollment Held – Uncertified Share of Cost
59 - Enrollment Held – Due to change in recipient’s status other than Medi-Cal hold.
Provider Manual
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Page 11 of 13
00 - Voluntary Disenrollment
10 – Voluntary Disenrollment
40 - Voluntary Disenrollment – Occurred before enrollment became effective
S0 - Voluntary Disenrollment – Retroactive
09 - Mandatory Disenrollment
19 - Mandatory Disenrollment
49 – Mandatory Disenrollment - Occurred before enrollment became effective
S9 - Mandatory Disenrollment – Retroactive
P4 - Pending Enrollment
HEALTHY FAMILIES and HEALTHY KIDS
28 - Active - Initial Enrollment
20 - Active - Change or Reinstatement
22 – Active – Change Dental/Vision Plan
43 – Active – Address change
XT – Active – Change Dental/Vision Plan
03 - Cancellation/ Termination due to death
07 - Cancellation/ Termination of benefits
14 - Voluntary Disenrollment
MEDICARE DUALCHOICE
01 – Active Enrollment
61 – Active Enrollment – Enrollment Verified by CMS
05 – Enrollment Held – Pending Enrollment Verification
00 – Voluntary Disenrollment
09 – Mandatory Disenrollment
Element:
Note #37:
37
PREVIOUS PCP CODE
This is populated if the eligibility status code is a C which indicates the previous provider if in the same IPA.
Element:
Note #38:
38
CAPITATION RATE
Member capitation rate is based on Member Aid Code Category as indicated on Note#6. For more details on the
Provider Manual
07/13
Page 12 of 13
capitation rate please refer to your IEHP Capitated Agreement.
Element:
Note #39:
39
PREVIOUS SUBSCRIBER #
Under specific circumstances we may have events that require us to change a member's primary ID number. In the
event that this occurs this field will be populated with the original IEHP Subscriber ID number for reference
purposes and field 8 will hold a new IEHP Subscriber ID Number.
Element:
Note #40:
40
IEHP PROV ID
The PCP ID replaces the Provider ID indicated in Field #1effective 03/01/2013.
Provider Manual
07/13
Page 13 of 13
Attachment - Eligibility Data File Transmission Schedule
ELIGIBILITY PROCESSING PROCEDURES
Eligibility Data File Transmission Schedule
The following schedule outlines when eligibility files are available to providers for review. Eligibility files
must be picked up within three days of file transmission.
RUN DATE
FIRST
WEEKLY
Eligibility File
(updates only)
RUN DATE
SECOND
WEEKLY
Eligibility File
(updates only)
RUN DATE
THIRD
WEEKLY
Eligibility File
(updates only)
RUN DATE
Jan 2013
01/31/2013
01/10/2013
01/17/2013
01/25/2013
Feb 2013
02/28/2013
02/11/2013
02/18/2013
02/22/2013
Mar 2013
03/31/2013
03/11/2013
03/18/2013
03/25/2013
Apr 2013
04/30/2013
04/10/2013
04/17/2013
04/25/2013
May 2013
05/31/2013
05/10/2013
05/17/2013
05/24/2013
Jun 2013
06/30/2013
06/10/2013
06/17/2013
06/25/2013
Jul 2013
07/31/2013
07/10/2013
07/17/2013
07/25/2013
Aug 2013
08/31/2013
08/09/2013
08/16/2013
08/26/2013
Sep 2013
09/30/2013
09/10/2013
09/17/2013
09/25/2013
Oct 2013
10/31/2013
10/10/2013
10/17/2013
10/25/2013
Nov 2013
11/30/2013
11/11/2013
11/18/2013
11/25/2013
Dec 2013
12/31/2013
12/10/2013
12/17/2013
12/23/2013
Jan 2014
01/31/2014
01/10/2013
01/17/2013
01/24/2014
Calendar
Month
MONTHLY
Eligibility File
(full file)
Attachment IVR Alpha Characters
How to enter an alpha character when using the IVR
To enter an alphabetic character, press the Star (*) key followed by the number that corresponds
to the alpha character on the key pad, followed by the number (1,2 or 3) to indicate the position
of the alpha character on the key. For example, the letter (K), would be entered Star (*), 5, 2.
Q
11
Z
12
A
21
1
G
41
H
42
R
72
C
23
D
31
2
I
43
J
51
4
P
71
B
22
K
52
T
81
U
82
F
33
3
L
53
M
61
5
S
73
E
32
N
62
O
63
6
V
83
W
91
X
92
7
8
9
*
0
#
Y
93
A
B
C
D
E
F
G
H
I
J
K
L
M
=
=
=
=
=
=
=
=
=
=
=
=
=
*21
*22
*23
*31
*32
*33
*41
*42
*43
*51
*52
*53
*61
N
O
P
Q
R
S
T
U
V
W
X
Y
Z
=
=
=
=
=
=
=
=
=
=
=
=
=
*62
*63
*71
*11
*72
*73
*81
*82
*83
*91
*92
*93
*12
Attachment - OEVS Training Manual
IEHP Online Eligibility Verification System (OEVS)
IEHP encourages the use of our OEVS for quick verification of Member eligibility. This
new verification system will assist your office and IEHP in accomplishing our joint goal
of delivering the highest quality of health care to our Members. Listed below are a few
benefits of using the OEVS:
•
•
•
•
Available 24 Hours a Day, 7 Days a Week, Including Holidays.
Eliminates Telephone Wait Times.
Ability to Submit Multiple Queries at the Click of a Button.
Print Verifications from your Computer.
There are several different search options to choose from to verify the Member’s
eligibility:
•
•
•
Social Security Number (SSN)/Client Index Number (CIN)
o Submit up to 10 requests at one time
o Submit up to 10 requests at one time
Last Name and Date of Birth
o Single search only
Please note that the OEVS is a means to verify Member eligibility only and does not
issue authorizations for services.
System Requirements Include:
1. Computer with an Internet Connection.
2. A browser that will support 128 bit Encryption.
3. A browser to accept Cookies.
4. Printer (Optional)
Access to OEVS requires your Provider ID and a password. If you do not have a Login
ID and Password, you can register online by clicking the “Secure Site Login” and then
clicking “Register for a Login.” For further assistance, please call your Provider Services
Representative or call (909) 890-2054.
Page -1-
LOGIN
To Login to IEHP’s OEVS, follow the steps below:
Steps
1. From your internet browser, go to http://www.iehp.org. This will bring up
IEHP’s home page.
2. Click the PROVIDERS button from the left hand menu.
3. From the bulleted list on the Provider Page, click the Secure Site Login option.
a. Enter your Login ID and Password.
4. Once you have successfully logged into the IEHP Provider Website, click the
“Eligibility” button on the toolbar located on the left hand side of the page.
5. You are now logged in to the Eligibility Verification System. If you receive an
error message, please check your ID number and Password for accuracy. If you
continue to receive an error message, call your Provider Service Representative
for Assistance.
6. If you do not have a Login ID and Password, you can register online by clicking
the button in the center of the screen.
Page -2-
Search by SSN/CIN
To search by SSN/CIN, follow the steps below:
Steps
1. Click on the Eligibility button on the toolbar located on the left-hand side of the
screen.
2. Click the SSN/CIN button on the toolbar located on the left-hand side of the
screen.
3.
Enter up to 10
SSNs or CINs.
You may enter a
different DOS for
each.
Click Submit
4. When you have completed your session, please remember to click the Log Off
button located on the left-hand side of the screen.
Page -3-
Search by IEHP Identification Number
To Search by IEHP ID, follow the steps below:
Steps
1. Click on the IEHP ID button on the toolbar located on the left-hand side of the
screen.
2.
Enter up to
10 IEHP
ID
Numbers.
You may
enter a
different
DOS for
each
number
entered.
Click Submit
Page -4-
Search by Last Name and Date of Birth
To Search by Last Name and Date of Birth, follow the steps below:
Steps
1. Click the LAST NAME button on the toolbar located on the left-hand side of the
screen.
2.
Enter the
Member’s
DOB and
Last Name.
DOB must
be in the
following
format:
07/01/2000
Click Submit
Page -5-

4. ELIGIBILITY AND VERIFICATION A. Eligibility Verification

Transcription

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