HHW HCC HIP PATHWAYS Member Assignment Response File to EB.xls
XLS spreadsheet 84 KB Posted
- Solicitation number
- RFP 27-87793
- Issued by
- Marion County, Indiana
About this file
This is an interface specification document for the HCC HHW HIP PATHWAYS Member Assignment Response File, a data exchange mechanism between CoreMMIS and the Enrollment Broker (EB) for the State of Indiana's Medicaid managed care programs. The document defines the technical layout and processing requirements for daily response files that confirm member managed care entity (MCE) selections across four health programs: HoosierHealth (R), HIP (H), HCC (A), and Pathways (P). The interface uses secure file transfer protocol to transmit response records containing member assignments, effective and end dates, provider information, transaction types (Add, Change, Terminate), and disposition status (Accepted or Rejected). The file format specifies 143 characters per detail record with trailer records indicating the total number of processed transactions, with modifications documented through September 2024 reflecting ongoing updates to program requirements and error handling procedures.
The specification contains comprehensive error code definitions (001-999) that identify validation failures across multiple categories including member eligibility, age restrictions, MCE validity, provider panel status, date conflicts, and program-specific requirements. Notable recent additions include error code 295 for Pathways age requirement violations, error code 997 for Pathways permanent hold restrictions, and error codes 700-714 addressing data quality issues such as duplicate records, eligible status mismatches between programs, reverse dates, and panel verification failures. The document serves as a technical reference for system administrators and developers implementing the member assignment process for Indiana's Title XIX Medicaid programs, with no pricing information, funding sources, or contract terms specified within the interface specification itself.
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Interface Spec Overview
| Interface Specification Overview | |
| Interface name: HCC HHW HIP PATHWAYS Member Assignment Response File to EB | |
| Description: This is the response file that CoreMMIS will send to EB for the member MCE selections. | |
| Record Selection Criteria: MC_FTS_MGDJD130 | |
| Frequency: Daily | |
| Sender: CoreMMIS | |
| Receiver: EB | |
| Business Unit Ownership: Managed Care | |
| Error Handling/Special Processing: N/A | |
| Interface Exchange Method: Secure FTP | |
| File Name: HRESPONSEyyyymmdd.nnnn for HIP and RESPONSEyyyymmdd.nnnn for HCC, HHW and Pathways | |
| Modification Log | |
| Change Description | Date |
| Assignment Reason 50 changed to 49. (Historical records will show 49. New records are expected to show 49.) | 12/23/13 |
| Provider ID from character 9 to character 10 | 3/20/14 |
| Group Provider ID from character 9 to character 10 | 3/20/14 |
| Remove Provider / Service Location field and one space | 3/20/14 |
| Provider ID from character 10 to 15 | 6/9/14 |
| Group Provider ID from character 10 to 15 | 6/9/14 |
| Updated CODE_STATE_REGION from State Region code (group of counties) and out of state providers, not available for HIP, Not Null for other programs to For all Programs the State Region Code is a SPACE = Statewide | 5/24/21 |
| Pathways Changes: |
Health Program Member Assigned "P" for Pathways
| Added Error Code 295 - Member Age Requirements Are Not Met | 9/11/23 |
| Pathways Changes: | |
| Added Error Code 997 - Pathways Recipient on PS "Pathways Permanent Hold" Unable to Modify | 5/10/23 |
| Overall Changes: | |
| Added Error Codes 700 - 714 as part of GT-18941 | 9/23/24 |
Interface Specs Layout
| Enter one line for each field on the table. All columns must be completed for all rows. Add lines as needed. Add tables as needed. Only related subsystem tables should be in the same spreadsheet. | See Interface Spec Process & Interface Spec Documentation Instructions | ||||||||
| Record Type | FIELD | FIELD SIZE | Field Start | Field End | FORMAT | TABLE NAME | COLUMN | DESCRIPTION | NOTES |
| Record Type | Field name | number of characters | Start Position | End Position | field type | table of origin/destination | column name | Any relevant information such as where field originated, unique or identifying information, acronymns speeled out. | |
| Detail | ID_MEDICAID | 12 | 1 | 12 | CHAR | t_re_base | id_medicaid | Identifies Member | |
| Detail | Filler | 1 | 13 | 13 | space | ||||
| Detail | DATE_EFFECTIVE | 8 | 14 | 21 | NUMBER | t_re_pmp_assign | dte_effective | Start Date in health sub program | |
| Detail | Filler | 1 | 22 | 22 | space | ||||
| Detail | CODE_REASON_START | 2 | 23 | 24 | CHAR | t_re_pmp_assign | cde_rsn_mc_start | Reason started in health sub program | |
| Detail | Filler | 1 | 25 | 25 | space | ||||
| Detail | DATE_END | 8 | 26 | 33 | NUMBER | t_re_pmp_assign | dte_end | End Date of Member in health program | New enrollment on 1st and 15th only; HPES default END OF TIME date is 22991231 |
| Detail | Filler | 1 | 34 | 34 | space | ||||
| Detail | CODE_REASON_STOP | 2 | 35 | 36 | CHAR | t_re_pmp_assign | cde_rsn_mc_stop | Reason health program was stopped for Member | |
| Detail | Filler | 1 | 37 | 37 | space | ||||
| Detail | PROVIDER ID | 15 | 38 | 52 | CHAR | t_re_pmp_assign | sak_prov | Provider ID | Spaces for HIP |
| Detail | Filler | 1 | 53 | 53 | space | ||||
| Detail | CODE_HEALTH_SUBPGM | 1 | 54 | 54 | CHAR | t_re_pmp_assign | cde_health_subpgm | Health program member assigned | R (HoosierHealth), H (HIP), A(HCC), P(PATHWAYS) |
Obsolete: C (Care Select), X (Medicaid Select),
| Detail | Filler | 1 | 55 | 55 | space | ||||
| Detail | PROVIDER_GROUP_ID | 15 | 56 | 70 | CHAR | t_re_pmp_assign | sak_prov_group | Group Provider ID | Spaces for HIP, Spaces if no Group Provider |
| Detail | Filler | 1 | 71 | 71 | space | ||||
| Detail | MCE_ID | 9 | 72 | 80 | CHAR | t_re_pmp_assign | sak_mco | Managed Care Entity ID assigned to the provider or group provider | |
| Detail | Filler | 1 | 81 | 81 | space | ||||
| Detail | CODE_STATE_REGION | 1 | 82 | 82 | CHAR | t_re_pmp_assign | cde_mc_region | For all Programs the State Region Code is a SPACE = Statewide | |
| Detail | Filler | 1 | 83 | 83 | space | ||||
| Detail | Enrollment ID (Transaction ID) | 12 | 84 | 95 | CHAR | n/a | n/a | HPES returns when supplied otherwise filled with spaces | |
| Detail | Filler | 1 | 96 | 96 | space | ||||
| Detail | TRANSACTION TYPE | 1 | 97 | 97 | CHAR | n/a | n/a | Source is from EB | A(Add), C(Change),T(Terminated) |
| Detail | Filler | 1 | 98 | 98 | space | ||||
| Detail | Transaction Disposition | 1 | 99 | 99 | CHAR | n/a | n/a | Selection Transaction Disposition | A(ccepted), R(ejected) |
| Detail | Filler | 1 | 100 | 100 | space | ||||
| Detail | Number of Errors | 2 | 101 | 102 | NUMBER | n/a | n/a | Number of Errors if Rejected. | One through Ten |
| Detail | Filler | 1 | 103 | 103 | space | ||||
| Detail | Error Reason 1 (If Rejected) | 3 | 104 | 106 | CHAR | n/a | n/a | Error Reason Number One | Error Reason size 3, start with 001 |
| Detail | Filler | 1 | 107 | 107 | space | ||||
| Detail | Error Reason 2 (If Rejected) | 3 | 108 | 110 | CHAR | n/a | n/a | Error Reason Number Two | |
| Detail | Filler | 1 | 111 | 111 | space | ||||
| Detail | Error Reason 3 (If Rejected) | 3 | 112 | 114 | CHAR | n/a | n/a | Error Reason Number Three | |
| Detail | Filler | 1 | 115 | 115 | space | ||||
| Detail | Error Reason 4 (If Rejected) | 3 | 116 | 118 | CHAR | n/a | n/a | Error Reason Number Four | |
| Detail | Filler | 1 | 119 | 119 | space | ||||
| Detail | Error Reason 5 (If Rejected) | 3 | 120 | 122 | CHAR | n/a | n/a | Error Reason Number Five | |
| Detail | Filler | 1 | 123 | 123 | space | ||||
| Detail | Error Reason 6 (If Rejected) | 3 | 124 | 126 | CHAR | n/a | n/a | Error Reason Number Six | |
| Detail | Filler | 1 | 127 | 127 | space | ||||
| Detail | Error Reason 7 (If Rejected) | 3 | 128 | 130 | CHAR | n/a | n/a | Error Reason Number Seven | |
| Detail | Filler | 1 | 131 | 131 | space | ||||
| Detail | Error Reason 8 (If Rejected) | 3 | 132 | 134 | CHAR | n/a | n/a | Error Reason Number Eight | |
| Detail | Filler | 1 | 135 | 135 | space | ||||
| Detail | Error Reason 9 (If Rejected) | 3 | 136 | 138 | CHAR | n/a | n/a | Error Reason Number Nine | |
| Detail | Filler | 1 | 139 | 139 | space | ||||
| Detail | Error Reason 10 (If Rejected) | 3 | 140 | 142 | CHAR | n/a | n/a | Error Reason Number Ten | |
| Detail | Filler | 1 | 143 | 143 | newline character | ||||
| Trailer | Filler | 3 | 1 | 3 | TRL' constant | ||||
| Trailer | Record Count | 11 | 4 | 14 | NUMBER | number of detail records | |||
| Trailer | Filler | 118 | 15 | 132 | spaces | ||||
| Trailer | Filler | 1 | 133 | 133 | newline character |
&L&G&C&"Arial,Bold"&12Interface Specification Document&R&8&D &L&8&F&C&8&P of &N &R&8EDS - Indiana Title XIX 950 N. Meridian St., Suite 1150 Indianapolis, IN 46204
Error Codes
| Error Code | Description | Explanation | Comments |
| 010 | Aid category / dates not effective/valid | Member aid category is not eligible for Managed Care | |
| 011 | Aid category not flagged as manage care category | ||
| 020 | Calculated new Start Date | Accept this start date | |
| 021 | Future segment exists | send a delete then an add | |
| 022 | Assignment Effective date not in future | Deletes must be in future | |
| 030 | Assignment End date Invalid | Effective Date must be <= End Date Or end date must be >= today | |
| 031 | Assignment End date past eligibility end date | Can not extend assignment past eligibility end date | |
| 040 | Assignment Start Reason Invalid | ||
| 050 | Assignment Stop Reason Invalid | ||
| 060 | Assignment Transaction Type Invalid | not a A, C, or D | |
| 070 | Code Health Subprogram invalid not R, C, or X | ||
| 080 | Dates not a valid calendar date | ||
| 090 | HIP Add record does not have corresponding Change/Delete record | ||
| 100 | HIP Change/Delete record does not have corresponding Add record | ||
| 110 | HIP Date end must consecutively follow date effective for assigned member with Term and Add records | ||
| 120 | HIP Rejected due to errors on the corresponding change or add record. | ||
| 121 | HIP Rejected currently processing a plan change for this member. | ||
| 130 | MCE ID Invalid | will show up as 430 | |
| 131 | Member already assigned to this MCE | ||
| 132 | Enrollment Broker cannot change plan to or from ESP | ||
| 133 | MCE ID Spaces | ||
| 134 | MCE ID does not match MCE ID in AIM for this recipient | ||
| 140 | Medicaid Eligibility dates not within range | Member's eligibility ends at the end of the current month | |
| 150 | Medicaid ID (RID) Invalid | ||
| 160 | Member Age - must be 13 years or older to enroll with an Internist | ||
| 170 | Member Age - must be less than 21 years of age to enroll with a pediatrician | ||
| 180 | Member Age - must meet age restriction for package C | ||
| 190 | Member Age < 13 not allowed | ||
| 200 | Member Age < 17 than allowed | ||
| 210 | Member Age < 21 not allowed | ||
| 220 | Member Age < 3 out of range allowed | ||
| 230 | Member Age > 17not allowed | ||
| 240 | Member Age > 2 not allowed | ||
| 250 | Member Age > 20 - out of range allowed | ||
| 260 | Member Age >= 65 only allowed | ||
| 270 | Member Age older than 12 | ||
| 280 | Member Age out of range 13 - 17 allowed | ||
| 290 | Member Age out of range 13 - 20 allowed | ||
| 295 | Member Age Requirements for Pathways are not met | ||
| 300 | Member Aid Category not Managed Care | ||
| 310 | Member has Dual eligibility and J, L aid category | ||
| 320 | Member has LOC (Level of Care) | Care Select may not have Nursing or Hospice types level of care | |
| 330 | Member has LOCKIN | ||
| 340 | Member has Medicare A or B | ||
| 350 | Member in invalid County/Region for health program | ||
| 360 | Member is a Ward/Foster | ||
| 370 | Member is already enrolled with the same PMP | ||
| 380 | Member is on Spend down | ||
| 381 | Member requires Disease State | Care Select - Milliman must have sent HP this member in the quarterly file. | |
| 390 | Member neHPES Medicare PMP | ||
| 400 | Member not alive/active/legal alien or has Emergency Services only Indicator | ||
| 410 | Newborn Preselection Invalid | Must be to a provider in same network/MCE. Newborn is not eligible for managed care, usually because the mother’s eligibility has expired | |
| 420 | PMP Group ID Invalid | ||
| 430 | PMP ID or service Location Invalid or PMP does not have an active service location | ||
| 440 | PMP OBGYN allowed for only Females | ||
| 442 | PMP sees only men | ||
| 444 | PMP sees only women | ||
| 446 | Member does not meet PMP scope of practice | ||
| 450 | PMP Obstetrics Indicator is OFF for Pregnancy aid category | ||
| 460 | PMP Panel is Full / PMP Panel reached maximum capacity | ||
| 470 | PMP Panel on Hold/Stop | ||
| 480 | PMP Panel Size not available for date range | ||
| 490 | Provider Ineligible | ||
| 500 | PMP not a managed care location | ||
| 600 | Member locked in to current MCO | Send Just Cause start reason | This error would be received if Maximus sent a selection for a 'closed' client without sending a just cause reason, correct? Yes |
| 605 | Invalid Start date sent for Open Enrollment period | Start date outside the OE period - Family member neHPES Just Cause Reason or an Open Status | Greg, can you clarify this? My understanding is that the tranfer transaction can be submitted up to and including the last day the member is in 'open' status. This message seems to indicate that the enrollment start date must be within the open enrollment period. Correct - I may change or delete this one - it is trying to catch an Open status with an invalid start date - I think we would end up changing the start date to the correct date and send an 020 or 620. |
| 610 | Member locked in to current MCO for Annual period | Member is in closed status and may not change MCO's - today must be within 89 days of 12 mth completed date (end of lockin ) | Does this mean that Maximus submited a selection for a member in 'closed' status without a valid just-cause reason? Sent in a 94 code but it is before the Annual enrollment date or after the end date of the 12th month |
| 620 | Annual enrollment stat date not 1st of month after AE end date | Changed Start date to 1st - Same as 020 code - HPES Accepted Assignment | Annual open enrollment selection start date must be the 1st day of the month following the open enrollment lockin completed date MONTH. For example, open enrollment lockin completed date is 12/15/2008; annual open enrollment selection effective date must be 1/1/2009. |
| 625 | After 25th of Month and near end of Annual OE period. | Too Late in Month to make a change | Maximus submitted a selection after the 25th of the last month of the annual open enrollment period. |
| 630 | Just Cause Reason not allowed | OE not implemetned in Region or for Health care plan | Just cause reason codes can only be used for members in open enrollment with a closed status or family member not open. |
| 693 | OE reason 93 not allowed for Member | Member has family member with an Open status | Send normal start reason code |
| 694 | OE reason 94 not allowed for in-plan PMP changes | Expecting a change of MCO or plan | OE reason code 94 may not be used for a PMP-only transfer |
| 695 | OE reason 95 not allowed for non BA Assistance members | Member is no longer on BA assistance | |
| 700 | Duplicate record on file | Duplicate record on file | |
| 701 | Incoming Record is Pathways Eligible | Incoming Record (Non Pathway) is Pathways Eligible. | This edit will only be applied to HHW, HCC and HIP Records. |
| 702 | Incoming Pathway records is HCC eligible | Incoming Pathway records is HCC eligible | This edit will only be applied to Pathway records. |
| 703 | The combination of Effective and End Date submitted results in a Reverse Date | Effective date (calculated or received) is greater than the end date (Calculated or Received). | Pathways Example: |
Cycle Date: 9/20/2024 Incoming Effective Date 10/01/2024 - Calculated Effective Date: 10/01/2024 Incoming End Date 9/30/2024
| 704 | EB Transaction received with PMP Data | EB Transaction has the Provider ID And/OR the Provider Group ID populated for the transaction | |
| 710 | PMP Actual Panel does not exist for submitted PMP | Could not verify the actual Panel for the MP ID Submitted . | |
| 711 | PMP does not have an actual Panel size record | Could not verify the panel size for the MP ID Submitted . | |
| 712 | PMP ID and Group ID combination submitted do not have an active service location | The combination of the Provider ID along with the Group ID submitted do not have an active service location | |
| 713 | Assignment End Date Received is greater than the PMP End Date | The Assignment End Date received (Or Calculated) on File is Greater than the PMP End Date in Core MMIS | Pathways Example: |
Cycle Date: 9/20/2024 Incoming End Date 12/21/2024 - Calculated Effective Date: 12/31/2024 PMP End Date 11/30/2024
| 714 | PMP Assignment End Date is Less than the current MCE assinment End date | The incoming PMP assignment End Date is less than the current MCE assignment |
| 800 | Ended previous assignment the day before new assignment starts | previous assignment ended to allow new assignment |
| 801 | Date overlap with new/added date segment | |
| 802 | Date overlap on an new/add for a plan change | |
| 803 | Change transaction causes a date overlap | |
| 831 | Recipient is not eligible for Disease Management/Case Management | |
| 832 | PMP Assingment record exists. | |
| 833 | Record already has opt-out record | |
| 834 | Date overlap with new Opt-in Decline and pmp_assign_rec | |
| 997 | Pathways Recipient in PS Hold unable to Assign/Modify | |
| 998 | Data values supplied do not equal the current assignment on record and can not be updated | |
| 999 | SQL error - database did not update record for unknown reason |
Recipient in Z-stop code
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