Exhibit_25_Carrier_Eligibility_Companion_Guide.pdf

Employees Group Insurance Division

Carrier Eligibility Companion Guide v2025.02.03

For

Business Associates

Prepared by:

OMES-ISD

Exhibit 25

4345 N. Lincoln Blvd

Suite 100

Oklahoma City, OK 73105

Contents

Export Overview

I. Business Overview

II. Export Sections and Sequence

Record Layouts

Header

Detail

General Info

Open Issues

Assumptions

Document Change Log

Sign-off

Contact Info

Export Overview

I. Business Overview

This export file will contain eligibility data for members and dependents enrolled in HMO, DMO and VMO plans.

HMOs and DMOs will receive a weekly ‘Incremental’ file that will contain changes to members and/or dependents since the last ‘Incremental’ file was generated. A reconciliation ‘Active’ file will be sent quarterly only if requested.

VMOs will receive a weekly ‘Active’ file which will contain eligibility data for members and dependents enrolled in vision plans at the time the file is generated.

File Length 1500

File Type Text

# of Files 1 file per carrier based on fund/plan combination

# of Records Multiple

Data Types Alphanumeric, date, numeric

Data Change Lookback 12 months (1 year)

General:

Fields without values must be left blank and space filled and should not contain zeros

Selection Criteria:

General:

1. Each eligible member and dependent will have its own record. Fields with demographic information should be specific to the member or dependent.

2. Each Export will only contain covered person(s) that are associated with the plan for that export.

3. The export will be limited to capture changes for eligibility where the term date is NULL or less than 12 months (1 year) from the export date.

For Each Export Parameter:

1. For Export Parameter type of file = Active File

• The file will include all ACTIVE members and their elected dependents as of the date of the export.

- ACTIVE is defined as Members and elected dependents whose enrollment termination date is > the export as of date or blank.

- Only members and elected legal dependents enrolled in each listed plan should be included. One active file for each plan should be created based on the export parameter.

- HMOs and DMOs ACTIVE files will contain current and future enrollment periods. For example, if a member is enrolled 1/1/2024 – 12/31/2024 and 1/1/2025 – open. On the export file of 11/1/2024, both records will be included.

- VMO ACTIVE files will only contain 1 line for member and/or dependent. If a current and future period exist for the date the file is generated – then the file will only send the current period, if no current period exists then the future period will be sent.

2. For Export Parameter type of file = Special EOY VMO File

• The file will include all future ACTIVE members and their elected dependents as of the date of the export.

- Future ACTIVE is defined as Members and elected dependents whose enrollment termination date is > the first day of the upcoming year or blank. For example, if a member is enrolled 1/1/2024 – 12/31/2024 and 1/1/2025 – open. On the export file of

11/1/2024, the 1/1/2025 period would be transmitted.)

- Only members and elected legal dependents enrolled in each listed plan should be included. One active file for each plan should be created based on the export parameter.

VMOs must submit a request to have a ‘Special EOY VMO’ file generated.

3. For Export Parameter type of file = Incremental

• The file will include members and/or dependents that have had a change conducted to either their eligibility, demographic or indicative information between the last generated export and the

‘as of date’ of the new generated export.

Eligibility changes are defined as changes to plan, tier code and/or covered person(s).

1) The following are examples of changes to be transmitted to the carrier. This list does not encompass all possible changes.

a. Member Adds/Removes Dependent with Tier Code Change

A type 3 record will be sent for the terminated coverage and the covered person(s) of the old tier code a stop date for the old coverage date followed by a type 3 record for the new coverage of the covered person(s) with the new tier code of the new coverage’s start date.

b. Member Adds/Removes Dependent without Tier Code Change

A type 3 record will be sent for the new coverage of the added or removed covered person(s) of the new coverage’s start date.

c. Member or Dependent Indicative Information Changed with Enrollment Change:

A type 3 record for the termination will be sent for the terminated coverage and a type 3 record will be sent for the new coverage with that coverage’s start date. The records will be sent with the current indicative information for the affected individual(s).

d. Member or Dependent Indicative Information Changed without Enrollment Change:

Send current indicative information for the affected individual. Send any current and future eligibility information; the effective date in file will equal the effective date of the continuous eligibility start date.

e. Member Custom/Dependent Custom Changed:

If Export Parameter Carrier is a Health Fund or Dental Fund, then include if the

Primary Care Physician and Primary Dental Provider updated date or inserted date > last export date. Field will be nulled after export is ran.

NOTE: If PCP/PCD is populated, then it will be sent on the file. Carrier should only load the data if the person is a new add or a reinstate to their plan.

f. Delete Coverage, Alter Coverage Dates or Opt-Out Dependent (Data entry error or correction)

i. Benefit Plan Option Changed on Existing Period

If a benefit is changed within the same plan but to a different option, the old plan option will be sent with a termination date equal to the enrollment date – 1 day.The new plan option will be sent with the new effective date.

ii. Dependent Opted Out on Existing Period with Tier Change

If a dependent is opted out of a previously transmitted period and causes the tier code to change; then a type 3 record will be sent for the altered coverage and ALL covered person(s) of the old tier code with a stop date equal to the enrollment date – 1 day. Followed by a type 3 record for the altered coverage date and ALL currently covered person(s) of the new tier code with current stop date or null if period is open ended.

iii. Dependent Opted Out on Existing Period without Tier Change

If a dependent is opted out of a previously transmitted period and does not cause the tier code to change; then a type 3 will be sent for the altered coverage and the affected covered person(s) with a stop date equal to the enrollment date – 1 day.

iv. Termination Date Adjusted Backwards on Existing Period

If the date for a termination is adjusted backwards, then the file will transmit a type 3 record for the previous coverage’s start date with a stop date equal to the enrollment date – 1 day followed by a type 3 record for the new coverage and new stop date.

v. Termination Date Adjusted Forwards on Existing Period

If the date for a termination is adjusted forwards, then the file will transmit a type 3 record for the modified coverage’s start date with new stop date.

vi. Start Date Adjusted Backwards on Existing Period

If the date for a start of coverage is adjusted backwards, then the file will transmit a type 3 record for the previous coverage’s start date with a stop date equal to the enrollment date – 1 day followed by a type 3 record for the new coverage start date.

vii. Start Date Adjusted Forwards on Existing Period

If the date for a start of coverage is adjusted forwards, then the file will transmit a type 3 record for the new coverage start date.

2) The following are examples of changes that do not get transmitted to the carrier. This list does not encompass all possible changes.

a. Group to Group/Division to Division Transfers

If a member transfers from one group to another group or from one division to another division with no other change in eligibility, demographic or indicative; then the record will not be sent.

If later, a non-eligibility change is conducted the new group/division will be transmitted to the carrier with the original effective date of the continuous coverage.

b. No Break in Continuous Coverage

If a member rolls over coverage to a new period and no change was done to the plan, tier code or covered person(s); then the coverage will not be sent.

Example is if a member rolls over their exact copy of coverage during Option Period where no change was conducted minus the new period being created.

II. Export Sections and Sequence

Records must be sorted in ascending order by SSN, opt out records (if any), then by person code, then by effective date. However, Vision plans have the effective date sorted descending.

Seq # Record Type Description/Selection Logic Optional / Required

1 Header Uniquely identifies the export R

2 Detail Member and/or Dependent eligibility data R

3 Trailer Tracking and verification information for the export R

Record Layouts

Header

Field

Start Stop Field Name Length

Data

Type Required Format

Value

Default Description

1 1 1 Record type A/N Y 1 Indicates header file

2 2 10 Carrier A/N Y 9010 Indicates this file is from EGID

3 11 35 Address1 A/N N 4345 N. Lincoln Blvd

4 36 60 Address2 A/N N Suite 100

5 61 80 City A/N Oklahoma City

6 81 82 State A/N N OK

7 83 92 Zip A/N N 73105

8 93 102 Phone A/N N 405-717-8888

9 103 110 Creation Date N Y YYYYMMDD Creation date of this file.

10 111 111 File Type A Y

The file type.

A = Active

I = Incremental

F = Full

11 112 1500 Filler

Detail

Start Stop Field Name Length

Data

Type Required Format

Value

Default Description

1 1 1 Record type 1 A/N Y 2, 3, 4, or

A for Active file

Indicate if the record type is an add record or a change record.

2 2 10 Carrier 9 A/N Y 9010 9010 Hard coded for every record, stands for EGID

3 11 20 Account 10 A/N Y

ST – State

ED – Education

LG – Local Govt

Populated for Vision Carriers only

4 21 30 Group 10 A/N Y Group Number

5 31 39 Member_SSN 9 A/N Y Member SSN

6 40 41 Person Code 2 A/N Y Member or dependent custom field

Start Stop Field Name Length

Data

Type Required Format

Value

Default Description

7 42 43 Relationship 2 A/N Y

Relationship of this person to the member.

Ex: S-spouse, C-child

8 44 93 Last Name 50 A/N N The last name of this person record.

9 94 143 First Name 50 A/N N The first name of this person record.

10 144 144 Middle Initial 1 A/N N The middle initial of this person record.

11 145 145 Sex 1 A/N Y The sex of this person record.

12 146 153 Date of Birth 8 N Y YYYYMMDD The birth date of this person record.

13 154 161 Effective Date 8 N Y YYYYMMDD The effective date for this person’s coverage

14 162 169 Termination Date 8 N Y YYYYMMDD The termination date for this person’s coverage

15 170 229 Mailing Address1 60 A/N Y

Address_Line1 of this person record, if it doesn’t exist then use the Member Address_Line1.

Address Type = ‘R’

16 230 259 Mailing Address2 30 A/N Y

Address_Line2 of this person record, if it doesn’t exist then use the Member Address_Line2.

Address Type = ‘R’

17 260 309 Mailing City 50 A/N Y

City of this person record, if it doesn’t exist then use the Member

City

Address Type = ‘R’

18 310 311 Mailing State 2 A/N Y

State of this person record, if it doesn’t exist then use the Member

State

Address Type = ‘R’

19 312 321 Mailing Zip 10 A/N Y

Zip of this person record, if it doesn’t exist then use the Member

Zip

Address Type = ‘R’

*Zip code will be right justified and padded with leading spaces.

Start Stop Field Name Length

Data

Type Required Format

Value

Default Description

20 322 331 Phone 10 A/N N

(Home) Phone of this person record, if it doesn’t exist then use the Member phone

Address Type = ‘R’

If not supplied: Null or

‘0000000000’

21 332 332 Alt Ins Indicator 1 A/N N Not Used

22 333 342 Alt Ins Code 10 A/N N Not Used

23 343 360 Alt Ins ID 18 A/N N Not Used

24 361 371 Filler 11 For Future Additions

25 372 381 Status 10 A/N N

Member or dependents status code. For example, Active, Medicare, Cobra etc.

26 382 391 Plan 10 A/N N

Selected benefit level, elected by the member. Examples

Healthchoice Hi option, Healthchoice Low option etc.

Enrollment_type_id

27 392 399 Plan Eff Date 8 N N Not used

28 400 400 New card Flag 1 A/N Y Not used

29 401 402 Martial Status 2 A/N Y

M = Married

N = Single

U = Undefined

Member/dependents marital status.

If not supplied: Null

30 403 412 Alt Phone 10 A/N N

Member/dependents alternate

(work) phone.

If not supplied: Null or

‘0000000000’

31 413 420 Hire Date 8 N N YYYYMMDD Not Used

32 421 429 Dependent Social 9 A/N Y

For member record leave blank, For dependent record put dependents SSN. If dependent SSN is not available leave blank. DO

NOT PUT MEMBER SSN

33 430 430 ID Handicap Code 1 A/N N

If dependent is handicapped, just a

Y or N or blank, Only applies to dependents. (Incapacitated Child)

34 431 431 Student Code 1 A/N N Not Used

Start Stop Field Name Length

Data

Type Required Format

Value

Default Description

35 432 441 Tier code 10 A/N Y Coverage level – such as Member, member and spouse etc

36 442 451 Division 10 A/N Y Division Number

37 452 459 Alt Ins From Date 8 N N Not used

38 460 467 Alt Ins Thru Date 8 N N Not used

39 468 468 Pen Claim 1 A/N N Y or N Not used

40 469 469 Pre Ex 1 A/N N Y or N Not used

41 470 480 HICN 11 A/N N

HCIN Number, SSN+ 1 or 2 special code to ID Medicare person.

Member Custom

42 481 490 Disenrollment Code 10 A/N N Disenrollment Code This is for

MAPD/PDP plans

43 491 500 Signature Date 10 A/N N MMDDYYYY Signature Date on MAPD/PDP enrollment form

44 501 509 From Member SSN 9 A/N N Old Member SSN

45 510 511 From Person_ Code 2 A/N N Old Person Code

46 512 519 Original Eff Date 8 N N YYYYMMDD Not used

47 520 527 Dental Penalty 8 N N YYYYMMDD Not used

48 528 535 Life Insurance Amt 8 N N 999999.99 Not used

49 536 550 Country 15 A/N N Country of Address. Populate the country

50 551 553 Reason 3 N Y or N

Change Type:

1st Position – Eligibility, 2nd Position – Address, 3rd Position – Indicative

51 554 561 Date of Death 8 N N YYYYMMDD The death date of this person record

52 562 571 Member_Code 10 A/N Y Unique Member Number Right

Justified

53 572 621 Employer Name 50 A/N N Employer Name

54 622 681 Permanent Address_1 60 A/N Y

Address_Line1 of this person record, if it doesn’t exist then use the Member Address_Line1.

Address Type = ‘C’

If ‘C’ is null, use ’R’

Start Stop Field Name Length

Data

Type Required Format

Value

Default Description

55 682 711 Permanent Address_2 30 A/N Y

Address_Line2 of this person record, if it doesn’t exist then use the Member Address_Line2.

Address Type = ‘C’

If ‘C’ is null, use ’R’

56 712 761 Permanent City 50 A/N Y

City of this person record, if it doesn’t exist then use the Member

City

Address Type = ‘C’

If ‘C’ is null, use ’R’

57 762 763 Permanent State 2 A/N Y

State of this person record, if it doesn’t exist then use the Member

State

Address Type = ‘C’

If ‘C’ is null, use ’R’

58 764 773 Permanent Zip 10 A/N

Y

Zip of this person record, if it doesn’t exist then use the Member

Zip

Address Type = ‘C’

If ‘C’ is null, use ’R’

59 774 798 County 25 A/N N

County of Permanent Residence of this person record

Member Medicare Info Datasheet

60 799 848 Email 50 A/N N Email Address of this person record

Address Type = ‘R’

61 849 849 Plan Premium Payment Option 1 A/N Y 1 1=EGID will bill the member

62 850 850 ESRD 1 A/N Y

Y=Yes

N=Blank

Member is ESRD

Medicare Info Datasheet

63 851 851 Request Materials in Language

Other Than English 1 A/N Y

Y=Yes

N-No

Default=N or <Blank>

Language preference or another format other than English

MAPD will contact the Beneficiary if the box on the enrollment form is marked ‘Yes’

Medicare Info Datasheet

Start Stop Field Name Length

Data

Type Required Format

Value

Default Description

64 852 852 Language Preference and

Alternative Formats 1 A/N Y N=No

Default=N

NOT USED

65 853 853

Beneficiary Signature and/or

Authorized Representative

Signature

1 A/N Y Y=Yes

Form is signed.

Default to Y since no enrollments will be sent if form is not signed.

66 854 903 Authorized Representative Last

Name 50 A/N Y

1) Medicare Info Datasheet

2) Person record is dependent child – use Primary Member’s

Indicative Info

3) <blank>

67 904 953 Authorized Representative First

Name 50 A/N Y

1) Medicare Info Datasheet

2) Person record is dependent child – use Primary Member’s

Indicative Info

3) <blank>

68 954 954 Authorized Representative

Middle Initial 1 A/N Y

1) Medicare Info Datasheet

2) Person record is dependent child – use Primary Member’s

Indicative Info

3) <blank>

69 955 1014 Authorized Representative

Address1 60 A/N Y

1) Medicare Info Datasheet

2) Person record is dependent child – use Primary Member’s

Indicative Info

3) <blank>

70 1015 1044 Authorized Representative

Address2 30 A/N N

1) Medicare Info Datasheet

2) Person record is dependent child – use Primary Member’s

Indicative Info

3) <blank>

71 1045 1094 Authorized Representative City 50 A/N Y

1) Medicare Info Datasheet

2) Person record is dependent child – use Primary Member’s

Indicative Info

3) <blank>

72 1095 1096 Authorized Representative

State 2 A/N Y

1) Medicare Info Datasheet

2) Person record is dependent child – use Primary Member’s

Indicative Info

3) <blank>

73 1097 1106 Authorized Representative Zip 10 A/N Y 1) Medicare Info Datasheet

Start Stop Field Name Length

Data

Type Required Format

Value

Default Description

2) Person record is dependent child – use Primary Member’s

Indicative Info

74 1107 1116 Authorized Representative

Phone 10 A/N N

1) Medicare Info Datasheet

2) Person record is dependent child – use Primary Member’s

Indicative Info

75 1117 1124 Employer or Union Name 8 A/N Y OSEEGIB

76 1125 1128 Employer or Union Group

Number 4 A/N Y 9010

77 1129 1129 Plan Change? 1 A/N Y Y=Yes

N=Blank

Yes=info is completed on form.

Used when changing from one plan to another under same carrier.

78 1130 1130 Info Provided Under “Please

Read and Sign Below”?

1 A/N Y

Y=Yes

N=No

Default is Y because info is on the form and member signed the form

79 1131 1131 Release of Information

Elements Provided?

1 A/N Y

Y=Yes

N=No

Default is Y because info is on the form and member signed the form

80 1132 1132 PCP/PCD Status 1 A/N

PCP/PCD Patient Status: N = New

C = Current

If the Fund is Health then populate

Primary Care Provider. If the Fund is Dental then populate Dental

Provider.

*Incremental file

81 1133 1182 PCP/PCD First Name 50 A/N

PCP/PCD Provider First Name

If the Fund is Health then populate

Primary Care Provider. If the Fund

82 1183 1232 PCP/PCD Last Name 50 A/N PCP/PCD Provider Last Name

Start Stop Field Name Length

Data

Type Required Format

Value

Default Description

If the Fund is Health then populate

Primary Care Provider. If the Fund

83 1233 1258 RX OGI 26 A/N Other Group Insurance Plan Name

84 1259 1278 RX ID# For OGI 20 A/N Other Group Insurance Member

ID#

85 1279 1293 RX Group# For OGI 15 A/N Other Group Insurance Group #

86 1294 1302 EBC Debit Card 9 A/N N

YYYYMMDD

(Ex.

A20100401)

A=Active I=Inactive

Blank

EBC Debit Card

Indicator and Start/Stop Date

87 1303 1319 Ethnicity 17 A/N N

Reported for Medicare health plans only for Member and/or

Dependent(s). See Note 2 for crosswalk.

*May have multiple values – separated by spaces.

88 1320 1363 Race 44 A/N N

Reported for Medicare health plans only for Member and/or

Dependent(s). See Note 2 for crosswalk.

*May have multiple values – separated by spaces.

89 1364 1364 Sex At Birth Code 1 A/N N

1 = Female

2 = Male

3 = Not Listed (Other)

4 = Not Sure

5 = I choose not to answer

90 1365 1389 Sex At Birth Other 25 A/N N

If ‘Sex At Birth Code’ is = 3, additional field to provide further details.

91 1390 1390 Gender Identity Code 1 A/N N

1= Female, 2= Male

3= Transgender female

4= Transgender male

5= Not Listed (Other)

6= Not Sure

7= I choose not to

Start Stop Field Name Length

Data

Type Required Format

Value

Default Description

92 1391 1415 Gender Identity Other 25 A/N N

If ‘Gender Identity Code’ is = 5, additional field to provide further details.

93 1416 1416 Sexual Orientation Code 1 A/N N

1= Lesbian or gay

2= Straight

3= Bisexual

4= Not Listed (other)

5= Not Sure

6= I choose not to

94 1417 1441 Sexual Orientation Other 25 A/N N

If ‘Sexual Orientation Code’ is = 4, additional field to provide further details.

95 1442 1500 Filler For Future Additions

Note 1:

To identify the record type is 2 or 3

All member and dependent records need to be identified as record type 2 (add record) or record type 3

(change record).

A member or dependent that is enrolled in a given plan for the first time is an ADD record and should be indicated as a record type 2.

A member or dependent that is or has been previously enrolled in a given plan and is being transmitted again for any other change is a CHANGE record and should be indicated as a record type 3.

To identify the record type 4.

For record type 4 the following fields will be populated at minimum:

i. Record Type

ii. Carrier

iii. Group

iv. Member SSN

v. Person Code

vi. Effective Date

vii. Division

viii. From Member SSN

ix. From Person Code

x. Member Code

xi. Employer Name

Type 4 records are created for following events:

a) When a dependent becomes a primary member

The Carrier, Member SSN, and Person Code will contain the Dependents data and the From Member

SSN and Person Code will contain primary member’s data under which this person was a dependent.

b) Primary member becomes dependent

The Carrier, Member SSN, and Person Code will contain the new member’s data under whom this person has become dependent and the From Member SSN and Person Code will contain the primary member’s data under which this person was a member.

c) When a dependent moves from one member to another member

The Carrier, Member SSN, and Person Code will contain the primary Member’s data and the From

Member SSN and Person Code will contain the old member’s data under which this person was a dependent.

d) When the SSN of member is changed

The Carrier, Member SSN, and Person Code will contain the new SSN information and the From SSN and Person Code will indicate the old SSN from which they moved. All the other fields for the record type 4 should be blank.

Note 2:

Medicare Ethnicity Code Field name: Ethnicity

NH No, not of Hispanic, Latino/a, or Spanish origin

YM Yes, Mexican, Mexican American, Chicano/a

YP Yes, Puerto Rican

YC Yes, Cuban

YH Yes, another Hispanic, Latino/a, or Spanish origin

NA Chose not to answer

Medicare Race Code Field name: Race

AN American Indian or Alaska Native

AI Asian Indian

AA Black or African American

CH Chinese

FI Filipino

GC Guamanian or Chamorro

JA Japanese

KO Korean

NH Native Hawaiian

OA Other Asian

OP Other Pacific Islander

SA Samoan

VI Vietnamese

WH White

NA Chose not to answer

Trailer

Start Stop Field Name Length

Data

Type Required Format

Value

Default Description

1 1 1 Record Type 1 A/N 9 Indicates trailer record

2 2 10 Carrier 9 A/N

3 11 19

Total records 9 N

Do NOT include header and trailer = Adds+ Changes+ Total count of records on the file

4 20 28

Total Adds 9 N

Total Number of Add Records.

Total count of record type 2

5 29 37

Total Changes 9 N

Total Number of Change Records.

Total count of record type 3

6 38 46

Total Move History 9 N

Total Number of Move Records.

Total count of record type 4.

7 47 1500 Filler

General Info

Open Issues

# Author Date Opened Issue Resolution Closed

Assumptions

# Author Assumptions

Document Change Log

Date of change Author Change Description

8/18/2004 Patti Claxton Document Created w/New Logic

8/25/2005 Patti Claxton Updated Fund/Plan for new HMOs

9/7/2005 Patti Claxton Removed language – Record Type 4 d

6/17/2008 Patti Claxton Remove Tricare. Add New DMO

9/25/2009 Patti Claxton Update Fund/Plan for Name Changes

3/24/2010 Patti Claxton Update language throughout layout and update Fund/Plan for Name Changes

6/9/2011 Patti Claxton Updated Fund/Plan for Name Changes

12/20/2011 Patti Claxton Updated Fund/Plan for Name Changes

3/14/2012 Patti Claxton Updated Fund/Plan & added field names (Disenrollment Code & Signature Date)

6/12/2012 Patti Claxton Added additional length to file; add Permanent Address fields, other Medicare required fields and update changes to PCP/PCD field(s)

7/11/2012 Patti Claxton Added additional new fields; RxOGI, RX ID# for OGI, and RX Group# for OGI.

7/20/2012 Patti Claxton Removed ‘LTC’ field, Updated Plan Premium Payment Option field, Updated Request Materials in

Language Other Than English field, and Updated Language Perference and Alternative Formats field.

8/19/2012 Patti Claxton Update verbage for Language Preference in Description

4/15/2015 Todd Marney Updated the following:

- Expected value/default codes for field name ‘Account’;

- Description for field name ‘Phone’;

- Expected value/default codes & description for field name ‘Martial Status’;

- Description for field name ‘Alt Phone’;

- Updated details under the section ‘Contact Information’

9/2/2015 Todd Marney Updated to include EBC members for files created 2016 and after.

10/12/2015 Todd Marney Added ‘Field Number’ column.

11/23/2015 Todd Marney Modified the following Incremental bullet points due to V3 Browser differences:

- If Current Coverage is terminated and New Coverage is created

- Delete Coverage, alter coverage dates or opt-out dependent in period (Data entry error or correction)

1/19/2016 Todd Marney Modified the ‘Description’ and ‘Data Type’ for fields #19, #58 and #73 to include: ‘See Description’ and ‘*Zip code will be right justified and padded with leading spaces.’

1/31/2017 Todd Marney - Updated examples from 2008/2009/2010 to 2015/2016/2017

- Updated contact information to OMES ISD Helpdesk

- Updated Fund/Plan

1/8/2019 Todd Marney - Added note “*Only provided in Incremental file.” For PCP information.

2/21/2020 Chad Davis - Updated Fund/Plan requirement in Export section

- Updated date examples to reflect current year

2/08/2021 Todd Marney - Updated EGID address

10/3/2022 Todd Marney - Added new fields for Medicare Ethnicity and Race fields (87 & 88)

6/25/2024 Todd Marney - Added new fields for Medicare Sex At Birth, Gender Identity and Sexual Orientation.

2/3/2025 Todd Marney - Updated EGID’s address & logo

Sign-off

Reviewed By: ___________________________________________ Date: ___________________________

Approved By: ___________________________________________ Date: ___________________________

Contact Info

Company: EGID

Address: 4345 N. Lincoln Blvd

Phone: 405-717-8790

Toll-free 844-804-2642

Fax 405-717-8977

Authored by: Todd Marney, System Analyst

Version: 2025.02.03