Transcription
NEW YORK STATEMEDICAID PROGRAMMANAGED CARE REFERENCE GUIDE:ENROLLEE ROSTERS
Managed Care Reference Guide: Enrollee Rosters –AppendicesTABLE OF CONTENTSSection I – Purpose Statement . 2Section II –Enrollee Rosters . 3Monthly Managed Care Roster File Layout and Field Descriptions . 4Monthly Disenrollment Report . 17Monthly Error Report . 19Medicaid Eligibility Verification System (MEVS) . 21Section III – Appendices . 22Appendix A – County / District Codes . 22Appendix B – Insurance Coverage Codes . 23Version 2019 – 1 (2/1/2019)Page 1 of 24
Managed Care Reference Guide: Enrollee Rosters –AppendicesSection I – Purpose StatementThe purpose of this document is to assist participating managed care organizations inunderstanding and complying with the New York State Medicaid (NYS-Medicaid)requirements.The guide addresses Enrollee Rosters.This document is customized for managed care providers as an instructional as well as areference tool.Version 2019 – 1 (2/1/2019)Page 2 of 24
Managed Care Reference Guide: Enrollee Rosters –AppendicesSection II –Enrollee RostersEnrollee information is contained in rosters compiled by the State Department of Health(SDOH) for the Plans. The enrollee roster is the vehicle by which data such as Planenrollment, and county of fiscal responsibility are distributed to the Plan.Rosters are available on the HCS (Health Commerce System) for the Plan according tothe SDOH Medicaid Monthly Schedule which is produced in November for the year ahead.All plans are required to utilize an Internet Service Provider (ISP) to access the HCS forpurposes of accessing the Medicaid and roster site.The Internet site through which to access the HCS tmlThe HCS requires each user to possess a User ID and password to enter the rosterapplication. This is a secure site with access granted by the Commerce AccountsManagement Unit (CAMU). If you do not have a User ID and password, you should emailthe CAMU at camu@its.ny.gov, or call 1-866-529-1890, option 1. You will not be grantedaccess to this site without proper authorization.Enter your User ID and passwordOnce you are signed in, select My Content, All Applications, and then Managed CareRoster/Report Download. Once you have selected the Rosters Home Page, you willbe able to select the files you have access to.The specifications for the enrollee rosters are on the following pages.A list of the County/District codes is provided in Appendix A and a list of InsuranceCoverage codes can be found in Appendix B at the end of this document. These lists ofcodes will help you to interpret information included on your enrollee rosters.Questions about information contained in a Roster, receipt date for Rosters, or theMedicaid Monthly Schedule may be directed to the State Department of Health’s Divisionof Health Plan Contracting and Oversight at (518) 473-1134.Version 2019 – 1 (2/1/2019)Page 3 of 24
Managed Care Reference Guide: Enrollee Rosters –AppendicesMonthly Managed Care Roster File Layout and Field DescriptionsThe Monthly Managed Care Recipient Roster lists every Medicaid recipient who is eligiblefor Medicaid as of the pulldown or processing date and enrolled in a managed care plan forthe upcoming month.There are two roster reports generated each month. One (Primary) is produced around tendays prior to the beginning of the effective month of the report, which is the weekend of thepulldown (for example, June 22nd for the July roster).A second roster is produced the first full weekend after the beginning of the effective month(for example, July 6th for the July roster). The second report shows only additionalenrollees who were not included on the first roster. These enrollees generally are addedbecause their Medicaid eligibility recertification occurred later than the processing date(pulldown date) of the first roster, but was completed before the first day of the effectivemonth. As a result, they were not reflected on the first roster, but added via the secondroster production.Data ElementsThe following data is reported for each enrollee on the roster:CIN – Enrollee’s Medicaid Client Identification NumberSocial Security Number – Enrollee’s Social Security NumberEnrollee’s NameEnrollee’s SexF – FemaleM – MaleU - UnbornLanguage CodeEnrollee’s Date of BirthCase Name – Name of the adult the assistance case is authorized underEnrollee’s AddressCare of Name – Name of the person in care of the enrolleeVersion 2019 – 1 (2/1/2019)Page 4 of 24
Managed Care Reference Guide: Enrollee Rosters –AppendicesMailing Address – Mailing address associated with the “Care of” contactCase Number – Case number assigned by the local districtLocal Office CodeExpiration Date – End of the month in which the roster expiresMedicaid CoverageCode which defines the enrollee’s type of Medicaid eligibility.ABGLPQRTUWY126Full Medicaid CoverageFull Medicaid Coverage except Long Term Care (LTC)PCP Guarantee CoveragePerinatal FamilyPrepaid Capitation Plan (PCP) CoveragePCP/HR CoveragePCP Guarantee/HRHR/UTFamily Health PlusFamily Health Plus/GuaranteeAliessa AlienCommunity Coverage w/Community Based LTCCommunity Coverage without LTCCommunity Coverage without LTC (legal alien during 5-yearban)Note1: Generally local districts are expected to change recipients’ fee for servicecoverage code from “A”, “B”, “L”, “T”, “Y”, “1”, “2” or “6” to “P” when enrolled in aMedicaid managed care plan; however, failure to do so does not change the validityof plan enrollment.Note2: Coverage Codes G, R, U, W are no longer active.Version 2019 – 1 (2/1/2019)Page 5 of 24
Managed Care Reference Guide: Enrollee Rosters –AppendicesAid Category - Defines the type of medical assistance the enrollee is eligible for with theMedicaid program. This code is used to derive the rate code under which the capitationclaim is paid (Aid to Dependent Children, HR, SSI).0110FP DefaultFA-Family 2526ADU-U (FP)IV-E and Non IV-E (FP)TANF with Deprivation (FP)TANF without Deprivation (FP)Safety Net w/out deprivation (FP)Safety Net - Non-Cash (FP)Supplemental Payment (NYC) (FNP) 100 %Local (TA) or 100% State (MA)LIF W/out Depriv/SCC (FP)RESERVE FOR FUTURE USEMA-CW (FP)MA-Aged (FP)MA-Blind (FP)MA-Disabled (FP)27ADC Medically Needy (FP)752830313235767778798136373839Public Home (FNP)Presumptive Eligibility for Children (FP)Poverty Level Child (FP)LIF Related w/deprivation (FP)Presumptive Eligibility Home Care (FNP)State/LocalRESERVE FOR FUTURE USEAlien Eligibility (FNP) State/LocalAlien Eligibility (FP)FNP Related Parent Living Child (FP)40414243Public Shelter Resident (FNP) 100% LocalPresumptive Eligibility Prenatal A (FP)Presumptive Eligibility Prenatal B (FP)Prenatal Care (FP)88899091444547Infant (223% FPL) (FP)Child 1-6 (154% FPL) (FP)Child Welfare (FNP) 100% Local92H0H148495051525354555657Child Continuous Coverage (FP)Expanded - Continuous CoverageSSI Aged (FP)SSI Blind (FP)SSI Disabled (FP)SSI Pend Aged (FP)SSI Pend Disabled (FP)SSI Pend Disabled (FP)Family Planning CoveragePoverty Level Infant (FP)ORP1P2P5P7P8P9Version 2019 – 1 (2/1/2019)68697071727482838687Infant – Continuous Coverage (200% FPL (FP)CAP/MA Guarantee (FNP) State/Local (Disabled10/22/07)Safety Net – Aged (FP)Safety Net – Blind (FP)Safety Net – Disabled (FP)Safety Net – (FP)Colorectal and Prostate Treatment Program (FNP)Emergency Shelter (FP)Safety Net w/deprivation (FP)FHP Singles/Childless Couples (FP)FHP Parents/19-20 years olds (FP)FHP Pregnant Woman 100%Child 6-18 (110-154% FPL) (FP)FHP Pregnant Woman 200% FPL (FP)Breast and Cervical Cancer Treatment Program(under 65)Breast and Cervical Cancer Treatment Program (65and over)Legal Alien (FNP)Breast Cancer Treatment Program (Male (FNP)LIF/SN/TL – Cash (FP)LIF/SN/TL – NC (FP)Child Continuous Coverage (100-133% FPL) (FP)Medicaid Buy In – Disabled Basic GroupMedicaid Buy In – Medically ImprovedChild 6-18 (111-154% FPL) (FP)Family Planning Extension Program Post-Partum(FNP)Inpatient OMH (FNP)Inpatient Prisoner (FP)FHP S/CC 0 100% or S/CC (FP)TANF/SN/LIF w/out deprivation and SN NC/SCC(FP)MA Formerly Foster Care (effective October 2018)Adult Group (19-64) S/CC 101-138% (FP) (100/0/0)Adult Group (19-64) Parent Caretaker Relatives LIF 133 OR 19-20 LIF 133138-155% MOE (FP) (50/25/25)LIF W/OUT Depriv (FP)LIF Related W/Depriv (FP)Safety Net W/Out Depriv (FP)ADC Medically Needy (FP)LIF/SN/TL – CASH (FP)LIF/SN/TL – NC (FP)Page 6 of 24
Managed Care Reference Guide: Enrollee Rosters –AppendicesIndividual Disposition Status Code - Indicates whether recipient’s case is active orclosed. Valid code values dDeniedDeceasedDeletedCase ClosedMedicaid Exception Code - There are two occurrences of Recipient Restriction Exceptioncodes on the roster. The hierarchy below determines which code(s) appear on the rosterwhen a client has more than two te: The above list reflects the hierarchy as of June 2018.Medicare Code - Indicates the type of Medicare coverage for an enrollee.2 Part A,3 Part B,1 Both Part A and BVersion 2019 – 1 (2/1/2019)Page 7 of 24
Managed Care Reference Guide: Enrollee Rosters –AppendicesNote: Any enrollee with Medicare coverage in a mainstream managed care plan orspecial needs plan must be disenrolled prospectively (based on the pulldown dates).Health Insurance Claim Number (HICN) or MCR Number (MBI) – Enrollee’s MedicareNumberNote: Prior to June 2018, this field always displayed the HICN. As a result of CMS’ SocialSecurity Number Removal Initiative, HICN was replaced by MBI. For the transition periodof April 1, 2018 through December 31, 2019, a MBI or HICN may be displayed in this field.After December 31, 2019, the MBI will be displayed in this field, or a “MBI Pending”message will be displayed if an enrollee has Medicare but the MBI has not yet beenprovided.Benefit Package - Benefit package number according to the list below.BP code70717273747576777879809701-62, 66DescriptionFamily Health Plus *Note: FHP ended 12/31/2014Medicaid Advantage (NYC)Medicaid Advantage Plus (NYC)Medicaid Advantage (Upstate)Medicaid Advantage Plus (Upstate)PACEReserved for future use for MLTC PartialsFIDAHealth and Recovery Plan (OMH HARP)Reserved for Developmental Disabilities IndividualizedServices and Supports Coordination Organization (OPWDDPeople First Waiver)Reserved for FIDA-IDDPrepaid Mental Health PlanBenefit Package Code for County (all other programs notlisted above)Capitation Code – Indicates enrollment in plan. “3” enrolledPCP Begin Date – Enrollee’s most recent effective enrollment dateVersion 2019 – 1 (2/1/2019)Page 8 of 24
Managed Care Reference Guide: Enrollee Rosters –AppendicesRate Code and Derivation Chart - Four-digit code assigned during claims processingwhich represents enrollee’s age, sex and aid categories. This corresponds to the capitationpremium group. This field is suppressed for Special Needs, Medicaid Advantage, andIntegrated Care Plans.Case TypeAid CategoryAgeMonthsSexAgeYearRateCodeTANF/SN10, 11, 12,16, 17, 18, 19, 21, 23, 27, 31, 32,39, 43, 44, 45, 48, 49, 57, 58, 63, 67, 78, 79,81, 86, 90, 91, 92, H0, H1, P1, P2, P5, P7,P8, P910, 11, 12,16, 17, 18, 19, 21, 23, 27, 31, 32,39, 43, 44, 45, 48, 49, 57, 58, 63, 67, 78, 79,90, 91, 92, H0, H1 P1, P2, P5, P7, P8, P924, 25, 26, 50, 51, 52, 53, 54, 55, 60, 61, 62,82, 830-251M/F0-202201252-999M/F21 22050 - 999M/F0 2209TANF/SNSSIDefault (When theabove rules are notmet)FHP**FHP programended 12/31/14220068, 69, 70, 72228-785M/F19-652232Guarantee Date - The date through which capitation payments are guaranteed to the plan(calculated as 6 months subsequent to the initial enrollment date).Note: Guarantee Dates were no longer populated after 12/31/2013.Authorization Through Date - The date through which the enrollee is eligible for MedicaidbenefitsRecertification Date - The date of the onset of the recertification process for an enrollee.This date is available for New York City enrollees only.Transaction Date - The date of the most recent capitation transaction for the enrollee onfileCopay Exempt Flag – Indicates whether the enrollee is copay exemptExcess Income - The amount taken from enrollee’s current budget.Note: If the Family Indicator is 'F', all the AC clients on the roster with the same casenumber enrolled in the same plan will have same surplus amount on the surplusfield, but the provider should collect the surplus only once for the whole house hold.Version 2019 – 1 (2/1/2019)Page 9 of 24
Managed Care Reference Guide: Enrollee Rosters –AppendicesNote: This field will be populated only for MLTC program plans that have spenddown consumers.Family IndicatorI - There is only one AC client on the roster with a particular case number and no otheractive client on the roster with that same case number enrolled in the same planF - There are more than one AC client on the roster with the same case number enrolled inthe same plan.Insurance Code - Indicates any third-party insurance for which the enrollee is eligibleBegin Date – The date third-party insurance is applicableEnd Date – The date third-party insurance is terminatedNote: This section repeats twice in the roster.Reason Code – Code indicates reason recipient is enrolled1 Enrollment Override2 Voluntary Enrollment (all input methods)05 Mandatory7 Automated Enrollment of a Newborn8 HX to WMS Enrollment (Entry limited to State MC Staff Only)Fee FlagNew Indicator - Indicated for enrollees whose most recent enrollment effective date on fileis equal to the roster effective date.Version 2019 – 1 (2/1/2019)Page 10 of 24
Managed Care Reference Guide: Enrollee Rosters –AppendicesMonthly Managed Care Recipient Roster File LayoutRecordPositionsField NameFieldFrom ToSizeExplanation2 digit county/district code assigned by NYS to county of fiscal12Trans-Dist2responsibility for enrollee.Provider ID3108MMIS ID number of plan in which recipient is enrolled.Recipient IDFillerSSN111922182130839MMIS ID number of the enrollee.SpacesThe SSN of enrollee (Provider Rosters).The Worker Id of enrollee (County Rosters).Last name of enrollee.Last NameFirst NameMiddle InitialSex CodeLanguageRace/EthnicityDate of BirthCase reetCityStateZip CodeCare of 541591872222372393515252835152Street address of enrollee.Zip CodePhoneNumberCase NumberLoc OffExpirationDate240245244254510Zip code of person in care of enrollee.2552652682642672751038Case number assigned by County DSS.Version 2019 – 1 (2/1/2019)First name of enrollee.Middle initial of enrollee.Sex of enrollee.Language spoken.Race/EthnicityDate of birth of enrollee. MMDDCCYYName of the adult the assistance case is authorized under.City address of enrollee.State of enrollee.Zip Code of enrollee.Name of person in care of enrollee.Street address of person in care of enrollee.City address of person in care of enrollee.State address of person in care of enrollee.Phone number of person in care of enrolleeCode which indicates the local DSS office.The date the roster expires. MMDDCCYYPage 11 of 24
Managed Care Reference Guide: Enrollee Rosters –AppendicesRecordPositionsMedicaidCoverageAid CategoryCode2762761Code defining whether the recipient is eligible for servicesthrough a MC plan.2772782Defines the type of medical assistance for which the enrollee iseligible within the MA program. This code is used to derive therate code under which the capitation claim is paid.CategoryCode2792802Defines the category of assistance the enrollee's eligibility is basedon.IndividualDispositionStatus CodeState/FederalCharge careCodeMCR Number2812822Code indicating if recipient's case is active or closed.2832842Code indicating State/Federal charges that are in effect.2852862Code used to restrict types of medical services or to place processingconstraints which require claims review.2872882Same as above.2892891Indicates the type of Medicare coverage for the enrollee.29030112Benefit PkgCapitationCodePCP BeginDateRate Code30230430330421Benefit package number assigned to a plan.3053128Recipient's most recent effective enrollment date. CCYYMMDD31331644-digit code assigned during claims processing which representsthe age, sex, and aid category of enrollee and corresponds to thecapitation payment amount.GuaranteeDateAuthorizationDate3173248Date through which capitation payments are guaranteed to theplan. CCYYMMDD3253328Date through which enrollee is eligible for MA benefits (indicateswhen recertification is necessary). CCYYMMDDRecertificationDate3333408The date of the onset of the recertification process for an enrolleeVersion 2019 – 1 (2/1/2019)Enrollee's Medicare Number.Indicates recipient's enrollment/disenrollment in a plan. Always'03' for rosters.Page 12 of 24
Managed Care Reference Guide: Enrollee Rosters xempt FlagExcessIncome3413488The most recent transaction date for enrollee onfile. CCYYMMDD3493491Indicates if the client is co-pay exempt or not.10Values are 'Y' or 'N'.The amount taken from client’s current budget.350359Also, If the Family Indicator is 'F', all the AC clients on the rosterwith the same case number enrolled in the same plan will havesame surplus amount on the surplus field, but the provider shouldcollect the surplus only once for the whole house hold.Note: This field will be populated only for MLTC program plansthat have spend down consumers.Note: This field will be populated only for MLTC program plansthat have spend down ranceCodeBegin Date3723776Indicates any insurance for which the enrollee is eligible.3783858Date for which insurance was applicable. CCYYMMDDEnd Date3863938Date for which insurance was terminated. CCYYMMDDInsuranceCodeBegin DateEnd DateReason Code3943996Indicates any insurance for which the enrollee is eligible.400408416407415417882Date for which insurance was applicable. CCYYMMDDFee FlagFillerNew Indicator418420428419427428281For future use.SpacesDate for which insurance was terminated. CCYYMMDDCode indicating reason recipient enrolled/disenrolled.Spaces.Indicates this is first time recipient appears on roster.Monthly Managed Care Recipient Roster File Layout01PCP-ROS-HEADER.05 PCP-ROS-HDR-ID05 FILLERVersion 2019 – 1 (2/1/2019)PIC X(18).PIC X(44).Page 13 of 24
Managed Care Reference Guide: Enrollee Rosters -ELIG-END-DTPCP-ROS-HDR-CREATION-DT.10 PCP-ROS-HDR-CRT-CC10 PCP-ROS-HDR-CRT-YY10 PCP-ROS-HDR-CRT-MM10 PCP-ROS-HDR-CRT-DDPCP-ROS-HDR-EXP-DATE.10 PCP-ROS-HDR-EXP-MM10 PCP-ROS-HDR-EXP-DD10 PCP-ROS-HDR-EXP-CC10 PIC9(2).9(2).9(2).9(2).X(366).PCP-ROS-RECORD.05 PCP-ROS-927-TRANS-DISTPIC X(02).05 PCP-ROS-048-PROV-ID-NUMPIC X(08).05 PCP-ROS-010-CINPIC X(08).05 PCP-ROS-031-SSNPIC X(09).05 PCP-ROS-NAME.10 PCP-ROS-005A-LAST-NAMEPIC X(16).10 PCP-ROS-005B-FIRST-NAMEPIC X(10).10 PCP-ROS-005C-MIPIC X(01).05 PCP-ROS-012-SEXPIC X(01).05 PCP-ROS-010-DOB.15 PCP-ROS-DOB-MMP
A list of the County/District codes is provided in Appendix A and a list of Insurance Coverage codes can be found in Appendix B at the end of this document. These lists of codes will help you to interpret information included on your enrollee rosters. Questions about informatio
