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:
