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Managed Care Enrollment 834 FAQs

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Q.

Will Medicaid billing be impacted at all? Will health plans remain responsible for billing Medicaid business through the existing 837 process?

 

 

Category: Billing

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Published: 3/24/2017

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Updated: 3/24/2017

|

QID: B01

 
 

Q.

Will there be a new link on the eMedNY website Home page where we can get the 834 Companion Guide, Supplemental Guide, Trading Partner Agreement, and Sample Test files when they are ready?

 

 

Category: Companion Guide & Documentation

|

Published: 3/24/2017

|

Updated: 3/24/2017

|

QID: CG01

 
 

Q.

Should we assume that only fields that are required in the 834 file will be sent, even if it's not documented in the companion guide?

Example: Loop 2000/Member Level Details; INS*05/Benefit Status Code.

 

 

Category: Companion Guide & Documentation

|

Published: 3/24/2017

|

Updated: 4/26/2017

|

QID: CG02

 
 

Q.

Do you expect this 834 to be similar to the NYSoH 834? Will you just revise the guides to include any differences?

 

 

Category: Companion Guide & Documentation

|

Published: 3/14/2017

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Updated: 4/20/2017

|

QID: CG03

 
 

Q.

Will we receive a mapping document that shows where each field on the Roster will be appear on the new 834?

 

 

Category: Companion Guide & Documentation

|

Published: 4/4/2017

|

Updated: 4/4/2017

|

QID: CG04

 
 

Q.

From the CG - When N102=RRE CODES then REF02 will contain all active 2-char RRE codes (concatenated without spaces).

Today, we only get 2 of these codes on the Roster. What is the maximum number of codes that we can get on this 834?

 

 

Category: Companion Guide & Documentation

|

Published: 5/10/2017

|

Updated: 5/10/2017

|

QID: CG05

 
 

Q.

Should we expect to receive another document outlining how Roster information is translated into 834 file and/or document outlining differences between HIX Medicaid and MMC Enrollment in 834 X12 format?

 

 

Category: Companion Guide & Documentation

|

Published: 5/10/2017

|

Updated: 5/10/2017

|

QID: CG06

 
 

Q.

There is no reference to a Pregnancy Due Date in the 2750 Reporting Category chart in the CG. Will this be supplied?

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

|

Updated: 3/8/2017

|

QID: DC01

 
 

Q.

Will existing Categories and Rate Codes be used? Will new ones be added?

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

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Updated: 3/8/2017

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QID: DC02

 
 

Q.

Will we continue to receive the H code values for members in the HARP program, or the N code values for members in the Nursing Home program?

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

|

Updated: 3/8/2017

|

QID: DC03

 
 

Q.

Will we continue to receive code 30 for members formerly in the Lombardi program?

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

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Updated: 3/8/2017

|

QID: DC04

 
 

Q.

Will we continue to receive Restriction/Exception code values that we receive today?

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

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Updated: 4/20/2017

|

QID: DC05

 
 

Q.

Are all the Disenrollment Reasons listed in the CG the only codes that we can expect in Loop 2750, where N102= DISENROLL RSN? This list does not match what we get from NYSoH.

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

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Updated: 5/24/2017

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QID: DC06

 
 

Q.

Will we receive address with 3 lines? Example - if there is a 'C/O'?

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

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Updated: 3/13/2017

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QID: DC07

 
 

Q.

The "Excess Income" field on the 834s will have to be incorporated into "Spenddown Invoicing." Unless there is an MLTC 834 companion guide already in existence that identifies where this information will be available, we would like to know more about how this information will be relayed to issuers.

The excess income amount may change with new effective dates (similar concept to APTC amount).

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

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Updated: 3/8/2017

|

QID: DC08

 
 

Q.

How will Handicapped/Disabled members be identified on the file? By Aid Category or a separate Indicator?

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

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Updated: 3/31/2017

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QID: DC09

 
 

Q.

How will we determine the member's residential county? FIPS code, County Name, or Zip Code?

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

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Updated: 3/8/2017

|

QID: DC10

 
 

Q.

How will Race code/Ethnicity code be reflected on the 834?

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

|

Updated: 3/8/2017

|

QID: DC11

 
 

Q.

How will Language code be reflected on the 834?

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

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Updated: 3/8/2017

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QID: DC12

 
 

Q.

Will we get MA or MAP members on 834s? If so, what field should be used to identify these members?

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

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Updated: 3/8/2017

|

QID: DC13

 
 

Q.

Loop 1000B/Payer: N104 - The companion guide states "8 character plan identifier will be valued", is this the same as the Provider ID/MMIS ID number of plan currently sent on the Roster?

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

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Updated: 3/8/2017

|

QID: DC14

 
 

Q.

Loop 2000/Member Level Detail: INS04/Maintenance Reason Code - Will NYS send value of '27' for unborn? Also should we be sending back '28' for effectuation transactions?

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

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Updated: 3/8/2017

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QID: DC15

 
 

Q.

Please confirm: Loop 2000/Member Policy Number; REF02/Reference Identification - is this the Provider ID/MMIS ID number of plan?

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

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Updated: 3/8/2017

|

QID: DC16

 
 

Q.

Please confirm: 3H/Case Number - Client Case ID

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

|

Updated: 3/8/2017

|

QID: DC17

 
 

Q.

Please confirm: ZZ/QHP Subscriber ID - for HIX we receive a plan specific subscriber ID number (and only on updates or terms, as this information is provided on our effectuation outbound).

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

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Updated: 3/8/2017

|

QID: DC18

 
 

Q.

Can clarifications be given to help us tell the difference between the following fields in the Loop 2000, REF02 fields? Are some expected to be the same?:

'0F' = Subscriber Identifier (eMedNY Generated, 8 digit ID?) '17' = Member Identifier (CIN?)
'23' = Client Number (CIN?) 'ABB' = Personal Identifier (CIN?)

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

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Updated: 4/26/2017

|

QID: DC19

 
 

Q.

In Loop 2300, REF01, the CE value (defined as "HIOS Identification Number"). How will these be generated? Can these be related to a value(s) that are currently on the Roster files?

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

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Updated: 4/26/2017

|

QID: DC20

 
 

Q.

Currently, the value in Loop 2000, DTP*303 (Maintenance Effective Date) on NYSoH's 834's cannot be relied on (sometimes not even sent). Will it be populated on the eMedNY 834's and can it be relied on to determine when a maintenance transaction is considered effective? If reliable, what change(s) should this date drive in Issuers' Member Maintenance systems?

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

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Updated: 5/24/2017

|

QID: DC21

 
 

Q.

Per the Q&A doc released in May, 2016, we understand we should be "sorting" and processing transactions received each day by the BGN02 value (Transaction Set Reference Number), so we assume that value will be "order-able". Will the format of the BGN02 value we receive in production files mirror the format that was presented in the sample X12 data in the Companion Guide? If so, can we understand the break-down of the value (for example, is the first part timestamp, then?....)?

(Example provided: 1614000000000004XF1612700000005700)

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

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Updated: 3/13/2017

|

QID: DC22

 
 

Q.

In Loop 2300, REF01, will the X9 value (defined as a "Policy Identification Number") be a new value generated by eMedNY?

Will the format be similar to NYSoH's where it includes the HIOS, then a NYSoH Generated Policy Number, then the NYSoH Generated Subscriber ID, then the Benefit Begin Date, all concatenated and separated by dashes? NYSoH Sample: 25303MC1000038-0001234567-0007654321-20161201

All that was provided in the Companion Guide sample X12 data was "QHP POLICY ID" in the REF*X9 value....

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

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Updated: 5/24/2017

|

QID: DC23

 
 

Q.

Will the source of the WMS member data for the 834 be the same as it is for the Roster data?

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

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Updated: 3/8/2017

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QID: DC24

 
 

Q.

If Unborn is sent to us - are we expected to send the Unborn back on the Response/Effectuation file? Or do we wait until we get the record for eMedNY that the child has been born?

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

|

Updated: 3/8/2017

|

QID: DC25

 
 

Q.

Will MCOs have the ability to reject an incoming enrollment transaction (e.g., member resides outside of contracted service area; member expired)?

 

 

Category: Data Fields and Code

|

Published: 3/8/2017

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Updated: 3/8/2017

|

QID: DC26

 
 

Q.

What code(s) will be present on the 834 to differentiate a Medicaid vs. a LTC member?

 

 

Category: Data Fields and Code

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Published: 3/14/2017

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Updated: 4/20/2017

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QID: DC27

 
 

Q.

What types of transactions will be sent on the verification file if one is requested? Will they all be 030 records?

 

 

Category: Data Fields and Code

|

Published: 3/14/2017

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Updated: 4/20/2017

|

QID: DC28

 
 

Q.

Is maintenance reason code needed/expected on any of incoming transactions?

 

 

Category: Data Fields and Code

|

Published: 5/10/2017

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Updated: 5/10/2017

|

QID: DC29

 
 

Q.

HIX has 2100A DMG02 as due date for Unborn. Why cannot it be sent along with pregnancy indicator in MMC 834 files?

 

 

Category: Data Fields and Code

|

Published: 5/10/2017

|

Updated: 5/10/2017

|

QID: DC30

 
 

Q.

Periodically, we identify a member who falls off the Roster and loses eligibility due to a WMS stacking issue, will the new process be able to detect if this occurs and prevent a break in coverage for the member?

 

 

Category: Enrollment / Eligibility Processes

|

Published: 3/24/2017

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Updated: 3/24/2017

|

QID: EN01

 
 

Q.

When encountering eligibility discrepancies between the portal (ePACES) and the roster file, the portal was considered the source of truth for roster membership. Will this continue to be the same when this membership is transitioned to an 834 file?

 

 

Category: Enrollment / Eligibility Processes

|

Published: 3/24/2017

|

Updated: 3/24/2017

|

QID: EN02

 
 

Q.

How will Aliessa members be identified on the new eMedNY 834?

Can Aid Category code be used, and if so, which codes should be considered 'Aliessa'?

Or should we use Money Code? Or a combination of these or other codes?

 

 

Category: Enrollment / Eligibility Processes

|

Published: 3/23/2017

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Updated: 5/19/2017

|

QID: EN03

 
 

Q.

Will we still be able to use ePACES?

 

 

Category: Enrollment / Eligibility Processes

|

Published: 3/24/2017

|

Updated: 3/24/2017

|

QID: EN04

 
 

Q.

Currently when a member has COB listed and the member proves that they no longer have COB, they contact their Case Worker at DSS who make the necessary update. Often the MCO is not notified of this change. Will the new process allow this type of change to be communicated with the MCO?

 

 

Category: Enrollment / Eligibility Processes

|

Published: 3/24/2017

|

Updated: 3/24/2017

|

QID: EN05

 
 

Q.

How does the new process handle MMC members who are being disenrolled for Medicare and the plan needs to check to see if they are receiving Personal Care Services?

 

 

Category: Enrollment / Eligibility Processes

|

Published: 3/21/2017

|

Updated: 3/21/2017

|

QID: EN06

 
 

Q.

Under the future state process, if a health plan has a question regarding eligibility, will we contact DSS counties to send an updated 834 file for correction or will there be a different process established?

We would like to maintain our relationship with our DSS contacts so that we can work together to resolve urgent matters.

 

 

Category: Enrollment / Eligibility Processes

|

Published: 4/4/2017

|

Updated: 4/4/2017

|

QID: EN07

 
 

Q.

If a member is received on the initial file, but is already active in our system from the NYSoH, what should we do?

For example - we have a member in our system as EP from the NYSoH. If he comes on the initial 834 Roster replacement file, should we change the member in our system to Medicaid?

 

 

Category: Enrollment / Eligibility Processes

|

Published: 4/4/2017

|

Updated: 4/4/2017

|

QID: EN08

 
 

Q.

For Primary Roster there is a concept of termination by absence on Roster. Will the same rule apply for 834 Monthly file? Or, should we rather expect explicit termination transaction, like for HIX Medicaid in daily process only?

 

 

Category: Enrollment / Eligibility Processes

|

Published: 5/10/2017

|

Updated: 5/10/2017

|

QID: EN09

 
 

Q.

Are we expected to only send records back when the member is effectuated from a 021 transaction? Or are we supposed to send something back after processing changes, terms, or cancels?

 

 

Category: File Details

|

Published: 3/14/2017

|

Updated: 5/15/2017

|

QID: FD01

 
 

Q.

Will the new 834 be sent from the eMedNY file transfer platforms, or will they be sent via NYSoH's SFTP mailbox?

 

 

Category: File Details

|

Published: 3/14/2017

|

Updated: 3/31/2017

|

QID: FD03

 
 

Q.

Will there be a new mailbox?

 

 

Category: File Details

|

Published: 3/14/2017

|

Updated: 3/28/2017

|

QID: FD04

 
 

Q.

What will be the file naming convention?

 

 

Category: File Details

|

Published: 3/14/2017

|

Updated: 3/14/2017

|

QID: FD05

 
 

Q.

Will we no longer receive a full file, and only get individual records daily with specific dates?

 

 

Category: File Details

|

Published: 3/14/2017

|

Updated: 3/14/2017

|

QID: FD06

 
 

Q.

Will all the Roster files including the Newborn and TPHI files be converted to the 834?

 

 

Category: File Details

|

Published: 3/14/2017

|

Updated: 3/14/2017

|

QID: FD07

 
 

Q.

How will eMedNY distinguish between Exchange 834's and the "Roster" 834's?

 

 

Category: File Details

|

Published: 3/14/2017

|

Updated: 3/14/2017

|

QID: FD08

 
 

Q.

Will there be a limit of 5,000 transactions per file? Can we expect to receive multiple files per day?

 

 

Category: File Details

|

Published: 3/14/2017

|

Updated: 3/14/2017

|

QID: FD10

 
 

Q.

Will we get multiple transactions for a single member on the same file? If so, what should we use to determine the correct sequence to process them?

 

 

Category: File Details

|

Published: 3/14/2017

|

Updated: 3/14/2017

|

QID: FD11

 
 

Q.

Will the NAMI Supplemental Files process remain the same (currently we receive these on separate "supplemental files")?

Guidance was provided in the Q&A doc in May, 2016:

 

 

Category: File Details

|

Published: 3/14/2017

|

Updated: 3/14/2017

|

QID: FD12

 
 

Q.

If the products are not on separate files - What code(s) will be present on the 834 to differentiate a Medicaid vs. a LTC member vs. a HARP member vs. a MAP member?

 

 

Category: File Details

|

Published: 4/4/2017

|

Updated: 4/20/2017

|

QID: FD13

 
 

Q.

When we experience problems downloading 820 files from the eMedNY FTP location, we go to the "eMedNY dashboard". Will we be able to go there and if so, what would we select in the drop down, to retrieve the 834 files? (834R?)

 

 

Category: File Details

|

Published: 3/14/2017

|

Updated: 3/14/2017

|

QID: FD14

 
 

Q.

Will there be a process for sending back records we cannot process?

 

 

Category: File Details

|

Published: 3/14/2017

|

Updated: 3/14/2017

|

QID: FD16

 
 

Q.

Will the files be posted daily?

 

 

Category: File Details

|

Published: 3/14/2017

|

Updated: 4/24/2017

|

QID: FD17

 
 

Q.

Currently we receive a full roster and a catch up, when we move to an 834: Will we receive an initial full file with all roster membership as of the cutover?

 

 

Category: File Details

|

Published: 4/4/2017

|

Updated: 4/4/2017

|

QID: FD18

 
 

Q.

Will we continue to receive the supplemental Nursing Home files? (Upstate Primary Managed Nursing Home File -mnhummdd.txt, Downstate Primary Managed Nursing Home File -mnhnmmdd.txt)?

 

 

Category: File Details

|

Published: 4/21/2017

|

Updated: 4/21/2017

|

QID: FD21

 
 

Q.

Will there be any HARP membership on these 834s? If so will they be on a separate 834 file or on the same file as non-HARP members?

 

 

Category: HARP

|

Published: 3/24/2017

|

Updated: 3/24/2017

|

QID: H01

 
 

Q.

If member is moving from Tanf to HARP are we going to get a term transaction for Tanf and a new on HARP roster?

 

 

Category: HARP

|

Published: 5/10/2017

|

Updated: 5/10/2017

|

QID: H02

 
 

Q.

Will there be opt-out information sent for HARP and if so where?

 

 

Category: HARP

|

Published: 5/10/2017

|

Updated: 5/10/2017

|

QID: H04

 
 

Q.

Will this new 834 process entirely replace the rosters, or will we continue to receive one or more roster files for some portion of the population?

 

 

Category: Implementation

|

Published: 3/14/2017

|

Updated: 3/14/2017

|

QID: IMP01

 
 

Q.

Apart from the 'Pilot' Plans - Are all Plans and Counties converting from Roster to 834 at the same time?

 

 

Category: Implementation

|

Published: 3/14/2017

|

Updated: 3/14/2017

|

QID: IMP02

 
 

Q.

Is there a final date for when the Rosters stop coming and we must be able to accept the 834s in their place?

 

 

Category: Implementation

|

Published: 3/14/2017

|

Updated: 3/14/2017

|

QID: IMP03

 
 

Q.

What levels of EDI Compliance are suggested to be implemented? Levels 1-7?

Currently with NYSoH, it was recommended we only implement 1-2...

 

 

Category: Implementation

|

Published: 3/14/2017

|

Updated: 3/28/2017

|

QID: IMP04

 
 

Q.

In the 834 new processes will plans continue to receive ALL Maximus files (NY Medicaid Choice)?

 

 

Category: Maximus

|

Published: 3/21/2017

|

Updated: 3/21/2017

|

QID: M01

 
 

Q.

If we continue to receive these 2 Maximus files, should we term a member based on data on either the T or L file? Or should we only term if we get 024 on the new 834 file?

 

 

Category: Maximus

|

Published: 3/24/2017

|

Updated: 3/24/2017

|

QID: M02

 
 

Q.

If we are going to continue to receive Maximus files, how do we prioritize transactions between those files and the eMedNY 834? For example, if we receive a record on the T or L file , but have not received a 024 from eMedNY, then should we term the member?

 

 

Category: Maximus

|

Published: 3/24/2017

|

Updated: 3/24/2017

|

QID: M03

 
 

Q.

Will Nursing Home Members be included? What will be the impact?

 

 

Category: Nursing Home

|

Published: 3/24/2017

|

Updated: 3/24/2017

|

QID: NH01

 
 

Q.

Will current enrollment and eligibility policies related to retro enrollment/retro disenrollment etc. remain in place?

 

 

Category: Policy Changes

|

Published: 3/24/2017

|

Updated: 3/24/2017

|

QID: PC01

 
 

Q.

Will there be enrollment deadlines?

 

 

Category: Policy Changes

|

Published: 3/24/2017

|

Updated: 3/24/2017

|

QID: PC02

 
 

Q.

How does this impact the LDSS enrollment pull down calendars?

 

 

Category: Policy Changes

|

Published: 3/24/2017

|

Updated: 3/24/2017

|

QID: PC03

 
 

Q.

Will there be cut-offs for enrollment/ disenrollments (i.e., 15th of month for 1st of following month)?

 

 

Category: Policy Changes

|

Published: 3/24/2017

|

Updated: 3/24/2017

|

QID: PC04

 
 

Q.

How does the new process impact Restricted Recipients and Foster Care members?

 

 

Category: Policy Changes

|

Published: 3/24/2017

|

Updated: 3/24/2017

|

QID: PC05

 
 

Q.

Will the Retro Term process now through HCS be changed?

 

 

Category: Policy Changes

|

Published: 3/24/2017

|

Updated: 3/24/2017

|

QID: PC06

 
 

Q.

How do we report duplicate members to the state? For example - If we find 2 members with the same Medicaid ID, how do we report that?

 

 

Category: Policy Changes

|

Published: 3/24/2017

|

Updated: 3/24/2017

|

QID: PC07

 
 

Q.

Should we update data manually in our system if a member calls us ? Or should we instruct the member to contact the state (eMedNY?) to do the change?

 

 

Category: Policy Changes

|

Published: 3/24/2017

|

Updated: 4/3/2017

|

QID: PC08

 
 

Q.

Currently NYSoH Medicaid and WMS/ePACES are not always in sync; will an update in eMedNY/ePACES/WMS trigger an 834 transaction for members?

 

 

Category: Reconciliation / Discrepancies

|

Published: 3/24/2017

|

Updated: 4/3/2017

|

QID: RD01

 
 

Q.

Often members appear as active/eligible on the Roster and we load them to our eligibility system. We later find that eMedNY shows them as Not Eligible or no Managed Care Plan is listed. This prevents us from getting paid or from submitting MEDS Claims Data. How will this process affect that issue?

 

 

Category: Reconciliation / Discrepancies

|

Published: 3/24/2017

|

Updated: 4/20/2017

|

QID: RD02

 
 

Q.

Roster provides PCP data in current state. As we understand NYSoH has had challenges with applying PCP data how will this be addressed in the new 834 file?

 

 

Category: Reconciliation / Discrepancies

|

Published: 4/21/2017

|

Updated: 4/21/2017

|

QID: RD03

 
 

Q.

When the cutover to the future state process occurs, will there be a reconciliation performed to identify discrepancies in eligibility between DOH and health plans?

 

 

Category: Reconciliation / Discrepancies

|

Published: 4/21/2017

|

Updated: 4/21/2017

|

QID: RD05

 
 

Q.

Is auditing process planned or this will be rolled into monthly verification file process?

 

 

Category: Reconciliation / Discrepancies

|

Published: 5/10/2017

|

Updated: 5/10/2017

|

QID: RD06

 
 

Q.

Will other HCS reports be replaced by the 834 (Fair Hearing, Disenroll roster, Newborns, TPHI, etc.)?

 

 

Category: Reports

|

Published: 3/24/2017

|

Updated: 3/24/2017

|

QID: R01

 
 

Q.

Will all Enrollment Rosters (Medicaid, LTC , HARP, MAP), Disenrollment Rosters, and Interim files be replaced?

 

 

Category: Reports

|

Published: 4/4/2017

|

Updated: 4/19/2017

|

QID: R02

 
 

Q.

Will the monthly Disenrollment Rosters be eliminated when the 834s are implemented?

 

 

Category: Reports

|

Published: 3/14/2017

|

Updated: 4/20/2017

|

QID: R03

 
 

Q.

Would we need to send an "effectuation" 834 response file, or would it just be assumed that the member was added/changed/cancelled/termed without a response from each issuer?

 

 

Category: Response Files

|

Published: 3/24/2017

|

Updated: 5/15/2017

|

QID: RF01

 
 

Q.

Will retroactive updates be sent through the 834?

 

 

Category: Retroactivity

|

Published: 4/21/2017

|

Updated: 4/21/2017

|

QID: RE01

 
 

Q.

How soon can we get a test file?

 

 

Category: Testing

|

Published: 3/24/2017

|

Updated: 3/24/2017

|

QID: TEST01

 
 
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