Attachment 6.pdf

Enrollment Broker Interfaces and ICDs

Contents MMIS and Managed Care Interfaces

Plan Provider File to State – Request

Provider File to Plans – Provider Master File

Automated Health Systems Enrollment File

AHS Plan/Provider Assignment and Response

AHS Pending Plan Assignment File

MCE Claim History File

ICDs

• Plan Provider File to State

• Provider File to Plans

• Automated Health Systems Enrollment File

• AHS Plan/Provider Assignment and Response

• AHS Pending Plan Assignment File

• MCE Claim History File

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 Plan Provider File to State - Request.docx

• Provider File to Plans Daily Provider File to

Plans.docx

• Automated Health Systems Enrollment File Automated Health

Systems Enrollment Fi

• AHS Plan/Provider Assignment and Response AHS - Automated

Health Systems Daily P

• AHS Pending Plan Assignment File AHS - Pending Plan

Assignment File.docx

• MCE Claim History File MCEs Claims History file.docx