Attachment 6.docx

Enrollment Broker Interfaces and ICDs Contents

The current Heritage Health enrollment broker is Automated Health Systems. The enrollment broker is known as the HHEB (Heritage Health Enrollment Broker.) Many files reference the Automated Health Systems in their file names (AHS).

MMIS and Managed Care Interfaces Plan Provider File to State – Request MCOs send this file to MMIS to report providers in their network. MMIS processes the file, sends the results to the MCO, and sends accepted records to AHS. The enrollment broker uses this data to support Plan assignment and to validate PCP and Dental Home Provider assignments.

Provider File to Plans – Provider Master File This file is sent daily to the MCOs and the HHEB. The file provides the HHEB with the providers who are currently Medicaid-approved providers who may be selected as a recipient’s PCP or Dental Home Provider. File Name:

· ProviderMasterFile_YYYYMMDD.TXT (Automated Health Systems)

Automated Health Systems Enrollment File MMIS sends the Heritage Health Enrollment Broker the Automated Health Systems Enrollment file on a daily and monthly basis.

There are two daily files. The first daily file is the AHS Enrollment File (pending) where MMIS sends only the recipients who are newly Medicaid eligible and need a managed care plan assignment. The file contains an indicator as to whether the recipient is mandatory for enrollment in managed care. The HHEB assigns the recipient to a managed care plan and returns that information to MMIS in the Plan Assignment file. Once the plan assignments are received from the HHEB and processed, MMIS is updated with the plan enrollment and notifies each plan of their new enrollees. HHEB gets the finalized enrollment information in the AHS Enrollment file.

The monthly AHS Enrollment file contains all Medicaid clients and their enrollment information for the prospective month. The monthly file also contains plan transfers and disenrollment information. File names:

· AHS.D.PEND.YYYYMMDD.TXT (Daily)

· AHS.D.ELIG.YYYYMMDD.TXT (Daily)

· AHS.M.ELIG.YYYYMMDD.TXT- (Monthly) Enrollment records may be sent for:

· The current and prospective months

· Retro months back as far as January 2021, including stand-alone/non-consecutive retro months

AHS Plan/Provider Assignment and Response The enrollment broker assigns all clients mandatory for enrollment in Heritage Health managed care to a Heritage Health plan and informs MMIS of the assignment via the AHS Plan/Provider Assignment file. Assignments are determined in two ways:

· AHS assigns Heritage Health plans based on either auto assignment or based on qualifying recipient transfer requests.

· MCOs assign providers, report them to AHS, and AHS reports to MMIS Upon processing the file from AHS, MMIS responds to AHS with the results of the plan/provider assignment processing. AHS in turn sends the response file to the MCO. File Names:

· AHS.PLAN.ASSIGN.TXT (AHS to MMIS)

· AHS.PLAN.ASSIGN.RESP.YYYYMMDD.TXT (MMIS to AHS)

· PCPASSG.[PlanNumber].YYYYMMDD.txt (MCO to AHS)

· PCPASSG.[PlanNumber].YYYYMMDD.rsp.txt (AHS to MCO)

AHS Pending Plan Assignment File MMIS sends Automated Health Systems a daily enrollment file that contains recipients who were previously sent in an AHS Enrollment file to be assigned a plan but have not yet been enrolled with a plan.

The file contains:

· Medicaid ID – 11 digits in length

· Initial Date sent to AHS – Date format CCYYMMDD

· Type of Enrollment – Valid Values = Blank, PACE, or Prospective The file generates daily after MMIS processes the Plan Assignment file.

Once the recipient is assigned to a plan or is no longer Medicaid eligible, the Medicaid ID will no longer display on the file. MMIS sends the file to the HHEB even if there are no recipients on the file. NOTE: The file is informational. MMIS automatically resends recipients who are still pending for plan assignment in the next day’s AHS Enrollment file (pending). File Name:

· AHS.PENDING.RECP.YYYYMMDD.TXT

MCE Claim History File The Claim History file contains non-pharmacy fee-for-service and managed care claim history. The Enrollment Broker uses this data to determine if the recipient has a history with a specific provider in order to assign them to a managed care plan where that provider is in-network. This supports continuity of care. File name:

· NE_EB_CLMS_HIST.TXT - Enrollment Broker

ICDs The ICDs contain the configuration, transport protocols, and file layouts of the interface documents.

Plan Provider File to State Provider File to Plans Daily Automated Health Systems Enrollment File AHS Plan/Provider Assignment and Response AHS Pending Plan Assignment File MCE Claim History File image2.emf

Provider File to Plans.docx

Provider File to Plans - daily V.1.0 / Final

Interface Control Document

MMIS

Provider File to Plans – Daily

Provider File weekly to other entities

NE EES

Business Process Gap Analysis Page 2 of 14

Table of Contents

1 Interface Introduction 7

1.1 Objective 7

1.2 Scope 7

1.3 Referenced Documents 8

1.4 Assumptions 10

1.5 Constraints 10

2 Interface Functionality 10

2.1 Interface Flow Diagram 10

3 General Processing Steps 13

4 Interface Data Elements 14

4.1 Interface Request Data Elements 14

4.2 Interface Response Data Elements 15

5 Communication Protocols 30

5.1 Exception / Error Handling 30

5.2 Operational Requirements 30

5.3 Security Requirements 31

6 Resources 32

6.1 Stakeholders and Authoritative Sources 32

7 Appendices 34

Appendix A Glossary 34

ICD Document Revisions

Revision Date

Author

Description of Change

02/07/2017

Joann Largent

New

08/17/2017

Samba Kona

MS00643 - Add MCNA

04/21/2020

Murad Smoqy

Changing provider file frequncy for IH and DN plans, and for DBH as well note: Automated Health System and Aetna-DSNP will remain on getting provider file weekly basis - MS01413

10/01/2020

Sridevi Koraganji

MS01417 - Add Healthy Blue

03/12/2021

Sravan Mekarthi

As part of SCR MS01173 Added new provider types 27 “Specialized Add-On Services (in NFs)”, 53 “Peer Support Specialist”, 54 “Psychological Assistant/Associate”, 55 “Multi-Systemic Therapy”

Changed the provider name for provider type 37 and 38 as below 37 Provisional Mental Health Professional/Masters Level Equivalent (MHP)

38 PHD Intern

03/12/2021

Muralee Turangi

As part of SCR MS01250 provider type 74 is updated as 74 - Case Management.

03/12/2021

Samba Kona

As part of SCRs MS01457 and MS01523

Provider type 51 is updated as Opioid Treatment Program (OTP).

Provider type 52 is updated as Medically Managed Inpatient Withdrawl (MMIW).

08/05/2022

Muralee Turangi

MS01553 / Work Front # 158754

· Expanded following address fields length from 20 bytes to 50 Bytes.

NMC-OFFICE-ADDRESS1

NMC-OFFICE-ADDRESS2

NMC-PAY-TO-ADDRESS1

NMC-PAY-TO-ADDRESS2

· Added office address line 3 field NMC-OFFICE-ADDRESS3

· Changed following fields type from Numeric to Char.

NMC-PROVIDER-SPECIALITY-1

NMC-PROVIDER-SPECIALITY-2

NMC-PROVIDER-SPECIALITY-3

NMC-PROV-TYPE

· FILLER length of NMC-MEDICAID-PROVIDER-HEADER is changed from 900 to 1070

· FILLER length of NMC-MEDICAID-PROVIDER-TRLR is changed from 894 to 1064

· Changed element type of NMC-PROVIDER-TYPE from Numeric to Char.

08/05/2022

Muralee Turangi

· Source File Length and Target File Length changed to 1085.

· Updated Stakeholders and Authoritative Sources.

01/04/2023

Sravan Mekarthi

· As Part of WF271055 Discontinue wellcare files effective 012023 deleting the wellcare interfaces

10/11/2023

Sridevi Koraganji

Added Aetna contact details

02/22/2023

Sravan Mekarthi

WF286301/WF519250 -

MCO Procurement/MCO Re-Procurement Provider Track

Molina Healthcare of Nebraska effective 01/01/2024

07/31/2024

Murad Smoqy make update to either provider type or specialty type description or peer group as applicable due to impacts by these Work requests

- WF442700- Treatment Family Care provider

- WF639702- Hospital Type Specialties

- WF852850 Provider Type and Specialty Description

Murad Smoqy - 08/07/2024 changed prov type 81 description from “Treatment Group Home”to “Therapeutic Group Home”. it was overlooked in last update in 7/31/2024

10/04/2024

Samba Kona

Added missing valid values for NMC-ENROLL-STATUS

11/25/2024

Sravan Mekarthi

Removing Healthy Blue of Nebraska as part of WF916950 – End Healthy Blue and MCNA files

01/21/2025

Indrakumar Duaisamy

Adding Humana DSNP as a recipient for the weekly Provider File [NEMedicaidMMDDYYYY.txt] to Plans

03/31/2025

Indrakumar Duraisamy

Added new provider type OG and OE

Updated description for speciality type 80

10/03/2025

Tom Sharp

WF1191250 - Add Provider Type and Specialty for School Psychologists to MMIS. Addition of new provider type SP - School Psychologists and new specialty M1 - Medicaid in Public Schools

WF1107700 - Certified Community Behavioral Health Clinics (CCBHCs) - Provider Enrollment. Addition of 2 new provider types 43 - Certified Community Behavioral Health Clinic (CCBHC) and SA - CCBHC Community Resource Specialist

10/27/2025

Muralee Turangi

Added Devoted Health of Nebraska

06/23/2026

Sandeep Maram

WF1538550 changed prov type code "07" and "11" descriptions from "Professional pharmacy" to "professional/other pharmacy" and "other" to "Tribal/Indian Health pharmacy".

07/01/2026

Murad Smoqy

WF1190350-Enroll New MIPS and other provider types or specialties.

07/01/2026

Tom Sharp

WF0297238-MMIS Provider Types and Specialties - DSD.

List of Tables

Table 1: Referenced Documents 8

Table 2: Summary of Assumptions 10

Table 3: Summary of Constraints 10

Table 3: Interface Request Data Elements 14

Table 4: Interface Response Data Elements 15

Table 5: Communication Protocols 30

Table 6: Error/ Exception Handling Table 30

Table 7: Operational Requirements 30

Table 8: Security Requirements 32

Table 9: Stakeholders and Authoritative Sources 32

Appendix A: Glossary 34

List of Figures

Figure 1: Interface Flow Diagram 9

Provider File to Plans - daily V.1.0 / Final

Last Update: 09/24/2025 Page 1 of 38

Interface Introduction

This Interface Control Document (ICD) describes detailed requirements and data flows, defines the message structure and protocols that govern the interchange of data, and identifies the communication paths along which the data is expected to flow.

Objective

Source: No Inbound Files

Target: UHCPROV.TXT (UnitedHealthcare)

Nebraska_MC_Prov_Inbound_YYYYMMDD_PROD.TXT (Nebraska Total Care) - daily

PROV_YYYYMMDD.TXT (Department of Behavioral Health, DBH) - daily

MOLINAPROV_YYYYMMDD_PROD.TXT (Molina Healthcare of Nebraska) - daily

ProviderMasterFile_YYYYMMDD.TXT (Automated Health Systems) – Weekly

NEMedicaidMMDDYYYY.TXT (Aetna –DSNP) – Weekly

NEMedicaidMMDDYYYY.TXT (Humana –DSNP) – Weekly

PROV_FILE_CCYYMMDD.txt (Devoted-DSNP) – Weekly

DHHS IT Owner: MMIS

DHHS Business Owner: MLTC

Interface Version: 1.0

Title/Description: Provider File to Plans – Daily

Purpose: The purpose of this interface is to read the Provider IMS Segments to create the Medicaid Provider File for managed care health plans and other entities.

Scope

The purpose of this interface is to provide an overview of the record format and establish the field contents for the Provider File to Plans – weekly/daily (see above). This includes sending Medicaid eligible providers file to the managed care plans, the managed care enrollment broker (Automated Health Systems), the Department of Behavioral Health, and the DSNP providers.

Referenced Documents

The following table summarizes other relevant reference documents used to prepare this document, such as system specific documents, business requirements, etc.

Table 1: Referenced Documents

Document Name

Document Number

Source /

Issuer

Issue Date

SCR MS01413 - Managed Care Provider Enrolment File Frequency Increase -BSRD

SCR MS01413 - Managed Care Provider Enrolment File Frequency Increase http://dhhsemployees/sites/MMIS/legacy/SCR%20Doc/SCR%20MS01413%20-%20Managed%20Care%20Provider%20Enrollment%20File%20Frequency%20Increase.docx

04/21/2020

SCR MS01413 - Managed Care Provider Enrolment File Frequency Increase -DSD

SCR MS01413 - Managed Care Provider Enrolment File Frequency Increase http://dhhsemployees/sites/MMIS/legacy/SCR%20Doc/MS01413%20-%20DSD%20-%20Managed%20Care%20Provider%20Enrollment%20File%20Frequency%20Increase.docx

04/21/2020

Interface Master Listing

Not Applicable http://dhhsemployees/sites/MMIS/legacy/MMISTechDoc/Interface%20Master.xlsx

Unknown

Provider File to Plans – Weekly/w

File – Managed Care http://dhhsemployees/sites/MMIS/legacy/MMISTechDoc/Provider%20File%20to%20Plans%20-%20Weekly.doc

Unknown

SCR MS01173 - MMIS Provider Type Creation and Repurposing – BSRD

SCR MS01173 - MMIS Provider Type Creation and Repurposing https://dhhsemployees/sites/MMIS/legacy/SCR%20Doc/1173%20BSRD.docx

03/12/2021

1250 BSRD

MS01250

Enabling MMIS Pertaining to Case Management Services https://dhhsemployees/sites/MMIS/legacy/SCR%20Doc/1250%20BSRD.docx

03/12/2021

SCR MS01457 - Medically Managed Inpatient Withdrawl Services(MMIW) - BSRD

SCR MS01457 - Medically Managed Inpatient Withdrawl Services(MMIW) https://dhhsemployees/sites/MMIS/legacy/SCR%20Doc/MS01457-Medically%20Managed%20Inpatient%20Withdrawl%20Services(MMIW)%20BSRD.docx

03/12/2021

SCR MS01523-Opioid Treatment Program Services (OTP)- BSRD

SCR MS01523-Opioid Treatment Program Services (OTP) https://dhhsemployees/sites/MMIS/legacy/SCR%20Doc/MS01523-Opioid%20Treatment%20Program%20Services%20(OTP)-%20BSRD.docx

03/12/2021

Discontinue WellCare files BSRD

SCR WF271055 – Discontinue WellCare files effective 012023 https://dhhsemployees/sites/MMIS/legacy/SCR%20Doc/Discontinue%20WellCare%20Files.docx

01/04/2023

WF286301 MCO Procurement Combined BSRD

WF286301/WF519250 -

MCO Procurement https://dhhsemployees/sites/MMIS/legacy/SCR%20Doc/Provider%20File%20to%20Plans_BSRD.docx

WF916950 – End Healthy Blue and MCNA files

WF916950 – End Healthy Blue and MCNA files

WF916950 - End Healthy Blue and MCNA Interface File Exchange BSRD

WF1107700 – Certified Community Behavioural Health Clinics (CCBHCs) – Provider Enrollment

WF1107700 – Certified Community Behavioural Health Clinics (CCBHCs) – Provider Enrollment https://dhhsemployees/sites/MMIS/legacy/SCR%20Doc/WF1107700-%20CCBHC-Provider%20Enrollment%20BSRD.docx

WF1191250 – Add Provider Type and Specialty for School Psychologists to MMIS

WF1191250 – Add Provider Type and Specialty for School Psychologists to MMIS https://dhhsemployees/sites/MMIS/legacy/SCR%20Doc/WF1191250%20-%20Add%20Provider%20Type%20and%20Specialty%20for%20School%20Psychologists%20to%20MMIS%20BSRD.docx

WF1213195 Add a DSNP Plan-Devoted

WF1213195 Add a DSNP Plan-Devoted https://dhhsemployees/sites/MMIS/legacy/SCR%20Doc/WF1213950%20Add%20a%20DSNP%20Plan-Devoted%20BSRD.docx

WF1538550 - Change language on certain Type of Practice provider enrollment fields

WF1538550 - Change language on certain Type of Practice provider enrollment fields https://dhhsemployees/sites/MMIS/legacy/SCR%20Doc/WF1538550%20Change%20language%20on%20certain%20Type%20of%20Practice%20provider%20enrollment%20fields.docx

06/23/2026

WF1190350 - Enrollment of new MIPS and other provider types and specialties - BSRD

WF1190350

https://dhhsemployees/sites/MMIS/legacy/SCR%20Doc/WF1190350%20Enrollment%20of%20new%20MIPS%20and%20other%20provider%20types%20and%20specialties%20BSRD.docx

07/01/2026

WF1190350 - Enrollment of new MIPS and other provider types and specialties - DSD

WF1190350

https://dhhsemployees/sites/MMIS/legacy/SCR%20Doc/WF1190350-DSD-%20Enrollment%20of%20new%20MIPS%20and%20other%20provider%20types%20and%20specialties.docx

07/01/2026

WF0297283 - MMIS Provider Types and Specialties BSRD

WF0297283

https://dhhsemployees/sites/MMIS/legacy/SCR%20Doc/WF0297283%20-%20MMIS%20Provider%20Types%20and%20Specialties%20BSRD.docx

07/01/2026

WF0297283 - MMIS Provider Types and Specialties - DSD

WF0297283

https://dhhsemployees/sites/MMIS/legacy/SCR%20Doc/WF0297283%20-%20MMIS%20Provider%20Types%20and%20Specialties%20-%20DSD.docx

07/01/2026

Assumptions

The following table summarizes the assumptions associated with this ICD.

Table 2: Summary of Assumptions

Assumption

Status/Last Review

Not Applicable

Constraints

The following table summarizes any constraints associated with this ICD.

Table 3: Summary of Constraints

Constraint

Status/Last Review

Not Applicable

Interface Functionality

This interfaces uses SFTP in the exchange of files.

Interface Flow Diagram

The following diagram identifies key components including hardware, software, and connectivity.

Figure 1: Interface Flow Diagram for Daily files

Figure 2: Interface Flow Diagram for Weekly files

MMIS

Provider file to plans weekly

Devoted DSNP

Humana DSNP

Aetna DSNP

General Processing Steps

Name

Value

Source File Name

NMC7.M0140

Source File Definition (copybook name, etc)

NMCCM140

Source File Creation Job

NMC140/ NMCDLY4Q

Source File Length

Target File Name

UHCPROV.TXT (UnitedHealthcare) - daily

Nebraska_MC_Prov_Inbound_YYYYMMDD_PROD.TXT (Nebraska Total Care) - daily

PROV_YYYYMMDD.TXT (Department of Behavioral Health) – daily

MOLINAPROV_YYYYMMDD_PROD.TXT (Molina Healthcare of Nebraska)

NEMedicaidMMDDYYYY.TXT (Aetna – DSNP) – weekly

NEMedicaidMMDDYYYY.TXT (Humana – DSNP) - weekly

ProviderMasterFile_YYYYMMDD.TXT (Automated Health System) – weekly

PROV_FILE_CCYYMMDD.txt (Devoted – DSNP) - weekly

Target File Definition

NMCCM140

Target File Process Job

NMCDLY4Q / NMCWKL4H(AETNA)

Target File Length

Transmission Job

NMCDLY4F/MCPDLY5T

NMCWKL4H/MCPDLY5T

NMCDLY4G/RFSDLY5T

Format Standard (Proprietary, X12, etc)

Proprietary

File Type (txt, cls, xls, html, etc) txt

Service Level Agreement (SLA) Created

Not Applicable

Interface Hosted Server (Hosted location or platform from where the Interface is hosted or transmission originates)

The State Of Nebraska transmits outbound files to the MCOs SFTP server. The MCOs SFTP server details would be on our mainframe jobs.

Transmission External Dependencies - Externally defined environments, technology, & software that complements the code to produce the desired output\ functionality

Not Applicable

Describe the process to be used to confirm successful file transmission. Include any acknowledgment messages. Identify any reports to be used to document the results of the processing.

By the values of the Return Codes in the JCL (Job Control Language).

Describe any special processing that will be performed if a certain percentage (threshold) of the records is rejected Identify any reports to be used to document the results of the processing.

Not Applicable.

Interface Data Elements

This section defines the characteristics of individual data elements/fields that comprise the request and response message being exchanged between the interfacing systems.

Interface Request Data Elements

The following table describes the individual data elements contained within the request message.

Table 3: Interface Request Data Elements

Element Name

Element Description

Req Y or N

Element Type

Length

Comments

Interface Response Data Elements

The following table describes the individual data elements contained within the response message.

Table 4: Interface Response Data Elements

Element Name

Element Description

Req Y or N

Element Type

Length

Comments

Provider Header Record:

NMC-HDR-ACTION-TYPE

Record Type Identifier

YES

Char

The only valid value for this field is an ‘H’.

NMC-HDR-SYSTEM-YEAR

Date/Time Stamp

YES

Num

Must be a valid date and time.

NMC-HDR-SYSTEM-MONTH

Date/Time Stamp

YES

Num

Must be a valid date and time.

NMC-HDR-SYSTEM-DAY

Date/Time Stamp

YES

Num

Must be a valid date and time.

NMC-HDR-SYSTEM-HOUR

Date/Time Stamp

YES

Num

Must be a valid date and time.

NMC-HDR-SYSTEM-MINUTE

Date/Time Stamp

YES

Num

Must be a valid date and time.

NMC-HDR-SYSTEM-SECOND

Date/Time Stamp

YES

Num

Must be a valid date and time.

FILLER

Not Used

No

Char

Not Used

Element Name

Element Description

Req Y or N

Element Type

Length

Comments

Provider Detail Record:

NMC-DTL-ACTION-TYPE

Detail Action Type

YES

Char

The only valid value for this field is ‘D’.

NMC-DTL-PROV-IND

Detail Provider Indicator

YES

Char

Valid Values:

N = New provider on file

C = Closed (provider is inactive in Medicaid)

U = Updated record (some fields on the provider have changed)

S = Same as previous file (no changes)

NMC-PROVIDER-NUMBER

Provider Identification Number

YES

Num

11 digit Nebraska Medicaid Provider number assigned by Health and Human Services.

NMC-PROVIDER -NAME

Provider Name

YES

Char

NMC-PROVIDER-TITLE

Provider Title

YES

Char

Must be non-blank.

NMC-OFFICE-ADDRESS1

Provider Office Address Line 1

YES

Char

NMC-OFFICE-ADDRESS2

Provider Office Address Line 2

NO

Char

NMC-OFFICE-ADDRESS3

Provider Office Address Line 3

NO

Char

NMC-OFFICE-CITY

Provider Office City

YES

Char

NMC-OFFICE-STATE

Provider Office State

YES

Char

NMC-OFFICE-ZIP-CODE

Provider Office Zip Code

YES

Num

The zip+4 in this field must be used for billing provider zip+4 submissions on 837 encounters.

NMC-PAY-TO-PROVIDER-NBR

Pay to Provider Number

YES

Num

This will be the working group of the provider.

NMC-PAY-TO-NAME

Pay to Provider name

YES

Char

NMC-PAY-TO-ADDRESS1

Pay to Provider Office Address – Line 1

YES

Char

NMC-PAY-TO-ADDRESS2

Pay to Provider Office Address – Line 2

NO

Char

NMC-PAY-TO-CITY

Pay to Provider Office City

YES

Char

NMC-PAY-TO-STATE

Pay to Provider Office State

YES

Char

NMC-PAY-TO-ZIP-CODE

Pay to Provider Office Zip Code

YES

Num

NMC-PROVIDER-TYPE

Provider Type

YES

Char

Valid Values: For a provider to be a Primary Care Provider un NMMCP, the provider type must be one of the following:

01 = Physicians (MD)

02 = Doctors of Osteopathy

(DO)

22 = Physician Assistant (PA)

29 = Nurse Practitioner (NP)

All valid values are:

01 = Physicians

02 = Doctors of Osteopathy

04 = Doctors of Surgical

Chiropody

05 = Doctors of

Chiropractic Medicine

06 = Optometrists

07 = Doctors of Podiatric

Medicine

09 = Ambulatory Surgical

Centers

10 = Hospitals

11 = Nursing Homes

12 = Clinic

13 = Professional Clinic

14 = Home Health Agency

15 = Anesthesiologist

16 = Laboratory

(Independent)

17 = Federally Qualified

Health Center

18 = MR Waiver Habilitation and Case Management Provider

19 = Rural Health Clinic-

Provider Based

20 = Rural Health Clinic-

Independent

21 = Dispensing Physician

22 = Physician Assistant

23 = Rural Health Clinic-

Provider Based

24 = Home Health Agency

Supplier

25 = Tribal Hospital

26 = Tribal Clinic

27 - Specialized Add-On Services (in NFs)

28 = Nurse Midwife

29 = Nurse Practitioner

30 = Registered Nurse

31 = Licensed Practical Nurse

32 = Registered Physical

Therapist

33 = Personal Care Aide

34 = Mental Health Personal

Care Aide

35 = Mental Health Home Health

Care Provider

36 = Licensed Mental Health

Practitioner

37 - Provisional Mental Health Professional/Masters Level Equivalent (MHP)

38 - PHD Intern

39 = Licensed Independent

Mental Health Practitioner

40 = Doctor of Dental Surgery -

Dentist

41 = Assertive Community

Treatment

42 = Licensed Dental Hygienist

43 = Certified Community Behavioral Health Clinic (CCBHC)

44 = Community Support

45 = Day Rehabilitation

46 = Residential Rehabilitation

47 = Substance Abuse

Treatment Center

48 = Substance Abuse Provider

49 = Pharmacists

50 = Pharmacy

51= Opioid Treatment Program (OTP)

52 = Medically Managed Inpatient Withdrawal (MMIW)

53-Peer Support Specialist

54-Psychological Assistant/Associate

55-Multi-Systemic Therapy

57 = Provisionally Licensed PhD

58 = Provisionally Licensed

Drug & Alcohol Counselors

59 = Hospice

60 = Hearing Aid Dealer

61 = Ambulance

62 = Rental and Retail Supplier

63 = Licensed Medical Nutrition

Therapist

64 = Specially Licensed PhD/

Psychology Resident

65 = Orthopedic Device Supplier

66 = Optical Supplier

67 = Licensed Psychologist

68 = Speech Therapy Health

Service

69 = Occupational Therapy

Health Services

70 = Qualified Health

Maintenance Organization

71 = Provisional Health

Maintenance Organization

72 = Health Insuring

Organization

73 = Preferred Provider

Organization

74 = Case Management

75 = Other Prepaid Health

Plan

76 = Volume Purchase Contract

77 = Day Treatment Provider

78 = Licensed Drug & Alcohol

Counselor

79 = Treatment Crisis

Intervention

80 = CRISIS SUPPORT SERVICE (CSS)

81 = Therapeutic Group Home

82 = Residential Treatment

Center

83 = Autism Waiver Supervising

Behavior Therapist

84 = Autism Waiver Lead

Therapist

85 = Autism Waiver Applied

Behavioral Analyst Technician

86 = Professional Resource

Family Care

87 = Psychiatric Residential

Treatment Facility

88 = Freestanding Birth Centers

94 = DD Waiver Case

Management

95 = Medicare Part B Premium

96 = Health Insurance Premium

97 = Early Intervention

98 = N-Focus Claims

OE = Housing and Employment SMI Specialist

OG = SMI Waiver Group

SA= CCBHC Community Resource Specialist

SP=School Psychologists

O1=Certified Occupational Therapy Assistant

P1= Certified Physical Therapy Assistant

H1=Health Technician

C1= Interpreter/Translator

L1= Certified Lactation Counselor

T1= Independent Diagnostic Testing Facility (IDTF)

X1= Portable X-Ray Supplier

A1 = Audiologist

NMC-PROVIDER-SPECIALITY-1

Provider Specialty Code 1

Yes

Char

For a provider to be a Primary Care Physician under NMMCP, the first occurrence of the three occurrences of provider specialty must be one of the following:

01 = General Practice

08 = Family Practice

11 = Internal Medicine

16 = OB-GYN

37 = Pediatrics

All valid values are:

01 = General Practice

02 = General Surgery

03 = Allergy

04 = Otology, Laryngology, Rhinology (ENT)

05 = Anesthesiology

06 = Cardiovascular Disease

07 = Dermatology

08 = Family Practice

09 = Reserved

10 = Gastroenterology

11 = Internal Medicine

(Includes Geriatrics and

Nephrology)

12 = Internal Medicine

(Restricted to group with multi spec) (Does not include spec 01, 02, 11, 37, and 39)

13 = Neurology

14 = Neurological Surgery

16 = OB-GYN

17 = Ophthalmology, Otology, Laryngology,Rhinology

(EENT)

18 = Ophthalmology

19 = Oral Surgery (Dentists

Only)

20 = Orthopedic Surgery

22 = Pathology - Lab

23 = Peripheral Vascular

Disease or Surgery

24 = Plastic Surgery

25 = Physical Medicine and

Rehabilitation

26 = Psychiatry/Mental Health/

Substance Abuse

28 = Proctology

29 = Pulmonary Disease

30 = Radiology - X-Ray

32 = Radiation Therapy

33 = Thoracic Surgery

34 = Urology

35 = Chiropractors (Licensed

Effective July, 1973)

36 = Nuclear Medicine (For MDs

Only)

37 = Pediatrics

38 = Endocrinology, Diabetes

39 = Gerontology

40 = Hand Surgery

41 = Oncology/Hematology

42 = Epidemiology/Infectious

Disease

43 = Certified Registered Nurse

Anesthetist (CRNA)

44 = Nephrology

45 = Neonatology

46 = Rheumatology

47 = Physiological Labs

(Independent)

48 = Podiatrist - Surgical

Chiropodist

49 = Miscellaneous

51 = Medical Supply Company with Certified Orthotist

(CO) Certification

52 = Medical Supply Company with Certified Prosthetist

(CP) Certification

53 = Medical Supply Company with Certified Orthotist-

Prosthetist (CPO) Certification

54 = Medical Supply Company not included in 51, 52, or 53.

55 = Individual Certified

Orthotist (CO)

56 = Individual Certified

Prosthetist (CP)

57 = Individual Certified

Orthotist-Prosthetist (CPO)

58 = Individual Not Included in 55, 56, or 57.

59 = Ambulance

60 = Public Health or Welfare

Agencies (Federal, State, and

Local)

61 = Voluntary Health or

Charitable Agencies (e.g., National Cancer Society, National Heart Association, etc.)

62 = Licensed Psychologist

(Clinical)

63 = Portable X-Ray Supplier

(Billing Independently)

64 = Audiologists (Billing

Independently)

65 = Physical Therapist

(Billing Independently)

66 = Hospitals (Defined by

Department of Social Services)

67 = Urgent Cared Health Plan (OPHP)

68 = Dialysis

69 = Independent Laboratory (Billing Independently)

70 = Clinic

71 = Diagnostic X-Ray Clinic

72 = Diagnostic Laboratory Clinic

73 = Physiotherapy

74 = Occupational Therapy

75 = Assisted Living Services

76 = Other Physician Specialist for HEALTH CHECK Follow-up

77 = Other Provider (non-MD) For HEALTH CHECK Follow-up

78 = Screening Physician & Other Physician Specialist for HEALTH CHECK Follow-up

79 = Adult Day Care

80 = Rehab Providers (MRO)

81 = Rehab Acute Hospital

82 = Hospice

83 = Autism

87 = All Other

88 = Unknown - Suppliers

89 = Chemical Dependency

90 = Nurse Midwife

91 = Nurse Practitioner

92 = RURAL EMERGENCY HOSPITALS

93 = LONG-TERM ACUTE CARE HOSPITALS

94 = PUBLIC SERVICE COMMISSION EXEMPT

95 = COMMERCIAL NON-EMERGENCY RANSPORTATION (PSC CERTIFIED CARRIER)

96 = INDIVIDUAL NON-EMERGENCY RANSPORTATION

99 = Unknown – Practitioners

M1=Medicaid in Public Schools (MIPS)

C1= Interpreter/Translator

T1=Tribal

CA=Critical Access Hospitals C1= Interpreter/Translator

T1=Tribal

CA=Critical Access Hospitals

NMC-PROVIDER-SPECIALITY-2

Provider Specialty Code 2

NO

Char

NMC-PROVIDER-SPECIALITY-3

Provider Specialty Code 3

NO

Char

NMC-TYPE-OF-PRACTICE

Type of Practice

YES

Num

Valid Values: The Nebraska

Medicaid system uses only the following type of practice codes:

0 = Not Assigned

1 = Group Practice, Hospital

Affiliated, Members Not

Billing Independently

2 = Group Practice, Partnership, Members Not

Billing Independently

3 = Group Practice, Corporation, Members Not

Billing Independently

4 = Group Practice, Health

Maintenance Organization, Not Billing Independently

5 = Group Practice, Group

Practice, Members Not

Billing Independently

6 = Group Practice, Reserved

7=Professional/other Pharmacy

8 = Independent Pharmacy

9 = Small Chain Pharmacy

10 = Large Chain Pharmacy

11 = Tribal/Indian Health Pharmacy

12 = Rehabilitation Facility

(Hospital Only)

13 = Alcohol (CDU) Facility

(Hospital Only)

14 = Children's Facility

(Hospital Only)

20 = Unit Dose, Large Chain

Pharmacy

21 = Unit Dose, Other Pharmacy

27 = Unit Dose, Professional

Pharmacy

28 = Unit Dose, Independent

Pharmacy

29 = Unit Dose, Small Chain

Pharmacy

31 = Group Practice Member, Hospital Affiliated, Members

Not Billing Independently

32 = Group Practice Member, Partnership, Members Not

Billing Independently

33 = Group Practice Member, Corporation, Members Not

Billing Independently

34 = Group Practice Member, Health Maintenance

Organization, Members Not

Billing Independently

35 = Group Practice Member, Group Practice, Members Not

Billing Independently

36 = Group Practice Member, Reserved

40 = Centralized Qualified

Health Maintenance

Organization

41 = Decentralized Qualified

Health Maintenance

Organization

42 = Centralized Provisional

Health Maintenance

Organization

43 = Decentralized Provisional

Health Maintenance

Organization

44 = Centralized Health

Insuring Organization

45 = Decentralized Health

Insuring Organization

46 = Case Management/

Individual Practice

47 = Case Management/

Partnership, Corporation, Group Practice

48 = Case Management/

Hospital Affiliated

49 = Preferred Provider

Organization (PPO)/Individual

Practice

50 = Preferred Provider

Organization (PPO)/

Partnership, Corporation, Group Practice

51 = Preferred Provider

Organization (PPO)/Hospital

Affiliated

52 = Other Prepaid Health

Plan

53 = Volume Purchase

61 = Hospital Based

Practitioner, Hospital

Affiliated, Billing

Independently

62 = Individual or Solo

Practice, Members

Billing Independently

63 = Partnership/Non-Solo

Practice, Members

Billing Independently

64 = Corporation/Non-Solo

Practice, Members

Billing Independently

65 = Health Maintenance

Organization, Members

Billing Independently

66 = Group Practice, Members Billing Independently

NMC-SOCIAL-SECURITY-NUMBER

Social Security Number

YES

Num

NMC-ENROLL-STATUS

Enroll Status

YES

Num

Valid Values:

01 = Active, Eligible to receive payment

02 = Voluntary Suspension, Ineligible to receive payment

03 = Involuntary Suspension, Ineligible to receive payment

04 = Provisional Status, Eligible to Receive Payment

05 = Ongoing Status, Eligible to Receive Payment

06 = Probationary Status, Eligible to Receive Payment

08 = Certified Independent Lab., Eligible to Receive Payment

09 = Non-enrolled NE Physician,Ineligible to Receive Payment.

NMC-ENROLL-DATE

Enroll date

YES

Num

NMC-ELIGIBLE-FROM

Provider Eligibility Dates

YES

Num

OCCURS 6 TIMES.

NMC-ELIGIBLE-TO

Provider Eligibility Dates

YES

Num

OCCURS 6 TIMES.

NMC-GROUP-NUMBER

Group Number

NO

Num

NMC-EFFECTIVE-FROM-DATE

Group Effective Dates

NO

Num

NMC-EFFECTIVE-TO-DATE

Group Effective Dates

NO

Num

NMC-HEALTH-DEPARTMENT

The license number is composed of nine characters which may be a combination of numbers and/or letters assigned by the department, followed by a two digit Nebraska Medicaid state code and a two digit provider type code.

If the number is longer than 13-bytes, this field populates the first 9 bytes followed by the state code and provider type code and the field D43 Provider License Number

Expanded field populates the full license number

YES

Char

NMC-LICENSE-NUMBER.

NMC-HEALTH-DEPARTMENT PIC X(09).

NMC-STATE-CODE PIC 9(02).

NMC-PROV-TYPE PIC X(02).

NMC-STATE-CODE

Two digit Nebraska Medicaid state code

YES

Num

NMC-LICENSE-NUMBER.

NMC-HEALTH-DEPARTMENT PIC X(09).

NMC-PROV-TYPE

Two digit provider type code

YES

Char

NMC-LICENSE-NUMBER.

NMC-HEALTH-DEPARTMENT PIC X(09).

NMC-PROVIDER-COUNTY

Provider County

YES

Num

NMC-PROVIDER-POA

Provider Present on Admission (POA) Exempt Indicator

YES

Char

Valid Values:

N = Provider is Not Exempt from POA Reporting

Y = Provider is Exempt from POA Reporting

NMC-NPI

Provider NPI Detail

YES

Char

OCCURS 5 TIMES

Valid Values:

10 digit NPI number.

NMC-NPI-BEG-EFF-DT

Provider NPI Detail

YES

Num

OCCURS 5 TIMES

NMC-NPI-END-EFF-DT

Provider NPI Detail

YES

Num

OCCURS 5 TIMES

NMC-ATYPICAL-IND

Provider Atypical Indicator

YES

Char

Valid Values:

Y = Atypical Provider

N = Health Care Provider

NMC-PAY-TO-NPI

Pay To NPI Detail

YES

Char

OCCURS 5 TIMES

NMC-PAY-TO-TXNMY-CODE

Pay To NPI Detail

YES

Char

OCCURS 5 TIMES

NMC- PAY-TO-NPI-BEG-EFF-DT

Pay To NPI Detail

YES

Num

OCCURS 5 TIMES

NMC- PAY-TO-NPI-END-EFF-DT

Pay To NPI Detail

YES

Num

OCCURS 5 TIMES

NMC-DRG-PEER-GRP

Peer Group Number

YES

Num

Valid values:

00 = Provider does not match Peer Group criteria

01 = Metro Acute Care

Hospital

02 = Other Urban Acute

Care Hospitals

03 = Rural Acute Care

Hospitals

04 = Indian Health Service and Beatrice State

Development Center

05 = Mental Health Inpatient

Hospital

06 = Physical Rehabilitation

Hospital

07 = Critical Access Hospital

08 = Rural Emergency Hospitals(Paid CCR)

09 = Long-Term Acute Care Hospitals(Paid Per Diem)

10 = Children’s Hospitals(Paid DRG)

Filler

Filler

YES

Char

Filler

NMC-PRAC-DEATH-DATE

Practitioner Date of Death

NO

Num

Valid values:

Valid date in CCYYMMDD format.

NMC-PHARM-DISP-FEE

Pharmacy Dispense Fee

NO

Num

9(3)V99

Valid values:

Valid decimal amount no larger than 999.99

(decimal implied).

NMC-DISP-FEE-EFF-DATE

Dispense Fee Effective Date

NO

Num

Valid values: Valid date in CCYYMMDD format.

NMC-DISP-FEE-TERM-DATE

Dispense Fee Termination Date

NO

Num

Valid values: Valid date in CCYYMMDD format

NMC-NCPDP-ID

NCPDP ID

NO

Char

Valid 7-digit NCPDP ID number.

NMC-NCPDP-EFF-DATE

NCPDP Effective Date

NO

Num

Valid values: Valid date in CCYYMMDD format.

NMC-NCPDP-TERM-DATE

NCPDP Termination Date

NO

Num

Valid values: Valid date in CCYYMMDD format.

NMC-LICENSE-NUMBER-EXPANDED

Provider License Number Expanded. This field contains the practitioner’s license number if the license number is more than 13 bytes long.

NO

Char

Valid values: Any 40 characters.

NMC-TRIBAL-PHARM-RATE

Tribal Pharmacy Encounter Rate

NO

Num

9(03)

V99

Valid values: Valid decimal amount no larger than 999.99 (decimal implied).

FILLER

Not Used

No

Char

Not Used

Element Name

Element Description

Req Y or N

Element Type

Length

Comments

Provider Trailer Record:

NMC-TRL-ACTION-TYPE

Trailer Action Type

YES

Char

Valid Values:

The only valid value for this field is a ‘T’.

NMC-TRL-SYSTEM-DATE

Trailer Date/Time Stamp

NMC-TRL-SYSTEM-YEAR

Trailer Date/Time Stamp

YES

Num

Valid Values:

Must be a valid date and time.

NMC-TRL-SYSTEM-MONTH

Trailer Date/Time Stamp

YES

Num

Valid Values:

NMC-TRL-SYSTEM-DAY

Trailer Date/Time Stamp

YES

Num

Valid Values:

NMC-TRL-SYSTEM-TIME

Trailer Date/Time Stamp

NMC-TRL-SYSTEM-HOUR

Trailer Date/Time Stamp

YES

Num

Valid Values:

NMC-TRL-SYSTEM-MINUTE

Trailer Date/Time Stamp

YES

Num

Valid Values:

NMC-TRL-SYSTEM-SECOND

Trailer Date/Time Stamp

YES

Num

Valid Values:

NMC-TRL-TOTAL-DETAIL-RECS

Total Detail Records

YES

Num

Valid Values:

Value must be numeric.

FILLER

Not Used

No

Char

Not Used

Communication Protocols

The following table documents the transmission protocols between the two systems.

Table 5: Communication Protocols

Connected Systems

Transmission Product

Transmission Protocol

Electronic or Physical

Txt Files

SFTP

Electronic

Exception / Error Handling

This section defines the steps to be taken if message/file are not processed, if partial records in the file are received, interface / host service is not available, etc. Identify any reports to be used. The alternate path if the interface / host service is not available. If there is any error/exception message, the error/exception message structure will be captured here.

Table 6: Error/ Exception Handling Table

Error Code

Error Condition

Reason

Action

File Transfer Failed

Value of Return Codes

Could be many reasons

Email to MMIS Production Support

Operational Requirements

Table 7: Operational Requirements

Name

Value

Is this interface real time or batch?

Batch

Frequency (Daily, Weekly, Hourly, etc)

Weekly –when weekly it is every Saturday

Daily –Monday- Friday including holidays

Frequency Details (3rd Tuesday of Month, etc)

Every Saturday

Daily – see above

Frequency Time

Every Saturday

Daily – see above

Average File/Message Size

Max File/Message Size

No of files/transactions exchanged per Frequency

Peak Load Volume and Time

Not Applicable

Expected annual growth in volume in the next five years

Not Applicable

Normal Business hours

After 8:00 pm

Peak Load Time – Specific Hours, Days, Months

When must systems be available? Are they needed 24 hours a day, 7 days a week (24x7)?

During the MMIS Batch Cycle

What are the planned and anticipated periods of scheduled and unscheduled system downtime, respectively

No anticipated Downtimes.

REAL TIME: Maximum number of concurrent Interface calls

Not Applicable

REAL TIME: Do business messages need to be persisted while in transit and recovered upon a system restart?

Not Applicable

Is there any manual process defined to handle potential failure cases?

Yes

Security Requirements

The following table describes security requirements for the interface.

Table 8: Security Requirements

Data

Value

Is the data Confidential? (restricted to individuals who have approved access)

Yes

If Confidential what type of data (PII, PHI, SSN, Payroll Info, etc) ? This data requires encryption when in transit.

Provider File to Plans – Weekly/Daily

Is the data Highly Restricted (applies to critical and sensitive information tied to a small subset of individuals)?

No

If Highly Restricted what type of data (FTI, Admin Accounts, etc)? This data requires encryption when in transit and enhanced logging and auditing.

Not Applicable

Transmission Encryption/Decryption

No

User Authentication

SSH Authentication

Auditing/Logging Requirements

Retention Requirements

Outbound file – when weekly 7 generations

Outbound file – when daily 90 generations

Transmission Security Information (certificates, userids, passwords required)

TWS.JOBLIB

PRD.EASYCTL

TCPIP.USER.SFTPPASS

Resources

Stakeholders and Authoritative Sources

This section specifies the respective stakeholders, their responsibilities, and information for which each stakeholder is the authoritative source.

Table 9: Stakeholders and Authoritative Sources

Stakeholder

Email/Phone

Responsibilities/Descriptions

Information for which Stakeholder is Authoritative Source

United Healthcare

Cassandra_Price@uhc.com ojuddi@uhc.com heather_a_johnson@uhc.com

Receives the information

Nebraska Total Care

Gail.Y.Hunt@NebraskaTotalCare.com

Adam.Proctor@NebraskaTotalCare.com

Receives the information

AETNA

Mason, Jennifer <MasonJ4@aetna.com> p 614-933-8384 dualsinfomgmt@aetna.com

Receives the information

Humana

Shivram Krishna <SKrishna11@humana.com>

Nesha Campbell <qcampbell@humana.com>

Collin Lucas <ALucas2@humana.com>

Rachel Ayer rayer@humana.com

Humana contacts for the weekly provider file related queries

Molina Healthcare of Nebraska – Saran Vinita

Vinita.Saran@Molinahealthcare.com

248-231-1752

Primary - Sr. Business Relationship Manager

Molina Healthcare of Nebraska – Mark Valencia

Mark.Valencia@molinahealthcare.com

M: 480-239-1016

Secondary - IT Program Director, PMO

Devoted Health of Nebraska

Hollyn Taylor hollyn.taylor@devoted.com

215-589-8299

Senior Manager Integrations

Devoted contacts for the weekly provider file-related queries.

Devoted Health of Nebraska

Skye Martin skye.martin@devoted.com

352-504-6826

Senior Associate Integrations

Devoted contacts for the weekly provider file-related queries.

Devoted Health of Nebraska

Devoted EDI Email Distribution edi@devoted.com

Devoted contacts for the weekly provider file-related queries.

1. Appendices

Appendix A Glossary

Appendix A: Glossary

Acronym/Term

Definition

DSNP

Dual Special Needs Plan

Last Update: 07/31/2024 Page 1 of 38 image1.jpg image5.emf

Microsoft_Visio_Drawing.vsdx image2.png image3.png image4.jpeg image3.emf

Automated Health Systems Enrollment File (8).docx

Automated Health Systems Enrollment File Draft / Final

Automated Health Systems Enrollment File

Automated Health Systems Enrollment File Information

Business Process Gap Analysis Page 2 of 14

1 Interface Introduction 5

1.1 Objective 5

1.2 Scope 5

1.3 Referenced Documents 6

1.4 Assumptions 6

1.5 Constraints 7

2 Interface Functionality 7

2.1 Interface Flow Diagram 7

3 General Processing Steps 16

4 Interface Data Elements 17

4.1 Interface Request Data Elements 17

4.2 Interface Response Data Elements 18

5 Communication Protocols 32

5.1 Exception / Error Handling 33

5.2 Operational Requirements 33

5.3 Security Requirements 34

6 Resources 35

6.1 Stakeholders and Authoritative Sources 35

7 Appendices 36

Appendix A Glossary 36

Revision Date

Author

Description of Change

Table 1: Referenced Documents 6

Table 2: Summary of Assumptions 6

Table 3: Summary of Constraints 7

Table 3: Interface Request Data Elements 17

Table 4: Interface Response Data Elements 18

Table 5: Communication Protocols 32

Table 6: Error/ Exception Handling Table 33

Table 7: Operational Requirements 33

Table 8: Security Requirements 34

Table 9: Stakeholders and Authoritative Sources 35

Appendix A: Glossary 36

Figure 1: Interface Flow Diagram 7

Automated Health Systems Enrollment File Draft / Final

Last Update: 4/23/2026 Page 1 of 36

This Interface Control Document (ICD) describes detailed requirements and data flows, defines the message structure and protocols that govern the interchange of data, and identifies the communication paths along which the data is expected to flow.

Objective

Source: NMC7.M0800.PNDHHEB - Daily

NMC.T0800D.HHEB - Daily

NMC.T0800M.HHEB – Monthly

NMC.T0800D.HHEB – Daily (DBH)

NMC.T0800M.HHEB – Monthly (DBH)

Target: AHS.D.PEND.YYYYMMDD.TXT

AHS.D.ELIG.YYYYMMDD.TXT - Daily

AHS.M.ELIG.YYYYMMDD.TXT- Monthly

ENRL_DAILY_YYYYMMDD.TXT (Daily - DBH)

ENRL_MONTHLY_YYYYMMDD.TXT (Monthly - DBH)

DHHS IT Owner: MMIS

DHHS Business Owner: MLTC

Interface Version: 1.0

Title/Description: Heritage Health Enrollment Broker File

Purpose: The purpose of this interface is to provide recipient information to the Enrollment Broker needed for plan assignment. Also provide the daily and monthly enrollment files to DBH.

The purpose of this interface is to provide recipient information to the Enrollment Broker needed for plan assignment. Also provide the daily and monthly enrollment files to DBH.

The following table summarizes other relevant reference documents used to prepare this document, such as system specific documents, business requirements, etc.

Table 1: Referenced Documents

Document Name

Document Number

Source /

Issue Date

Table 2: Summary of Assumptions

Assumption

Status/Last Review

Not Applicable

Table 3: Summary of Constraints

Constraint

Status/Last Review

Not Applicable

This interface uses SFTP in the exchange of files.

Figure 1: Interface Flow Diagram

HHEB Enrollment File and Plan Assignment File Exchange

Change in N-FOCUS information

Plan Transfer from HHEB

Disenrollment (Monthly Only)

Monthly HHEB Enrollment File Scenarios

Name

Value

Source File Name

NMC7.M0800.PNDHHEB - Daily

NMC.T0800D.HHEB – Daily

NMC.T0800M.HHEB – Monthly

NMC.T0800D.HHEB – Daily (DBH)

NMC.T0800M.HHEB – Monthly (DBH)

Source File Definition (copybook name, etc)

NMCC800

Source File Creation Job

NMC800/NMCDLY7O

NMC800/NMCDLY7P

NMC800/NMCMON1P

Source File Length

Target File Name

AHS.D.PEND.YYYYMMDD.TXT

AHS.D.ELIG.YYYYMMDD.TXT

AHS.M.ELIG.YYYYMMDD.TXT

ENRL_DAILY_YYYYMMDD.TXT (DBH)

ENRL_MONTHLY_YYYYMMDD.TXT (DBH)

Target File Definition

NMCC800

Target File Process Job

MCPDLY5T /NMCDLY7O

MCPDLY5T/NMCDLY7Z

MCPDLY5T/NMCMON1Z

MCPDLY5T/NMCDLY7Z (DBH)

MCPDLY5T/NMCMON1Z (DBH)

Target File Length

Transmission Job

NMCDLY7O

NMCDLY7Z

NMCMON1Z

NMCDLY7Z (DBH)

NMCMON1Z (DBH)

Format Standard (Proprietary, X12, etc)

Proprietary

File Type (txt, cls, xls, html, etc)

Txt

Service Level Agreement (SLA) Created

Not Applicable

Interface Hosted Server (Hosted location or platform from where the Interface is hosted or transmission originates)

The State of Nebraska transmits Outbound Files to the AHS’s SFTP Server. The AHS’s SFTP Server details would be on our MainFrame jobs.

Transmission External Dependencies - Externally defined environments, technology, & software that complements the code to produce the desired output\ functionality

Not Applicable

Describe the process to be used to confirm successful file transmission. Include any acknowledgment messages. Identify any reports to be used to document the results of the processing.

By the value of the Return Codes in the JCL (Job Control Language).

Describe any special processing that will be performed if a certain percentage (threshold) of the records is rejected Identify any reports to be used to document the results of the processing.

Not Applicable

This section defines the characteristics of individual data elements/fields that comprise the request and response message being exchanged between the interfacing systems.

Interface Request Data Elements

The following table describes the individual data elements contained within the request message.

Table 3: Interface Request Data Elements

Element Name

Element Description

Req Y or N

Element Type

Length

Comments

Table 4: Interface Response Data Elements

Element Name

Element Description

Req Y or N

Element Type

Length

Comments

Header Record Follows:

NMC-HDR-RECORD-TYPE

Header Record Type

YES

Char

The only valid value for this field is a ‘H’.

NMC-HDR-SYSTEM-DATE

Header Date/Time Stamp

YES

Char

Valid date in YYYYMMDD format.

NMC-HDR-SYSTEM-TIME

Header Date/Time Stamp

YES

Char

Valid time in 24 hour HHMMSS format

Element Name

Element Description

Req Y or N

Element Type

Length

Comments

Detail Record Follows:

NMC-DTL-RECORD-TYPE

Detail Record Type

YES

Char

The only valid value for this field is a ‘D’.

NMC-MC-ACTION-TYPE

Managed Care Action Type

NO

Char

Valid Values:

A = Active (Client is changed from a pending status to an active status and given a begin date for managed care)

D = Disenrolled (Client is no longer eligible for managed care and given an end date for managed care)

P = Pending (Client is newly eligible for managed care)

R = Retro Enrolled (Client is in a standalone retro enrollment period)

NMC-MANAGED-CARE-IND

Managed Care Indicator

YES

Char

Valid Values: Y = Yes

N = No

NMC-MEDICAID-CASE-NBR

Client Medicaid Identification Number

YES

Num

11 digit Medicaid number.

NMC-CLIENT-CASE-ID

Client Medicaid Identification Number

YES

Num

11 digit Medicaid number.

NMC-CLIENT-SSN

Client Social Security Number

YES

Num

Valid Values:

Social security number of client if a SSN is unknown or does not exist at the time, all 9's will be used until a valid

SSN is received.

NMC-CLIENT-FNAME

Client Name

YES

Char

599 CHIP clients will have the first name ‘Unborn’.

NMC-CLIENT-MNAME

Client Name

YES

Char

NMC-CLIENT-LNAME

Client Name

YES

Char

NMC-CLIENT-DOB

Client Date of Birth

YES

Char

For 599 CHIP clients, the date of birth is 00010101.

NMC-CLIENT-DOD

Client Date of Death

NO

Char

NMC-CLIENT-GENDER

Client Gender

YES

Char

Valid Values:

M = MALE

F = FEMALE

U = UNBORN

NMC-CLIENT-RACE

Client Race

YES

Num

Valid Values:

1 = White

2 = Black or African American

3 = American Indian or Alaska

Native

4 = Asian

5 = Hispanic or Latino (No race information available)

6 = Native Hawaiian or Other

Pacific Islander

7 = Hispanic or Latino and one or more races

8 = More than one race

(Hispanic or Latino not indicated)

9 = Unknown

NMC-COPAY-IND

Co-Pay Indicator

YES

Char

Valid Values:

0-Individual not subject to co-pay

1-Individual subject to co-pay

NMC-CLIENT-MARITAL-STATUS

Client Marital Status

NO

Num

Valid Values:

0 = CHILD

1 = COMMON, SSI DE FACTO,

FSP DE FACTO, MARRIED

2 = LEGALLY SEPARATED

3 = NEVER MARRIED, ANNULLED

4 = DIVORCED, NO LONGER SSI

DE FACTO, FSP DE FACTO NO

LONGER

5 = WIDOWED

NMC-CLIENT-LIVING-ARRANGE

Client Living Arrangement

YES

Num

Valid Values:

01-Apartment or House, Single

Family House, House Arrest

Community Service, Halfway

House, House Arrest Work

Release, Adoptive Home, Adult Day Home

03-Homeless Shelter for

Profit or Non Profit, Room

Only, (Dorms, Sororities, Fraternities - Meals Not

Provided, Hospital - Acute

Hospital Care, Room Only

No Meals Provided, Job

Corps, Military, Hospital

05-Public Housing (not responsible for paying heating bills), (Dorms, Sororities, Fraternities

- Meals Provided), Battered Women and

Children Shelter – Non

Profit, Temporary Lodging

06-Public Housing, Pub Hsing

- Multi-Fam Hse Not

Responsible for Heating &

Cooling Bills, Pub Hsing -

Multi-Fam Hse Not

Responsible for Heating

Bills, Pub Hsing - Multi-

Fam Hse Not Responsible for Cooling Bills, Multi-

Family Dwelling, Adult Day

Center, Adult Day Health

Center

07-Pub Hsing - Single Fam

Hse Responsible for

Heating Bills & Cooling

Bills, Pub Hsing - Single

Fam Hse Responsible for

Heating Bills, Pub Hsing –

Single Fam Hse Responsible for Cooling Bills, Child

Care Center

09-Board and Room, Chemical

Dependency Treatment and

Rehabilitation Center

10-Licensed Mental Health

Center, Licensed Domiciliary

Facility, Assisted Living

Waiver

12-Veterans Hospital/Veterans

Nursing, Nursing Home/Long

Term Care, Nursing Home

13-Institution - Psychiatric

Care – IMD, Psych Residential

Treatment Facility

14-Child Caring Agency, Child

Caring Agency, Child Placing

Agency, Emergency Shelter

Center, Family Child Care

Home I, Family Child Care

Home II

17-Licensed/Approved Foster

Home, Emergency Shelter

Foster Home, Foster Home, Foster Home - Agency Based, Foster Home - Child Specific, Foster Home – Relative

18-Licensed Residential Care

Facility, Assisted Living

19-Licensed Center for

Developmentally Disabled

20-Certified Adult Family

Home, Adult Family Home

30-Group Home For Profit, Group Home - Institution

Non-Profit Meals Provided, Boarder - Board And Rooms

- Meals Provided, Incarceration, Residential

Care, Preschool

32-Boardinghouse -

Commercial - Non-Profit, Boardinghouse - Commercial

- For Profit, licensed Drug

Treatment Center, Boarding

Home

35-Licensed/Approved Group

Home For Children, Disabled

Group Home - Non Profit -

Meals Provided, Group Home, Group Home for Adults

36-Institution for…