Appendix H_020926.pdf
PDF 150 KB Posted
- Attached to
- Part D Transaction Facilitator
- Solicitation number
- 260108J
About this file
This document is a technical specification for the Transaction Facilitator E1 Medicare Eligibility Matching Logic used in pharmacy submission systems. The document defines the requirements and procedures for matching patient eligibility information against Medicare beneficiary records.
Pharmacies must submit eligibility inquiries containing one of three Cardholder ID identifiers: Medicare Beneficiary Identifier (MBI), nine-digit Social Security Number (SSN), or the last four digits of SSN. All submissions require five mandatory fields: Patient Last Name, at least the first character of Patient First Name, Patient Date of Birth, and Patient Zip Code. The matching logic employs a scenario-rank hierarchy that varies based on the identifier type submitted. When the last four SSN digits are submitted, the system performs matches across four scenarios ranked by specificity, with Scenario 1 requiring exact matches on DOB, last name, first name character, and ZIP code, descending to Scenario 4 which does not require ZIP code matching. For full SSN or MBI submissions, the system requires a single patient match with exact last name and at least the first character of first name matching, with DOB and ZIP code treated as required submission fields despite not being used in the actual matching algorithm. The system returns specific reject codes including "NO PATIENT MATCH FOUND," "MISSING REQUIRED FIELD," and "PATIENT NOT FOUND: CARDHOLDER ID MATCHED BUT LAST NAME DID NOT." All Medicare Part D eligibility request rejects are prefixed with "MCARE ELIG;" and the system excludes matches to terminated or compromised MBIs.
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Other files
| File | Type | Posted |
|---|---|---|
| Appendix C_020526.pdf | ||
| Appendix I_020926.pdf | ||
| Appendix F_020226.pdf | ||
| Appendix B_020226.pdf | ||
| Appendix G_020226.pdf | ||
| Appendix A_020526.pdf | ||
| Appendix E_020226.pdf | ||
| Appendix D_020226.pdf | ||
| Draft SOO - Part D Transaction Facilitator.pdf | ||
| RFI Memo - Part D Transaction Facilitation.pdf |
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Text version
E1 Medicare Eligibility Matching Logic 1
Transaction Facilitator E1 Medicare Eligibility Matching Logic
Pharmacy Submission Requirements
The eligibility inquiry (E1) transaction submitted to the Transaction Facilitator by the pharmacy must include population of the Cardholder ID field with one of the following with valid values:
• Medicare Beneficiary Identifier (MBI)
• Nine-digit Social Security Number (SSN)
• Last four digits of the Social Security Number (SSN) – match probability increases with submission of a full ID number
In addition, the following are required fields:
• Patient Last Name
• At least the first character of the Patient First Name – match probability increases with submission of a complete first name
• Patient Date of Birth (DOB)
• Patient Zip Code
NOTE: Failure to submit all 5 required fields will result in a reject.
Matching Logic
The following matching logic is based upon the submission of the Cardholder ID is as follows:
1. If the last 4 digits of the SSN are submitted, then the Transaction Facilitator pulls all matches where the last 4 digits of the SSN exactly match and the Patient Name matches based on the match scenarios for last 4 of SSN outlined in the grid below. Then the Transaction Facilitator looks to find a single match within the lowest scenario number rank, (see grid below for
“scenario rank” number) and returns the eligibility information.
2. If the last 4 digits of the SSN are submitted and there is more than one match is found with the same scenario number rank, then the Transaction Facilitator will provide the “NO PATIENT
MATCH FOUND” reject.
3. If a complete and exact MBI or SSN is submitted and matches exactly to a MBI or SSN number in the Transaction Facilitator database, then the Patient Name (first and last) determines the scenario number rank as outlined in the scenarios for full ID submitted found in the grid below, then the Transaction Facilitator looks to find a single match within the lowest scenario number rank and returns the eligibility information.
4. If a complete and exact MBI or SSN number is submitted and matches exactly to a MBI or SSN number in the Transaction Facilitator database, but there is not a single match within the lowest scenario number rank as outlined in the scenarios for full ID submitted
E1 Medicare Eligibility Matching Logic 2 in the grid below, then the Transaction Facilitator will return the reject “PATIENT NOT
FOUND: CARDHOLDER ID MATCHED BUT LAST NAME DID NOT”.
5. If the pharmacy submits the Cardholder ID as required, but does not submit all the other required fields (Patient First Name (either first letter or full name), Patient Last
Name, DOB and Zip), then the Transaction Facilitator will return the “MISSING
REQUIRED FIELD” reject.
6. If no exact match is found on the Cardholder ID submitted, the TrOOP System will return the “NO PATIENT MATCH FOUND” reject.
If the pharmacy does not submit a valid Cardholder ID as required, then the TrOOP System will return the “MISSING REQUIRED FIELD” reject.
NOTE: All rejects associated with a Medicare Part D eligibility request start with “MCARE ELIG;”
The following are matching scenarios for when the last 4 digits of the SSN is submitted in the
Cardholder ID field:
Scenario Rank
Last 4 of SSN
DOB Last Name First Name ZIP
1 Exact Match
Matches on Year, Month, and Day
Exact Last Name Match
At least first char of First Name
Exact ZIP
Match 2 Exact
Match Matches on Year, Month, and Day
Exact Last Name Match
At least first char of First Name
Exact Match on first 3 of
ZIP
3 Exact Match
Matches on Year, Month, and Day
Exact Last Name Match
At least first char of First Name
Exact Match on first 2 of
ZIP
4 Exact
Match
Matches on Year, Month, and Day
Exact Last
Name Match At least first char of First Name
No Match on
Zip
To get a match when searching by full SSN/MBI in the CardholderId field:
1. A single patient must be found with the submitted SSN/MBI
2. Last name must be exact match
3. At least the first character of the First Name must match.
As with SSN4 we try the name both ways in case they reverse the first and last names.
Even though the DOB and Zip are not used in a full SSN/MBI search, they are required fields. Claims submitted without the DOB and/or Zip will be returned with the “MISSING REQUIRED FIELD” reject.
When searching by MBI will we not match to a terminated MBI that has been compromised.
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