Member Information Requirements. The CONTRACTOR’s Member information requirements shall include, but not be limited to accepting, maintaining, and transmitting all required Member information. The CONTRACTOR shall receive, process, and update enrollment files sent daily by HCA. The CONTRACTOR shall update its eligibility/enrollment databases within twenty-four (24) hours of receipt of said files. The CONTRACTOR shall be capable of uniquely identifying a distinct Member across multiple populations and systems within its span of control. The CONTRACTOR shall be able to identify potential duplicate records for a single Member and, upon confirmation of said duplicate record by HCA, resolve the duplication such that the enrollment, service utilization and customer interaction histories of the duplicate records are linked or merged. The CONTRACTOR shall: Provide a means for Providers and Major Subcontractors to verify Member eligibility and enrollment status twenty-four (24) hours a day, seven (7) days a week, three hundred sixty-five (365) Calendar Days a year; Ensure that current and updated eligibility information received from HCA is available to all Providers via the CONTRACTOR’s eligibility verification system and all Subcontractors’ eligibility verification systems within twenty-four (24) hours of receipt of any and all enrollment files from HCA; Assign as the key Medicaid Member ID number, the RECIP-MCD- CARD-ID-NO that is sent on the enrollment roster file and capture and store the Medicare ID, SSN and pseudo-SSN if they are included on the enrollment roster file for use in identification, eligibility verification, and Claims adjudication by the CONTRACTOR or any Subcontractor, Major Subcontractor, or Contract Provider that pay Claims. These numbers will be cross-referenced to the Member’s Social Security number and any internal number used in the CONTRACTOR’s system to identify Members; Meet federal CMS and HIPAA standards for release of Member information (applies to Subcontractors, Major Subcontractors, and Providers as well). Standards are specified in the MCO Systems Manual and at 42 C.F.R. § 431.306(b); Maintain accurate Member eligibility and demographic data to include but not be limited to, XXX, CCL, population identification and risk stratification, NF LOC and SOC, Community Benefit status, copayment maximum, copayment spent amount, Medicare status, Health Home status, Behavioral Health needs, age, sex, race, residence county, parent/non parent status, Native American status,...
Member Information Requirements. The CONTRACTOR’S member information requirements shall include, but not be limited to:
A. Accepting, maintaining and transmitting member information:
B. Monitoring newborns to ensure minimal lapse in time between the infant’s birth and their determination of Medicaid eligibility. The CONTRACTOR shall submit electronic claims for newborn capitations until the MMIS is capable of issuing the capitations automatically. The anticipated date for this capability is October 1, 2001, after which the CONTRACTOR shall only be responsible for submitting capitation claims in unusual circumstances, such as to correct a previously unidentified problem. Retroactive capitations shall only be issued for the first three months of life, during which time the mother’s MCO shall cover the services of the newborn. After the time, if that newborn has not appeared on a roster for the CONTRACTOR, the CONTRACTOR shall not be responsible for the continuing health care for the child. However, the parent or guardian may choose a different MCO for the newborn as early as the second month of life. In such a case, the MCO of the mother is only entitled to the capitation for the birth month;
C. Generating member information to providers within five (5) business days of receipt of the enrollment roster from HSD;
D. Using all four occurrences of the Medicaid member ID number sent to the CONTRACTOR on the enrollment roster to ensure the CONTRACTOR can differentiate between a change in an existing client’s Medicaid member ID number and a new client. These numbers needs to be available to staff to be used as a cross reference when providers or others submit a number other than the number maintained by the CONTRACTOR as the primary number and as a means to update the member’s ID number when eligibility changes necessitate a change to the number;
E. Maintaining a special medical status identifier on their system’s database consistent with HSD’s for this field. This requirement also applies to any subcontractor who maintains a copy of the member rosters for the purpose of distributing eligibility or roster information to providers or verifying member eligibility;
F. Meeting federal HCFA standards for release of member information (applies to subcontractors as well). Standards are specified in the SALUD! Systems Manual and at 42 CFR 431.306(b);
G. Track changes in the members’ category of eligibility to ensure appropriate services are covered and appropriate application of co-pays;
H. Maintaining a...
Member Information Requirements. The CONTRACTOR’s Member information requirements shall include, but are not limited to,
(1) accepting, maintaining, and transmitting all required Member information;
(2) generating Member information to Network Providers within twenty-four (24) hours of receipt of the enrollment roster from HSD/MAD. The CONTRACTOR must ensure that current eligibility information is available to subcontractors for eligibility verification on weekends and holidays;
(3) assigning as the key Medicaid client ID number, the RECIP-MCD-CARD-ID-NO that is sent on the Enrollment Roster file, but accepting and using all four (4) occurrences of the Medicaid client ID number sent to the CONTRACTOR on the Enrollment Roster file for identification, eligibility verification and claims adjudication by the CONTRACTOR or any subcapitated contractors that pay claims. These numbers will be cross-referenced to the Member’s social security number and any internal number used in the CONTRACTOR’s system to identify Members;
(4) meeting federal CMS and HIPAA standards for release of Member information, such requirement applying to all Network Providers and subcontractors. Standards are specified in the Medicaid Systems Manual and 42 C.F.R. §431.306(b);
(5) tracking changes in the Member’s category of eligibility to ensure appropriate services are covered and appropriate application of co-payments;
(6) maintaining accurate Member eligibility and demographic data;
(7) providing automated access to Network Providers regarding Member eligibility. Automated Voice response systems, electronic verifications systems, and the use of swipe cards or smart cards would all be considered automated access. It is expected that the information would always be current, or if the information is out of date, that the information still be honored because the error would originate with the CONTRACTOR; and
(8) transmitting an electronic interface file to HSD/MAD monthly no later than the 15th of the month to communicate the setting of care (nursing facility, PCO, and 1915(c) waiver) and Provider ID for Members with NF Level of Care.
