4.
ELIGIBILITY AND VERIFICATION
A.
Eligibility Verification
1. Medicare DualChoice (HMO SNP)
APPLIES TO:
A.
This policy applies to all IEHP Medicare DualChoice (HMO SNP) Members.
POLICY:
A.
Accurate and timely eligibility information is a key concern of all participants in the IEHP
network and is a primary goal of IEHP.
B.
The IEHP Medicare DualChoice (HMO SNP) ID card, the Medi-Cal Benefit
Identification Card (BIC), and/or the Medicare Card do not guarantee eligibility. These
cards are issued for Member convenience and identification purposes only.
C.
Member eligibility should be verified at each visit.
PROCEDURE:
A.
IEHP receives data files including both eligibility and demographic data from the Centers
for Medicare and Medicaid Services (CMS).
B.
IEHP processes the eligibility data files received, assigns a PCP and Hospital to each
Member and updates Member demographic information.
C.
Recognizing that the network is comprised of Providers with existing systems employing
varying technologies, IEHP offers a number of methods for distributing eligibility
information to Providers and PCPs.
D.
Providers can receive updated eligibility information on Members through the following
methods:
1.
Eligibility files. Refer to Policy 4B1, “Eligibility Verification Methods Eligibility Files” for more information.
2.
IEHP’s Interactive Voice Response (IVR) system (888) 440-4340 or (909) 8903800. Refer to Policy 4B3, “Eligibility Verification Methods - Interactive Voice
Response (IVR)” for more information.
3.
IEHP website @ IEHP.org. Refer to Policy 4B5, “Eligibility Verification Methods
- Online Eligibility Verification System (OEVS).”
4.
State Automated Eligibility and Verification System (AEVS) (800) 456-2387 or
www.medi-cal.ca.gov/eligibility/login.asp. Refer to Policy 4B7, “Eligibility
Verification Methods - Other” for more information for State Program (Medi-Cal)
Members.
IEHP Provider Policy and Procedure Manual
Medicare DualChoice
07/14
MA_04A1.1
4.
F.
ELIGIBILITY AND VERIFICATION
A.
Eligibility Verification
1. Medicare DualChoice (HMO SNP)
5.
These methods offer Providers and PCPs different levels of detail in the
information reported for each Member. The information reported about the
Member may contain:
1.
Member Name
2.
IEHP Identification Number
3.
Birth date
4.
Gender (female or male)
5.
Member Address
6.
Member Phone Number
7.
Language Preference
8.
Status (member is currently active)
9.
Effective date of terminations or transfers
10.
Co-payment Information
11.
Aid Code
12.
County Code
13.
Plan or Program, e.g., Special Needs Program (SNP).
14.
Assigned PCP
15.
PCP effective date
16.
PCP Phone Numbers
17.
IPA Affiliation
18.
Assigned Hospital
19.
Claims billing address
When a Member visits his/her assigned PCP or Provider, the PCP/Provider should verify
eligibility before rendering services. In addition to verifying eligibility, the PCP/Provider
is encouraged to verify the Member’s identification through a secondary means, such as a
driver’s license or state identification with both a picture and signatures.
INLAND EMPIRE HEALTH PLAN
Chief Approval: Signature on file
Original Effective Date:
January 1, 2007
Chief Title: Chief Network Officer
July 1, 2013
Revision Date:
IEHP Provider Policy and Procedure Manual
Medicare DualChoice
07/14
MA_04A1.2
4.
ELIGIBILITY AND VERIFICATION
A.
Eligibility Verification –
2. IEHP DualChoice Cal MediConnect Plan(Medicare –
Medicaid Plan)
APPLIES TO:
A.
This policy applies to all IEHP DualChoice Cal MediConnect Plan (Medicare – Medicaid
Plan) Members.
POLICY:
A.
Accurate and timely eligibility information is a key concern of all participants in the IEHP
network and is a primary goal of IEHP.
B.
The IEHP DualChoice Cal MediConnect Plan (Medicare – Medicaid Plan) ID card, the
Medi-Cal Benefit Identification Card (BIC), and/or the Medicare Card do not guarantee
eligibility. These cards are issued for Member convenience and identification purposes
only.
C.
Member eligibility should be verified at each visit.
PROCEDURE:
A.
IEHP receives data files including both eligibility and demographic data from the
Department of Health Care Services (DHCS) and the Centers for Medicare and Medicaid
Services (CMS).
B.
IEHP processes the eligibility data files received, assigns a PCP and Hospital to each
Member and updates Member demographic information.
C.
Recognizing that the network is comprised of Providers with existing systems employing
varying technologies, IEHP offers a number of methods for distributing eligibility
information to Providers and PCPs.
D.
Providers can receive updated eligibility information on Members through the following
methods:
1.
Eligibility files. Refer to Policy 4B2, “Eligibility Verification Methods Eligibility Files” for more information.
2.
IEHP’s Interactive Voice Response (IVR) system (888) 440-4340 or (909) 8903800. Refer to Policy 4B4, “Eligibility Verification Methods - Interactive Voice
Response (IVR)” for more information.
3.
IEHP website @ IEHP.org. Refer to Policy 4B6, “Eligibility Verification Methods
- Online Eligibility Verification System (OEVS).”
4.
State Automated Eligibility and Verification System (AEVS) (800) 456-2387 or
www.medi-cal.ca.gov/eligibility/login.asp. Refer to Policy 4B4, “Eligibility
Verification Methods - Other” for more information for State Program (Medi-Cal)
Members.
IEHP Provider Policy and Procedure Manual
Medicare DualChoice
07/14
MA_04A2.1
4.
F.
ELIGIBILITY AND VERIFICATION
A.
Eligibility Verification –
2. IEHP DualChoice Cal MediConnect Plan(Medicare –
Medicaid Plan)
5.
These methods offer Providers and PCPs different levels of detail in the
information reported for each Member. The information reported about the
Member may contain:
1.
Member Name
2.
IEHP Identification Number
3.
Birth date
4.
Gender (female or male)
5.
Member Address
6.
Member Phone Number
7.
Language Preference
8.
Status (member is currently active)
9.
Effective date of terminations or transfers
10.
Co-payment Information
11.
Aid Code
12.
County Code
13.
Plan or Program, e.g., Special Needs Program (SNP).
14.
Assigned PCP
15.
PCP effective date
16.
PCP Phone Numbers
17.
IPA Affiliation
18.
Assigned Hospital
19.
Claims billing address
When a Member visits his/her assigned PCP or Provider, the PCP/Provider should verify
eligibility before rendering services. In addition to verifying eligibility, the PCP/Provider
is encouraged to verify the Member’s identification through a secondary means, such as a
driver’s license or state identification with both a picture and signatures.
IEHP Provider Policy and Procedure Manual
Medicare DualChoice
07/14
MA_04A2.2
4.
ELIGIBILITY AND VERIFICATION
A.
Eligibility Verification –
2. IEHP DualChoice Cal MediConnect Plan(Medicare –
Medicaid Plan)
INLAND EMPIRE HEALTH PLAN
Chief Approval: Signature on file
Original Effective Date:
July 1, 2013
Chief Title: Chief Network Officer
July 1, 2014
IEHP Provider Policy and Procedure Manual
Medicare DualChoice
Revision Date:
07/14
MA_04A2.3
4.
ELIGIBILITY AND VERIFICATION
B.
Eligibility Verification Methods
1.
Eligibility Files – Medicare DualChoice (HMO SNP)
APPLIES TO:
A.
This policy applies to all IEHP Medicare DualChoice (HMO SNP) Members.
POLICY:
A.
IEHP processes eligibility data, including assigning a PCP to each Member and updating
Member demographics.
B.
Eligibility files created for Providers only contain those Members assigned to the
Provider.
C.
IEHP places eligibility files for ancillary providers on the IEHP Secure File Transfer
Protocol (SFTP) server in accordance with the schedule published in the IEHP EDI
Manual (Provider Eligibility and Encounter File Format Requirements Manual).
D.
Member Eligibility rosters are available on the IEHP website at www.IEHP.org.
E.
It is the responsibility of each Provider to retrieve eligibility files within three days of file
transmission and update their eligibility system.
F.
If month end files are not loaded by the first of the month, providers must use alternative
IEHP methods to verify eligibility. Alternative methods include IEHP’s website,
www.iehp.org, the State’s Automated Eligibility Verification System (AEVS), and the
IVR. See Policy 4B7, “Eligibility Verification Methods – Other.”
PROCEDURE:
A.
All eligibility files are compressed (to save transmission time), encrypted (for security),
and password protected (additional security).
B.
By the first business day of each month, IEHP places a full eligibility file on the IEHP
SFTP server.
1.
IEHP supplies one copy of the decompression and decryption software necessary,
along with a password unique to each Provider, to read the files once retrieved.
2.
Each Provider must retrieve their eligibility files within three days of data file
transmission and upload them into the eligibility system in place at the Provider’s
location.
3.
If month end files are not loaded by the first of the month, providers must use
alternative IEHP methods to verify eligibility. Alternative methods include
IEHP’s website, www.iehp.org, the State’s Automated Eligibility Verification
System (AEVS), and the IVR. See Policy 4B7, “Eligibility Verification Methods
- Other.”
IEHP Provider Policy and Procedure Manual
Medicare DualChoice
07/14
MA_04B1.1
4.
ELIGIBILITY AND VERIFICATION
B.
C.
Eligibility Verification Methods
1.
Eligibility Files – Medicare DualChoice (HMO SNP)
The eligibility file contains important information about the Member including:
1. Eligibility status
2. Assigned PCP
3. Assigned Hospital
4. Effective date
5. Termination date (if applicable)
6. Address
7. Phone
8. Language preference
9. Birth date
10. Gender
11. Plan/Aid Code
12. County Code
13. Co-payment information
14. Capitation Rate
15. Medicare Type Coverage, i.e., Part A, Part B, Part AB and/or Part D.
(For more detailed information refer to the EDI Manual - Provider Eligibility and
Encounter File Format Requirements Manual.)
D.
Because Member eligibility changes frequently, IEHP provides periodic file updates
during the month. These file updates contain only changes within the Provider’s
network.
INLAND EMPIRE HEALTH PLAN
Chief Approval: Signature on file
Original Effective Date:
January 1, 2007
Chief Title: Chief Network Officer
July 1, 2012
Revision Date:
IEHP Provider Policy and Procedure Manual
Medicare DualChoice
07/14
MA_04B1.2
4.
ELIGIBILITY AND VERIFICATION
B.
Eligibility Verification Methods
2.
Eligibility Files – IEHP DualChoice Cal MediConnect
Plan (Medicare – Medicaid Plan)
APPLIES TO:
A.
This policy applies to all IEHP DualChoice Cal MediConnect Plan (Medicare – Medicaid
Plan) Members.
POLICY:
A.
IEHP processes eligibility data, including assigning a PCP to each Member and updating
Member demographics.
B.
Eligibility files created for Providers only contain those Members assigned to the
Provider.
C.
IEHP places eligibility files for ancillary providers on the IEHP Secure File Transfer
Protocol (SFTP) server in accordance with the schedule published in the IEHP EDI
Manual (Provider Eligibility and Encounter File Format Requirements Manual).
D.
Member Eligibility rosters are available on the IEHP website at www.IEHP.org.
E.
It is the responsibility of each Provider to retrieve eligibility files within three days of file
transmission and update their eligibility system.
F.
If month end files are not loaded by the first of the month, providers must use alternative
IEHP methods to verify eligibility. Alternative methods include IEHP’s website,
www.iehp.org, the State’s Automated Eligibility Verification System (AEVS), and the
IVR. See Policy 4B8, “Eligibility Verification Methods - Other.”
PROCEDURE:
A.
All eligibility files are compressed (to save transmission time), encrypted (for security),
and password protected (additional security).
B.
By the first business day of each month, IEHP places a full eligibility file on the IEHP
SFTP server.
1.
IEHP supplies one copy of the decompression and decryption software necessary,
along with a password unique to each Provider, to read the files once retrieved.
2.
Each Provider must retrieve their eligibility files within three days of data file
transmission and upload them into the eligibility system in place at the Provider’s
location.
3.
If month end files are not loaded by the first of the month, providers must use
alternative IEHP methods to verify eligibility. Alternative methods include
IEHP’s website, www.iehp.org, the State’s Automated Eligibility Verification
IEHP Provider Policy and Procedure Manual
Medicare DualChoice
07/14
MA_04B2.1
4.
ELIGIBILITY AND VERIFICATION
B.
Eligibility Verification Methods
2.
Eligibility Files – IEHP DualChoice Cal MediConnect
Plan (Medicare – Medicaid Plan)
System (AEVS), and the IVR. See Policy 4B8, “Eligibility Verification Methods
- Other.”
C.
The eligibility file contains important information about the Member including:
1. Eligibility status
2. Assigned PCP
3. Assigned Hospital
4. Effective date
5. Termination date (if applicable)
6. Address
7. Phone
8. Language preference
9. Birth date
10. Gender
11. Plan/Aid Code
12. County Code
13. Co-payment information
14. Capitation Rate
15. Medicare Type Coverage, i.e., Part A, Part B, Part AB and/or Part D.
(For more detailed information refer to the EDI Manual - Provider Eligibility and
Encounter File Format Requirements Manual.)
D.
Because Member eligibility changes frequently, IEHP provides periodic file updates
during the month. These file updates contain only changes within the Provider’s
network.
INLAND EMPIRE HEALTH PLAN
Chief Approval: Signature on file
Original Effective Date:
July 1, 2013
Chief Title: Chief Network Officer
July 1, 2014
Revision Date:
IEHP Provider Policy and Procedure Manual
Medicare DualChoice
07/14
MA_04B2.2
4.
ELIGIBILITY AND VERIFICATION
B.
Eligibility Verification Methods
3.
Interactive Voice Response (IVR) – Medicare
DualChoice (HMO SNP)
APPLIES TO:
A.
This policy applies to all IEHP Medicare DualChoice (HMO SNP) Members.
POLICY:
A.
IEHP offers the IEHP Interactive Voice Response (IVR) system for convenience in
verifying eligibility.
B.
The IVR is a commonly employed technology that uses a telephone to access Member
eligibility information.
C.
The IVR accesses IEHP’s computer system dynamically and provides the most current
information IEHP has on its Members. It is also helpful in determining if a co-payment is
due.
PROCEDURE:
A.
Member eligibility can be easily checked through the IVR 24 hours a day, seven days a
week by using the following information:
Example
1.
IEHP’s 14-digit Member Identification number
19961100000000
2.
Member social security number
123121234
3.
Member Medicare Claim Number (HICN)
12345678911
4.
Member 9-digit pseudo social security, with alpha character
12312123a
5.
Member 9-character alpha numeric CIN
12345678A
Note: If the social security number contains an alpha character, refer to Attachment “IVR
Alpha Characters” in Section 4.”
B.
The IVR can be accessed by dialing (888) 440-4340 or (909) 890-3800.
C.
The IVR system searches IEHP’s Member database for a record corresponding to the
number entered by the caller.
D.
When the record is found, the Member’s name, gender and birth date is supplied to verify
this is the Member that the Provider is calling for eligibility verification.
E.
The caller then has the option of verifying current eligibility or historical eligibility based
on the date entered into the phone via the touch-tone keys.
IEHP Provider Policy and Procedure Manual
Medicare DualChoice
07/14
MA_04B3.1
4.
ELIGIBILITY AND VERIFICATION
B.
F.
Eligibility Verification Methods
3.
Interactive Voice Response (IVR) – Medicare
DualChoice (HMO SNP)
Once the above have been entered, information and benefits about a Member available
through the IVR include:
1.
3.
5.
7.
9.
11.
13.
15.
17.
Name
Birth date
Gender
Plan or Program (Medi-Cal,
Open Access, Special Needs
Program, etc.)
Current Eligibility
Historical Eligibility
County Code
Aid Code
Effective Date
2.
4.
6.
8.
IEHP ID #
PCP
PCP’s telephone number
PCP’s IPA affiliation
10.
12.
14.
16.
18.
Member’s assigned Hospital
Co-Pay Information
Claims Billing Addresses
Verification Code
Member Medicare Claim
Number (HICN)
G.
The IVR also provides co-payment information.
H.
In addition, through the IVR the caller can check multiple dates of service, verify an
unlimited number of Members, check eligibility with identification numbers that have
alpha characters and obtain a verification code as proof of the transaction.
INLAND EMPIRE HEALTH PLAN
Chief Approval: Signature on File
Original Effective Date:
January 1, 2007
Chief Title: Chief Network Officer
Revision Date:
July 1, 2012
IEHP Provider Policy and Procedure Manual
Medicare DualChoice
07/14
MA_04B3.2
4.
ELIGIBILITY AND VERIFICATION
B.
Eligibility Verification Methods
4.
Interactive Voice Response (IVR) – IEHP DualChoice
Cal MediConnect Plan(Medicare – Medicaid Plan)
APPLIES TO:
A.
This policy applies to all IEHP DualChoice Cal MediConnect Plan (Medicare – Medicaid
Plan) Members.
POLICY:
A.
IEHP offers the IEHP Interactive Voice Response (IVR) system for convenience in
verifying eligibility.
B.
The IVR is a commonly employed technology that uses a telephone to access Member
eligibility information.
C.
The IVR accesses IEHP’s computer system dynamically and provides the most current
information IEHP has on its Members. It is also helpful in determining if a co-payment is
due.
PROCEDURE:
A.
Member eligibility can be easily checked through the IVR 24 hours a day, seven days a
week by using the following information:
Example
1.
IEHP’s 14-digit Member Identification number
19961100000000
2.
Member social security number
123121234
3.
Member Medicare Claim Number (HICN)
12345678911
4.
Member 9-digit pseudo social security, with alpha character
12312123a
5.
Member 9-character alpha numeric CIN
12345678A
Note: If the social security number contains an alpha character, refer to Attachment “IVR
Alpha Characters” in Section 4.
B.
The IVR can be accessed by dialing (888) 440-4340 or (909) 890-3800.
C.
The IVR system searches IEHP’s Member database for a record corresponding to the
number entered by the caller.
D.
When the record is found, the Member’s name, gender and birth date is supplied to verify
this is the Member that the Provider is calling for eligibility verification.
IEHP Provider Policy and Procedure Manual
Medicare DualChoice
07/14
MA_04B4.1
4.
ELIGIBILITY AND VERIFICATION
B.
Eligibility Verification Methods
4.
Interactive Voice Response (IVR) – IEHP DualChoice
Cal MediConnect Plan(Medicare – Medicaid Plan)
E.
The caller then has the option of verifying current eligibility or historical eligibility based
on the date entered into the phone via the touch-tone keys.
F.
Once the above have been entered, information and benefits about a Member available
through the IVR include:
1.
3.
5.
7.
9.
11.
13.
15.
17.
Name
Birth date
Gender
Plan or Program (Medi-Cal,
Open Access, Special Needs
Program, etc.)
Current Eligibility
Historical Eligibility
County Code
Aid Code
Effective Date
2.
4.
6.
8.
IEHP ID #
PCP
PCP’s telephone number
PCP’s IPA affiliation
10.
12.
14.
16.
18.
Member’s assigned Hospital
Co-Pay Information
Claims Billing Addresses
Verification Code
Member Medicare Claim
Number (HICN)
G.
The IVR also provides co-payment information.
H.
In addition, through the IVR the caller can check multiple dates of service, verify an
unlimited number of Members, check eligibility with identification numbers that have
alpha characters and obtain a verification code as proof of the transaction.
INLAND EMPIRE HEALTH PLAN
Chief Approval: Signature on file
Original Effective Date:
July 1, 2013
Chief Title: Chief Network Officer
Revision Date:
July 1, 2014
IEHP Provider Policy and Procedure Manual
Medicare DualChoice
07/14
MA_04B4.2
4.
ELIGIBILITY AND VERIFICATION
B.
Eligibility Verification Methods
5.
Online Eligibility Verification System (OEVS) –
Medicare DualChoice (HMO SNP)
APPLIES TO:
A.
This policy applies to all IEHP Medicare DualChoice (HMO SNP) Members.
POLICY:
A.
IEHP offers the IEHP Web Page for convenience in verifying Member eligibility.
B.
The IEHP Web Page is an efficient alternative source that enables providers to submit
multiple eligibility verification requests at the same time.
C.
The IEHP Eligibility Verification Web Page is a free-transaction service for providers,
which reduces the amount of time spent verifying Member eligibility through the IEHP’s
IVR system or contacting the IEHP Provider Services department.
PROCEDURE:
A.
Providers can log onto IEHP’s web page at www.iehp.org.
B.
To access the IEHP Web Page, providers need to contact IEHP Provider Relations Team
at (909) 890-2054 to receive a login ID, and be able to register online to access the
eligibility section of the web page.
C.
IEHP has created an Online Eligibility Verification System Training Manual to provide
instructions for using the online system (See Attachment, “OEVS Training Manual” in
section 4).
D.
Providers must meet the following system requirements in order to have access to the
IEHP website:
1. Computer with an Internet Connection.
2. A browser that supports 128 bit Encryption.
E.
Providers can access Member eligibility information through IEHP’s Web Page, 24 hours
a day, 7 days a week, including holidays.
IEHP Provider Policy and Procedure Manual
Medicare DualChoice
07/14
MA_04B5.1
4.
ELIGIBILITY AND VERIFICATION
B.
F.
The IEHP’s Web Page provides the following Member information:
1.
3.
5.
6.
G.
Eligibility Verification Methods
5.
Online Eligibility Verification System (OEVS) –
Medicare DualChoice (HMO SNP)
2.
4.
7.
8.
Effective Date with PCP
Eligibility Status
PCP ID
PCP Phone Number
9.
11.
12.
13.
Name
IEHP Identification Number
Social Security Number
Medicare Claim Number
(HICN)
Gender
Date of Birth
Assigned PCP
Assigned IPA
10.
14.
15.
16.
Assigned Hospital
Billing Addresses
17.
18.
Copay
Plan or Program (Special Needs Plan,
Medi-Cal, Healthy Kids, Open Access,
Medicare DualChoice (HMO SNP),
IEHP DualChoice Cal MediConnect Plan
(Medicare – Medicaid Plan), etc.)
Aid Code
County Code
Providers can use the following information to verify Member eligibility:
1.
Member Social Security Number (SSN)/Client Index Number (CIN)
2.
IEHP Member Identification Number
3.
Member Medicare Claim Identification Number (HICN)
4.
Member Last Name and Date of Birth
H.
Providers can check eligibility of up to 10 Members at once.
I.
Providers receive a verification number for every transaction using the Web Page.
J.
Providers can also access the IEHP formulary through the IEHP Web Page.
K.
Providers with any questions regarding the IEHP’s Web Page should call an IEHP
Provider Services Representative at (909) 890-2054.
INLAND EMPIRE HEALTH PLAN
Chief Approval: Signature on file
Original Effective Date:
January 1, 2007
Chief Title: Chief Network Officer
July 1, 2014
IEHP Provider Policy and Procedure Manual
Medicare DualChoice
Revision Date:
07/14
MA_04B5.2
4.
ELIGIBILITY AND VERIFICATION
B.
Eligibility Verification Methods
6.
Online Eligibility Verification System (OEVS) – IEHP
DualChoice Cal MediConnect Plan (Medicare –
Medicaid Plan)
APPLIES TO:
A.
This policy applies to all IEHP DualChoice Cal MediConnect Plan (Medicare – Medicaid
Plan) Members.
POLICY:
A.
IEHP offers the IEHP Web Page for convenience in verifying Member eligibility.
B.
The IEHP Web Page is an efficient alternative source that enables providers to submit
multiple eligibility verification requests at the same time.
C.
The IEHP Eligibility Verification Web Page is a free-transaction service for providers,
which reduces the amount of time spent verifying Member eligibility through the IEHP’s
IVR system or contacting the IEHP Provider Services department.
PROCEDURE:
A.
Providers can log onto IEHP’s web page at www.iehp.org.
B.
To access the IEHP Web Page, providers need to contact IEHP Provider Relations Team
at (909) 890-2054 to receive a login ID, and be able to register online to access the
eligibility section of the web page.
C.
IEHP has created an Online Eligibility Verification System Training Manual to provide
instructions for using the online system (See Attachment, “OEVS Training Manual” in
section 4).
D.
Providers must meet the following system requirements in order to have access to the
IEHP Website:
1. Computer with an Internet Connection.
2. A browser that supports 128 bit Encryption.
E.
Providers can access Member eligibility information through IEHP’s Web Page, 24 hours
a day, 7 days a week, including holidays.
IEHP Provider Policy and Procedure Manual
Medicare DualChoice
07/14
MA_04B6.1
4.
ELIGIBILITY AND VERIFICATION
B.
F.
The IEHP’s Web Page provides the following Member information:
1.
3.
5.
6.
G.
Eligibility Verification Methods
6.
Online Eligibility Verification System (OEVS) – IEHP
DualChoice Cal MediConnect Plan (Medicare –
Medicaid Plan)
2.
4.
7.
8.
Effective Date with PCP
Eligibility Status
PCP ID
PCP Phone Number
9.
11.
12.
13.
Name
IEHP Identification Number
Social Security Number
Medicare Claim Number
(HICN)
Gender
Date of Birth
Assigned PCP
Assigned IPA
10.
14.
15.
16.
Assigned Hospital
Billing Addresses
17.
18.
Copay
Plan or Program (Special Needs Plan,
Medi-Cal, Healthy Kids, Open Access,
Medicare DualChoice (HMO SNP),
IEHP DualChoice Cal MediConnect Plan
(Medicare – Medicaid Plan), etc.)
Aid Code
County Code
Providers can use the following information to verify Member eligibility:
1.
Member Social Security Number (SSN)/Client Index Number (CIN)
2.
IEHP Member Identification Number
3.
Member Medicare Claim Identification Number (HICN)
4.
Member Last Name and Date of Birth
H.
Providers can check eligibility of up to 10 Members at once.
I.
Providers receive a verification number for every transaction using the Web Page.
J.
Providers can also access the IEHP formulary through the IEHP Web Page.
K.
Providers with any questions regarding the IEHP’s Web Page should call an IEHP
Provider Services Representative at (909) 890-2054.
INLAND EMPIRE HEALTH PLAN
Chief Approval: Signature on file
Original Effective Date:
July 1, 2013
Chief Title: Chief Network Officer
July 1, 2014
Revision Date:
IEHP Provider Policy and Procedure Manual
Medicare DualChoice
07/14
MA_04B6.2
4.
ELIGIBILITY AND VERIFICATION
B.
Eligibility Verification Methods
7.
Other – Medicare DualChoice (HMO SNP)
APPLIES TO:
A.
This policy applies to all IEHP Medicare DualChoice (HMO SNP) Members.
POLICY:
A.
In addition to eligibility files and IEHP Interactive Voice Response (IVR), IEHP provides
other methods Providers and PCPs may use to verify Member eligibility outlined below:
PROCEDURE:
A.
Other methods to verify Member eligibility may include:
1.
AEVS - For Medi-Cal and Medicare DualChoice (HMO SNP) Members.
a.
Providers and PCPs can still utilize the State’s Automated Eligibility
Verification System (AEVS) to verify Member eligibility information.
AEVS is available via phone or the internet.
b.
AEVS identifies if an individual has Medi-Cal, Medicare Part A, Part B
and/or, Part D health benefits. If the individual has Medi-Cal benefits,
AEVS further identifies if the individual is enrolled in a Managed Care
Plan.
c.
If AEVS indicates that the individual has Medicare coverage, please call
IEHP’s IVR to determine the effective date of eligibility, type of coverage
available and whether or not the individual is an IEHP Member. AEVS
can be accessed by calling (800) 456-2387 or logging onto the AEVS
website at www.medi-cal.ca.gov/eligibility/login.asp.
d.
In order to access AEVS, the Provider needs to have an assigned Medi-Cal
Provider Identification Number (PIN), the individual’s Benefit
Identification Card (BIC) number, date the BIC was issued, and patient’s
date of birth. For AEVS Key Codes (See Attachments, “IVR Alpha
Characters” and “AEVS Alpha Codes” in section 4).
e.
To obtain a PIN number or to get assistance in using AEVS, please call the
EDS Provider Support Center at (800) 541-5555.
f.
If AEVS identifies an individual as a Member, but the IEHP IVR does not
confirm this information, please call IEHP’s Member Services at (800)
440-4347.
IEHP Provider Policy and Procedure Manual
Medicare DualChoice
07/14
MA_04B7.1
4.
ELIGIBILITY AND VERIFICATION
B.
Eligibility Verification Methods
7.
Other – Medicare DualChoice (HMO SNP)
INLAND EMPIRE HEALTH PLAN
Chief Approval: Signature on file
Original Effective Date:
January 1, 2007
Chief Title: Chief Network Officer
July 1, 2014
Revision Date:
IEHP Provider Policy and Procedure Manual
Medicare DualChoice
07/14
MA_04B7.2
4.
ELIGIBILITY AND VERIFICATION
B.
Eligibility Verification Methods
8.
Other – IEHP DualChoice Cal MediConnect Plan
(Medicare – Medicaid Plan)
APPLIES TO:
A.
This policy applies to all IEHP DualChoice Cal MediConnect Plan (Medicare – Medicaid
Plan) Members.
POLICY:
A.
In addition to eligibility files and IEHP Interactive Voice Response (IVR), IEHP provides
other methods Providers and PCPs may use to verify Member eligibility outlined below:
PROCEDURE:
A.
Other methods to verify Member eligibility may include:
1.
AEVS - For Medi-Cal and IEHP DualChoice Cal MediConnect Plan (Medicare –
Medicaid Plan) Members.
a.
Providers and PCPs can still utilize the State’s Automated Eligibility
Verification System (AEVS) to verify Member eligibility information.
AEVS is available via phone or the internet.
b.
AEVS identifies if an individual has Medi-Cal, Medicare Part A, Part B
and/or, Part D health benefits. If the individual has Medi-Cal benefits,
AEVS further identifies if the individual is enrolled in a Managed Care
Plan.
c.
If AEVS indicates that the individual has Medicare coverage, please call
IEHP’s IVR to determine the effective date of eligibility, type of coverage
available and whether or not the individual is an IEHP Member. AEVS
can be accessed by calling (800) 456-2387 or logging onto the AEVS
website at www.medi-cal.ca.gov/eligibility/login.asp.
d.
In order to access AEVS, the Provider needs to have an assigned Medi-Cal
Provider Identification Number (PIN), the individual’s Benefit
Identification Card (BIC) number, date the BIC was issued, and patient’s
date of birth. For AEVS Key Codes (See Attachments, “IVR Alpha
Characters” and “AEVS Alpha Codes” in section 4).
e.
To obtain a PIN number or to get assistance in using AEVS, please call the
EDS Provider Support Center at (800) 541-5555.
IEHP Provider Policy and Procedure Manual
Medicare DualChoice
07/14
MA_04B8.1
4.
ELIGIBILITY AND VERIFICATION
B.
Eligibility Verification Methods
8.
Other – IEHP DualChoice Cal MediConnect Plan
(Medicare – Medicaid Plan)
f.
If AEVS identifies an individual as a Member, but the IEHP IVR does not
confirm this information, please call IEHP’s Member Services at (800)
440-4347.
INLAND EMPIRE HEALTH PLAN
Chief Approval: Signature on file
Original Effective Date:
July 1, 2013
Chief Title: Chief Network Officer
July 1, 2014
Revision Date:
IEHP Provider Policy and Procedure Manual
Medicare DualChoice
07/14
MA_04B8.2
4.
ELIGIBILITY AND VERIFICATION
C.
Member Co-payments
1. Medicare DualChoice (HMO SNP)
APPLIES TO:
A.
This policy applies to all IEHP Medicare DualChoice (HMO SNP) Members.
POLICY:
A.
IEHP Medicare DualChoice (HMO SNP) Members may have a co-payment for
pharmaceuticals depending on their Low-Income Subsidy (LIS) level.
PROCEDURE:
A.
IEHP Members are issued an IEHP ID card that identifies the co-payment.
1. Medicare DualChoice (HMO SNP) Members have no co-pays, except for
prescriptions.
2. Since an IEHP ID card does not guarantee eligibility, practitioners must confirm
Member eligibility before collecting a co-payment as discussed in Policy 4A1,
“Eligibility Verification”. Additionally, practitioners are encouraged to verify
Members’ identification through secondary means, such as a driver’s license or state
ID card with both a picture and signature.
B.
C.
Members who present an IEHP ID card with co-payment amount listed as $0 will not be
charged a co-payment.
1.
Practitioners must confirm whether or not co-payments are required when
verifying eligibility even if the Member’s ID card does not indicate $0 for copayment.
2.
If the IEHP Interactive Voice Response (IVR) system states that no co-payments
are required, the practitioner should not collect a co-payment regardless of what
the IEHP ID card indicates.
While the Member is present, discrepancies regarding whether or not a co-payment is due
should be directed to IEHP Member Services (877) 273-4347.
INLAND EMPIRE HEALTH PLAN
Chief Approval: Signature on file
Original Effective Date:
January 1, 2007
Chief Title: Chief Network Officer
July 1, 2014
Revision Date:
IEHP Provider Policy and Procedure Manual
Medicare DualChoice (HMO SNP)
07/14
MA_04C1.1
4.
ELIGIBILITY AND VERIFICATION
C.
Member Co-payments
2. IEHP DualChoice Cal MediConnect Plan (Medicare –
Medicaid Plan)
APPLIES TO:
A.
This policy applies to all IEHP DualChoice Cal MediConnect Plan (Medicare – Medicaid
Plan) Members.
POLICY:
A.
IEHP DualChoice Cal MediConnect Plan (Medicare – Medicaid Plan) may have a copayment for pharmaceuticals depending on their Low-Income Subsidy (LIS) level.
PROCEDURE:
A.
IEHP Members are issued an IEHP ID card that identifies the co-payment.
1. IEHP DualChoice Cal MediConnect Plan (Medicare – Medicaid Plan) Members have
no co-pays, except for prescriptions.
2. Since an IEHP ID card does not guarantee eligibility, practitioners must confirm
Member eligibility before collecting a co-payment as discussed in Policy 4A2,
“Eligibility Verification”. Additionally, practitioners are encouraged to verify
Members’ identification through secondary means, such as a driver’s license or state
ID card with both a picture and signature.
B.
C.
Members who present an IEHP ID card with co-payment amount listed as $0 will not be
charged a co-payment.
1.
Practitioners must confirm whether or not co-payments are required when
verifying eligibility even if the Member’s ID card does not indicate $0 for copayment.
2.
If the IEHP Interactive Voice Response (IVR) system states that no co-payments
are required, the practitioner should not collect a co-payment regardless of what
the IEHP ID card indicates.
While the Member is present, discrepancies regarding whether or not a co-payment is due
should be directed to IEHP Member Services (877) 273-4347.
IEHP Provider Policy and Procedure Manual
Medicare DualChoice
07/14
MA_04C2.1
4.
ELIGIBILITY AND VERIFICATION
C.
Member Co-payments
2. IEHP DualChoice Cal MediConnect Plan (Medicare –
Medicaid Plan)
INLAND EMPIRE HEALTH PLAN
Chief Approval: Signature on file
Original Effective Date:
July 1, 2013
Chief Title: Chief Network Officer
July 1, 2014
IEHP Provider Policy and Procedure Manual
Medicare DualChoice
Revision Date:
07/14
MA_04C2.2
4.
ELIGIBILITY AND VERIFICATION
Attachments
DESCRIPTION
IVR Alpha Characters
AEVS Alpha Codes
OEVS Training Manual
Eligibility Data File Transmission Schedule
Eligibility Data File Format
IEHP Provider Policy and Procedure Manual
Medicare DualChoice
POLICY CROSS
REFERENCE
4B2
4B4
4B3
07/14
MA_04.1
Attachment - IVR Alpha Characters
How to enter an alpha character when using the IVR
To enter an alphabetic character, press the Star (*) key followed by the number that corresponds
to the alpha character on the key pad, followed by the number (1,2 or 3) to indicate the position
of the alpha character on the key. For example, the letter (K), would be entered Star (*), 5, 2.
Q
11
Z
12
A
21
1
G
41
H
42
R
72
C
23
D
31
2
I
43
J
51
4
P
71
B
22
K
52
T
81
U
82
F
33
3
L
53
M
61
5
S
73
E
32
N
62
O
63
6
V
83
W
91
X
92
7
8
9
*
0
#
Y
93
A
B
C
D
E
F
G
H
I
J
K
L
M
=
=
=
=
=
=
=
=
=
=
=
=
=
*21
*22
*23
*31
*32
*33
*41
*42
*43
*51
*52
*53
*61
N
O
P
Q
R
S
T
U
V
W
X
Y
Z
=
=
=
=
=
=
=
=
=
=
=
=
=
*62
*63
*71
*11
*72
*73
*81
*82
*83
*91
*92
*93
*12
Attachment - AEVS Alpha Codes
Quick Reference for AEVS Alphabetic Codes
(Please refer to Section 100-54, Automated Eligibility
Verification System (AEVS) for more information.)
Alphabetic Code Listing
Press * before entering the two-digit code
Q
11
Z
12
A
21
1
G
41
H
42
R
72
C
23
D
31
2
I
43
J
51
K
52
S
73
T
81
U
82
E
32
F
33
3
L
53
M
61
5
4
P
71
B
22
N
62
O
63
6
V
83
W
91
X
92
7
8
9
*
0
#
Y
93
AEVS: 1-800-456-AEVS (2387)
LETTER
2-DIGIT CODE
A
B
C
D
E
F
G
H
I
J
K
L
M
* 21
* 22
* 23
* 31
* 32
* 33
* 41
* 42
* 43
* 51
* 52
* 53
* 61
Keys
#
*#
**
* 99 #
LETTER
N
O
P
Q
R
S
T
U
V
W
X
Y
Z
Function Keys
2-DIGIT CODE
* 62
* 63
* 71
* 11
* 72
* 73
* 81
* 82
* 83
* 91
* 92
* 93
* 12
Purpose
End data entry in a field; proceed to next field
Repeat the menu option
Delete the current data entry in a field
Return to the main menu
Attachment - OEVS Training Manual
IEHP Online Eligibility Verification System (OEVS)
IEHP encourages the use of our OEVS for quick verification of Member eligibility. This
new verification system will assist your office and IEHP in accomplishing our joint goal
of delivering the highest quality of health care to our Members. Listed below are a few
benefits of using the OEVS:
Available 24 Hours a Day, 7 Days a Week, Including Holidays.
Eliminates Telephone Wait Times.
Ability to Submit Multiple Queries at the Click of a Button.
Print Verifications from your Computer.
There are several different search options to choose from to verify the Member’s
eligibility:
Social Security Number (SSN)/Client Index Number (CIN)
o Submit up to 10 requests at one time
IEHP Identification Number
o Submit up to 10 requests at one time
Last Name and Date of Birth
o Single search only
Please note that the OEVS is a means to verify Member eligibility only and does not
issue authorizations for services.
System Requirements Include:
1. Computer with an Internet Connection.
2. A browser that will support 128 bit Encryption.
3. A browser to accept Cookies.
4. Printer (Optional)
Access to OEVS requires your Provider ID and a password. If you do not have a Login
ID and Password, you can register online by clicking the “Secure Site Login” and then
clicking “Register for a Login.” For further assistance, please call your Provider Services
Representative or call (909) 890-2054.
Page -1-
Attachment - OEVS Training Manual
LOGIN
To Login to IEHP’s OEVS, follow the steps below:
Steps
1. From your internet browser, go to http://www.iehp.org. This will bring up
IEHP’s home page.
2. Click the PROVIDERS button from the left hand menu.
3. From the bulleted list on the Provider Page, click the Secure Site Login option.
a. Enter your Login ID and Password.
4. Once you have successfully logged into the IEHP Provider Website, click the
“Eligibility” button on the toolbar located on the left hand side of the page.
5. You are now logged in to the Eligibility Verification System. If you receive an
error message, please check your ID number and Password for accuracy. If you
continue to receive an error message, call your Provider Service Representative
for Assistance.
6. If you do not have a Login ID and Password, you can register online by clicking
the button in the center of the screen.
Page -2-
Attachment - OEVS Training Manual
Search by SSN/CIN
To search by SSN/CIN, follow the steps below:
Steps
1. Click on the Eligibility button on the toolbar located on the left-hand side of the
screen.
2. Click the SSN/CIN button on the toolbar located on the left-hand side of the
screen.
3.
Enter up to 10
SSNs or CINs.
You may enter a
different DOS for
each.
Click Submit
4. When you have completed your session, please remember to click the Log Off
button located on the left-hand side of the screen.
Page -3-
Attachment - OEVS Training Manual
Search by IEHP Identification Number
To Search by IEHP ID, follow the steps below:
Steps
1. Click on the IEHP ID button on the toolbar located on the left-hand side of the
screen.
2.
Enter up to
10 IEHP
ID
Numbers.
You may
enter a
different
DOS for
each
number
entered.
Click Submit
3. When you have completed your session, please remember to click the Log Off
button located on the left-hand side of the screen.
Page -4-
Attachment - OEVS Training Manual
Search by Last Name and Date of Birth
To Search by Last Name and Date of Birth, follow the steps below:
Steps
1. Click the LAST NAME button on the toolbar located on the left-hand side of the
screen.
2.
Enter the
Member’s
DOB and
Last Name.
DOB must
be in the
following
format:
07/01/2000
.
Click Submit
3. When you have completed your session, please remember to click the Log Off
button located on the left-hand side of the screen.
Page -5-
Attachment - Eligibility Data File Transmission Schedule
ELIGIBILITY PROCESSING PROCEDURES
Eligibility Data File Transmission Schedule
The following schedule outlines when eligibility files are available to providers for review. Eligibility files
must be picked up within three days of file transmission.
RUN DATE
FIRST
WEEKLY
Eligibility File
(updates only)
RUN DATE
SECOND
WEEKLY
Eligibility File
(updates only)
RUN DATE
THIRD
WEEKLY
Eligibility File
(updates only)
RUN DATE
Jan 2014
01/01/2014
01/10/2014
01/17/2014
01/24/2014
Feb 2014
02/01/2014
02/10/2014
02/17/2014
02/25/2014
Mar 2014
03/01/2014
03/10/2014
03/17/2014
03/25/2014
Apr 2014
04/01/2014
04/10/2014
04/17/2014
04/25/2014
May 2014
05/01/2014
05/09/2014
05/16/2014
05/23/2014
Jun 2014
06/01/2014
06/10/2014
06/17/2014
06/25/2014
Jul 2014
07/01/2014
07/10/2014
07/17/2014
07/25/2014
Aug 2014
08/01/2014
08/11/2014
08/18/2014
08/25/2014
Sep 2014
09/01/2014
09/10/2014
09/17/2014
09/25/2014
Oct 2014
10/01/2014
10/10/2014
10/17/2014
10/24/2014
Nov 2014
11/01/2014
11/10/2014
11/17/2014
11/25/2014
Dec 2014
12/01/2014
12/10/2014
12/17/2014
12/23/2014
Jan 2015
01/01/2015
01/09/2015
01/16/2015
01/26/2015
Calendar
Month
MONTHLY
Eligibility File
(full file)
Att – Eligibility Data File Format
#
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
DATA ELEMENT
PCP ID
PCP Name
Current Eligibility Status Code
Effective Date
Termination Date
Group
Aid Code
Subscriber ID #
Last Name
First Name
Middle Initial
Date of Birth
Gender
Race Code
Ethnicity Code
Language Code - Spoken
Language Code – Written
Phone Number
Alternative Phone Number
C/O Address
Street Address
City/State
Zip Code + 4
Mailing C/O Address (Pending)
Mailing Street Address (Pending)
Mailing City/State (Pending)
Mailing Zip Code + 4 (Pending)
T
Y
P
E
A
A
A
N
N
A
A
A
A
A
A
N
A
A
A
A
A
N
N
A
A
A
A
A
A
A
A
28
Social Security Number
A
Eligibility Data File Format
P
O
S
1
8
38
39
47
55
65
67
81
96
106
107
115
116
117
119
120
122
132
142
168
194
220
229
255
281
307
B
Y
T
E
S
7
30
1
8
8
10
2
14
15
10
1
8
1
1
2
1
2
10
10
26
26
26
9
26
26
26
9
FORMAT
AXX9999
X(30)
X
CCYYMMDD
CCYYMMDD
X(10)
X(2)
CCYYMMX(8)
X(15)
X(10)
X
CCYYMMDD
X
X
X(2)
X
X
X(10)
X(10)
X(26)
X(26)
X(26)
X(9)
X(26)
X(26)
X(26)
X(9)
316
9
X(9)
DESCRIPTION
IEHP assigned PCP code. A=IPA, XX=Hospital, 9999=PCP code
Provider Name
Represents status of eligibility (see note # 3)
The effective date the Member was with this PCP (see note # 4)
The date the Member was terminated from this PCP (see note # 5)
The group for this Member (see note # 6)
Identifies Member's aid code. (See note # 7)
The IEHP assigned # for the Member (see note # 8)
Member Last Name
Member First Name
Member Middle Initial
Member date of birth
M= Male or F= Female
Identifies race of Member (see note # 14)
Identifies ethnicity of Member (see note # 15)
Identifies spoken language of Member (see note #16)
Identifies written language of Member (see note # 17)
Identifies Member 10 character phone number. Example 9094302752
Member Alternative Phone Number Example 9094302752 (see note # 19)
Member C/O address
Member Street address
Member City and State
Member Zip Code
Member Mailing C/O address (Field will be passed but may not contain data)
Member Mailing Street address (Field will be passed but may not contain data)
Member Mailing City/State (Field will be passed but may not contain data)
Member Mailing Zip Code (Field will be passed but may not contain data)
This field consists of one of the following: SSN#, PSEUDO# or Blank (see
note # 28)
Revision Date: 02/24/2014
Page 1 of 14
Att – Eligibility Data File Format
29
Previous Social Security Number
A
325
9
X(9)
30
31
32
33
34
35
36
CIN#
Medicare Number
Alternate ID #
Prior Alternate ID #
Part D
Copay
PHP Status Code
A
A
A
A
A
A
A
334
343
355
369
383
384
385
9
12
14
14
1
1
2
X(9)
X(12)
CCAAX(10)
CCAAX(10)
X
X
X(2)
37
Previous PCP code
A
387
7
AXX9999
38
39
Capitation Rate
Previous Subscriber ID #
N
394
401
7
14
X(7)
CCYYMMX(8)
40
IEHP PROV ID
A
415
9
AAAXX9999
41
42
43
44
45
LTSS CBAS Indicator
LTSS IHSS Indicator
LTSS LTC Indicator
LTSS MSSP Indicator
FILLER
A
A
A
A
N
424
425
426
427
428
1
1
1
1
133
X
X
X
X
TOTAL RECORD SIZE
Eligibility Data File Format
This field consists of the previous SSN# as identified above or blank (see note
#29)
CIN# (see notes#30)
Health Insurance Number (HICN) (See note # 31)
Medicaid # for dual eligible’s (see note # 32)
Medicaid # for dual eligible’s (see note # 33)
Identifies if Member is active with Medicare Part D (see note # 34)
Identifies if copay exists. Y = Yes or N = No (see note # 35)
Health Plan Status Code (See note # 36)
IEHP assigned PCP code. A=IPA, XX=Hospital, 9999=PCP code (See note #
37)
Category (See note#38)
The previous IEHP assigned # for the Member (see note # 39)
Assigned IEHP Provider ID. AAA=IPA, XX=Hospital, 9999=Sequential ID
number (See note #40)
This field passes the LTSS CBAS Indicator coverage (See note #41-44)
This field passes the LTSS IHSS Indicator coverage (See note #41-44)
This field passes the LTSS LTC Indicator coverage (See note #41-44)
This field passes the LTSS MSSP Indicator coverage (See note #41-44)
Spaces from position 428 through 561
561
Revision Date: 02/24/2014
Page 2 of 14
NOTES:
Data Element
Element:
Note #3:
3
CURRENT ELIGIBILITY STATUS CODE
This code can be an A, C, T, or N:
A = Active (on weekly and monthly files) identifies existing Members or Members who were part of your organization
last month.
C = Change (on both weekly and monthly updates) identifies Members who have demographic changes or have changed
PCPs, but remain assigned to your organization.
T = Termed (on both weekly and monthly updates) identifies Members who are no longer assigned to your organization.
N = New (on both weekly and monthly updates) identifies Members who are newly assigned to your organization.
NOTE: Members who are not included in the IEHP monthly eligibility file who are active in the health plan’s
membership database are not eligible for the new month and should be disenrolled effective the first day of the current
month.
Element:
Note #4:
4
EFFECTIVE DATE
Effective Date Logic – Applies to both Daily and Monthly Files
1. If the member is active (status “A”), the Effective Date could be any date of the month since the HK members can be
effective any date of the year, including holidays and weekends.
2. If the member is Disenrolled/Termed (status “T”), the Effective Date will show the same date as the “Termination
Date”.
See “Term Date Logic” section below.
3. Effective Date field showing a date prior to the current date is due to demographic and/or Provider Changes.
4. Members are still active and new demographic information must be updated in the provider’s member database.
5. HK effective dates might look like 20110115, since HK members can become eligible any day of the month.
Eligibility Data File Format
Revision Date: 02/24/2014
Page 3 of 14
Element:
Note #5:
5
TERMINATION DATE
Term Date Logic – Applies to both Daily and Monthly Files
1. This field should always be populated with a date.
2. If it is an “Active” record noted with an “A”, the Term date is defaulted to the last day of the month being reported.
For instance, if the Effective date is 20120901 then the Term Date shows 20120930.
3. If it is a disenrollment record noted with a “T”, the Term Date and Effective Date are set to the last day of the month
when the member was active. For instance, if member is disenrolled effective 20121201, then both Effective date and
Term Date fields show 20111130.
4. Once a member is sent as a brand new member in a daily file, in the subsequent monthly file, the member’s effective
date is sent as the 1st of the new month. For instance, if the member was submitted with an active eligibility status with
the effective date of 20121103 in the daily file, the member will be sent in the December 2012 file with the Effective
Date of 20121201.
Element:
Note #6:
6
GROUP
MEDI-CAL
RIVERSIDE
RVC-FAMILY
RVC-ADULT
RVC-AGED
RVC-DISABLED
RVC- NONCVR (*)
RVC-TLICH
HEALTHY KIDS
RIVERSIDE
RVC-HKI
RVC-HKC
IEHP DUALCHOICE
RIVERSIDE
RVC-SNPMD**
RVC-SNPMO**
SAN BERNARDINO SAN BERNARDINO
SBC-HKI
SBC-SNPMD**
SBC-HKC
SBC-SNPMO**
MEDI-CAL
EXPANSION
RIVERSIDE
RVC-ADLTMI
RVC-FAMIMI
RVC-TLICMI
SAN BERNARDINO
SBC-ADLTMI
SBC-FAMIMI
SBC-TLICMI
SAN BERNARDINO
SBC-FAMILY
SBC-ADULT
SBC-AGED
SBC-DISABLED
SBC- NONCVR (*)
SBC-TLICH
(**) XXX-SNPMD = IEHP for Medi-Cal and Medicare DualChoice; XXX-SNPMO = IEHP Medicare Only
Eligibility Data File Format
Revision Date: 02/24/2014
Page 4 of 14
Element:
Note #6:
6
GROUP CONT’D
Duals Coordinated Care Initiative (CCI)
Medi-Cal Only with LTSS
RIVERSIDE
RVC-MOLTSS
RVC-MPLTSS
RVC-MBLTSS
RVC-MTLTSS
Cal MediConnect
Medicare DualChoice (Medicare – Medicaid Plan)
RIVERSIDE
RVC-CMCMD
RVC-CMCMO
RVC-CMCMT
SAN BERNARDINO
SBC-MOLTSS
SBC-MPLTSS
SBC-MBLTSS
SBC-MTLTSS
SAN BERNARDINO
SBC-CMCMD
SBC-CMCMO
SBC-CMCMT
Eligibility Data File Format
Revision Date: 02/24/2014
Page 5 of 14
Element:
Note #7:
7
AID CODE
Medi-Cal – The following aid codes are covered by IEHP
MEDI-CAL AID CODES*
Mandatory
Child
Family
Disabled**
Aged**
Disabled
(TLICH)***
01
3M
20 6V
10
5C
0N
6J
14
5D
02
3N
24
0P
6N
16
H1
08
3P
26
0W
6P
1E
H2
1H
H3
0A
3R
2E
20
6V
H4
30
3U
2H
24
H5
32
3W
36
26
Voluntary****
Adult
86
Family
03
4G
04
4H
06
4K
07
4L
10
4N
14
4S
33
47
60
2E
16
4T
34
59
64
2H
1E
4W
35
7A
66
36
1H
5K
38
7X
6A
60
40
3A
72
6C
64
42
3C
8P
6E
66
43
3E
8R
6G
6A
45
3F
82
6H
6C
46
3G
K1
6J
6E
49
3H
6N
6G
4A
3L
6P
6H
4F
*Medi-Cal recipients residing in the Two-Plan Model area, must enroll with IEHP or the Mainstream Plan.
**Mandatory for Non-Duals, Non-Mandatory for Dual-Eligible members.
Eligibility Data File Format
Revision Date: 02/24/2014
Page 6 of 14
***TLICH: Targeted Low-Income Children
****Non-mandatory means these Medi-Cal recipients may elect to join IEHP, but are not required by the State to enroll.
Healthy Kids – The following aid codes are covered by IEHP
00
Cal MediConnect
Medicare DualChoice (Medicare – Medicaid Plan)
Medicare DualChoice (HMO SNP)
IEHP Medicare DualChoice and
IEHP Medi-Cal
IEHP Medicare DualChoice and Fee
For Services Medi-Cal
IEHP Medicare DualChoice and No
Medi-Cal
MD
MF
MN
MD
Medicare DualChoice and IEHP Medi-Cal
MF
IEHP Medicare DualChoice and Fee For Services Medi-Cal
MN
IEHP Medicare DualChoice and No Medi-Cal
MT
Opt-out/Medicare FFS – Medi-Cal with IEHP
Medi-Cal Expansion
Voluntary
Mandatory
Element:
Note #8:
Adult
Child
L1
M1
T1
T2
T3
T4
T5
E7
M5
Family
39
4M
54
59
E2
E5
M3
M7
P5
P7
P9
Adult
Family
7U
4M
7J
7W
8
SUBSCRIBER ID #
The Subscriber ID # is the IEHP assigned number for each Member. An example of a Subscriber ID # is 201101000001,
a Medicare Subscriber ID# ends in 00. Ex 20110100000100.
Eligibility Data File Format
Revision Date: 02/24/2014
Page 7 of 14
Element: 14
Note #14: RACE CODE*
1 - White
A – Amerasian
2 - Hispanic
C – Chinese
3 - Black
H – Cambodian
4 - Other Asian or Pacific Islander
J – Japanese
5 - Alaskan Native or American Indian
K – Korean
6 - Not a Valid value
M – Samoan
7 - Filipino
N – Asian Indian
8 - No Valid Data Reported (MEDS generated)
P – Hawaiian
*Race Code is not a required Healthy Kids Field and may be blank.
Element: 15
Note #15: ETHNICITY CODE*
1 - White
2 - Hispanic
3 - Black
4 - Other Asian or Pacific Islander
5 - Alaskan Native or American Indian
6 - Not a Valid value
7 - Filipino
8 - No Valid Data Reported (MEDS generated)
9 – Not Reported
A – Amerasian
AA – African-American
AG – Argentinean
AR – Arab
AI – American
AM – Armenian
BG – Bangladeshi
BZ – Brazilian
C – Chinese
Eligibility Data File Format
CL – Chilean
CO – Colombian
CR – Costa Rican
CU – Cuban
EE – Eastern European
ET – Ethiopian
EU – Ecuadorian
GT – Guatemalan
H – Cambodian (Khmer)
HM – Hmong
HT – Haitian
ID – Indonesian
IQ – Iraqi
IR – Iranian
J – Japanese
LT – Latino
M – Samoan
MX – Mexican
N – Asian Indian (India)
Revision Date: 02/24/2014
R – Guamanian
T – Laotian
U – Unknown
V – Vietnamese
X – Multiple Race
Z – Other
NC – Nicaraguan
OL – Other Latino
P – Hawaiian
PK – Pakistani
PR – Puerto Rican
PU – Peruvian
R – Guamanian
RS – Russian
SA – South American
SL – Sri Lankan
SV – Salvadoran
T – Laotian
TA – Thai
TN – Trinidadian
TW – Taiwanese (Chinese)
V – Vietnamese
WE – Western European
Z – Other
Page 8 of 14
*Ethnicity code is not a required Healthy Kids Field and may be blank.
Element:
Note #16:
16
LANGUAGE CODE – SPOKEN*
0 - American Sign Language C - Other Chinese Languages
1 – Spanish
D – Cambodian
2 – Cantonese
E – Armenian
3 – Japanese
F – Ilacano
4 – Korean
G – Mien
5 – Tagalog
H – Hmong
6 - Other non-English
I – Lao
7 – English
J – Turkish
8 - No valid data reported
K – Hebrew
9 – No valid data reported
L – French
A - Other Sign Language
B – Mandarin
M – Polish
N – Russian
O - Default to 0 (zero)
P – Portuguese
Q – Italian
R – Arabic
S – Samoan
T – Thai
U – Farsi
V – Vietnamese
*Language code – Spoken is not a required Healthy Kids Field and may be blank.
Eligibility Data File Format
Revision Date: 02/24/2014
Page 9 of 14
Element:
Note #17:
17
LANGUAGE CODE – WRITTEN
7S – English Standard
7B – English Braille
7C – English Audio - Cassette
7D – English Audio – CD
7E – English Electronic
7L – English Large Print
1S – Spanish Standard
1B – Spanish Braille
1C – Spanish Audio – Cassette
1D – Spanish Audio – CD
1E – Spanish Electronic
1L - Spanish Braille
Language code - Written is not a required Healthy Kids Field and may be blank.
Element:
Note #19:
19
ALERNATIVE PHONE NUMBER
This field may be blank.
Element:
Note
#24-27:
24-27
Element:
Note #28:
MEMBER MAILING ADDRESS
This data will be provided at a later date. IEHP will be adding mailing address information at
a later date.
28
SOCIAL SECURITY NUMBER*
This field is not required and may be blank.
For Medi-Cal and or Medicare Members, this field consists of one:
1. SSN- Member SSN or
Eligibility Data File Format
Revision Date: 02/24/2014
Page 10 of 14
2. PSEUDO- This number appears in this field if no SSN is available as provided by
Medical. First digit begins with the number "8 or 9" and ends with a letter.
3. May be blank
For Healthy Kid members, this field will be blank.
*SSN is not a required Healthy Kid field.
Element:
Note #29:
29
PREVIOUS SOCIAL SECURITY NUMBER
Previous SSN - Member previous SSN if available or may be blank.
Element
Note #30:
30
CIN #
The Member ID # is a 9 digit alphanumeric Client Index Number (CIN #).
For Healthy Kids, the Member ID# is a 9-digit number in the format HK####### (IEHP ID number). First two
digits begin with “HK”.
For Medicare members this field may be blank.
Element:
Note #31:
31
MEDICARE NUMBER
Members who are eligible for DualChoice for the current month have the HICN displayed in this field.
Element:
Note #32:
32
ALTERNATE ID #
Medi-Cal and Medicare Members: The Member ID # is a 14 digit Medi-Cal # in the format of CC = County Code,
AA = Aid Code, X = “9” + SSN or X = Case #, Family Budget Unit, and Person #.
For Healthy Kids, the Member ID# is a 9-digit number in the format HK####### (IEHP ID number). First two
digits begin with “HK”.
Eligibility Data File Format
Revision Date: 02/24/2014
Page 11 of 14
Element:
Note #33:
33
PRIOR ALTERNATE ID #
Medicare Members: The Member ID # is a 14 digit Medi-Cal # in the format of CC = County Code, AA = Aid Code,
X = “9” + SSN or X = Case #, Family Budget Unit, and Person #.
Member ID # may be blank.
For Healthy Kids, the Member ID# is a 9-digit number in the format HK####### (IEHP ID number). First two
digits begin with “HK”.
Member ID # may be blank.
Element:
Note #34:
34
PART D
If Member is active with Medicare Part D, it is indicated with a “D”. If Healthy Kids member this field will be blank.
Element:
Note #35:
35
COPAY
COPAY is presented as a Y or N. Y = Copay due from Member. N = No copay due from Member.
Element:
Note #36:
36
PHP STATUS CODE
MEDI-CAL
01 –Active Enrollment
S1 – Active Enrollment– Activated from hold Retroactive
51 - Active Enrollment – Activated from hold
05 - Enrollment Held – Due to Medi-Cal hold
55 - Enrollment Held – Uncertified Share of Cost
59 - Enrollment Held – Due to change in recipient’s status other than Medi-Cal hold.
00 - Voluntary Disenrollment
10 – Voluntary Disenrollment
40 - Voluntary Disenrollment – Occurred before enrollment became effective
S0 - Voluntary Disenrollment – Retroactive
09 - Mandatory Disenrollment
19 - Mandatory Disenrollment
49 – Mandatory Disenrollment - Occurred before enrollment became effective
Eligibility Data File Format
Revision Date: 02/24/2014
Page 12 of 14
S9 - Mandatory Disenrollment – Retroactive
P4 - Pending Enrollment
HEALTHY KIDS
28 - Active - Initial Enrollment
20 - Active - Change or Reinstatement
22 – Active – Change Dental/Vision Plan
43 – Active – Address change
XT – Active – Change Dental/Vision Plan
03 - Cancellation/ Termination due to death
07 - Cancellation/ Termination of benefits
14 - Voluntary Disenrollment
MEDICARE DUALCHOICE
01 – Active Enrollment
61 – Active Enrollment – Enrollment Verified by CMS
05 – Enrollment Held – Pending Enrollment Verification
00 – Voluntary Disenrollment
09 – Mandatory Disenrollment
Element:
Note #37:
37
PREVIOUS PCP CODE
This is populated if the eligibility status code is a C which indicates the previous provider if in the same IPA.
Element:
Note #38:
38
CAPITATION RATE
Member capitation rate is based on Member Aid Code Category as indicated on Note#6. For more details on the
capitation rate please refer to your IEHP Capitated Agreement.
Element:
Note #39:
39
PREVIOUS SUBSCRIBER #
Under specific circumstances we may have events that require us to change a member's primary ID number. In the
event that this occurs this field will be populated with the original IEHP Subscriber ID number for reference
purposes and field 8 will hold a new IEHP Subscriber ID Number.
Eligibility Data File Format
Revision Date: 02/24/2014
Page 13 of 14
Element:
Note #40:
40
IEHP PROV ID
The IEHP Provider ID replaces the PCP ID indicated in Field #1effective 06/01/2013.
Element:
Note #4144:
41-44
LTSS
This field passes the Long Term Services and Supports (LTSS) coverage.
#
41
FIELD
LTSS CBAS Indicator
42
43
44
LTSS IHSS Indicator
LTSS LTC Indicator
LTSS MSSP Indicator
Eligibility Data File Format
VALUES
Y
N
Y
N
Y
N
Y
N
DESCRIPTION
Member is in a Community Based Adult Services Program (CBAS).
Member is not in a Community Based Adult Services Program
(CBAS).
Member is in an In-Home Supportive Services Program (IHSS)
Member is not in an In-Home Supportive Services Program (IHSS).
Member is in a Long Term Care Program (LTC).
Member is not in a Long Term Care Program (LTC).
Member is in a Mutipurpose Senior Services Program (MSSP).
Member is not in a Mutipurpose Senior Services Program (MSSP).
Revision Date: 02/24/2014
Page 14 of 14