XEROX 04D- Client 4intf
4.4 Client Subsystem Interface Functionality
The interfaces supported by this subsystem are:
• CPS Eligibility File Interface
• CMS Eligibility File Interface
• Bendex Interface
• Buy-in Interface
• Swipe Card Interface
• Privacy Notice File Interface
• TPL HSD COE 031/035 ONLY File Interface OBSOLETE
• TPA Eligibility File Interface
• IHS Eligibility File Extract Interface
• Defense Enrollment Eligibility System (Deers) Eligibility File Extract Interface
• Client Claims Transfer PDCS File Interface
• IHS Client Race Code Interface
• CMS Dual Eligible MMA Interface
• CMS Dual Eligible MMA Response File Interface
• CRM Client Interface
• OCR/RRI Client Interface
• Medicare COBA Eligibility Interface
• Date of Death Update Interface (NM Office of Vital Statistics and HMS)
• Low Income Subsidy (LIS) Beneficiary File Interface LIS Referrals to MSP Interface-
• FOCos Eligibility Extract
• Finity Eligibility Extract
• Family Infant Toddler Extract
• Batch Client Merge
• Omnicaid to Aspen MCO interface
• SDX monthly file retroactive span update interface
• Aspen to Omnicaid TPL interface
• Omnicaid to Aspen TPL interface
• ASPEN/HMS/MCOs to Omnicaid TPL Interface
• Omnicaid to ASPEN/HMS/MCOs TPL Interface
• TPS Buy-in Interface
• ASPEN Eligibility File Interface
• ASPEN Eligibility Interface Error File
• Spectrum Informatics – Client Interface
• HMS Client Interface
• Daily MCO to HSD Interface
• Daily MCO to HSD Interface Error File
• Daily CareLink NM to HSD Interface
• Daily CareLink NM to HSD Interface Error File
• Daily Eligibility Void Reinstatement Interface
• On Request MCI ID Update Interface
• On Request Batch COE spans update
• Omnicaid to CMS TBQ Request
• CMS to Omnicaid TBQ Response (Phase 1 – Close Open Medicare)
• CMS to Omnicaid TBQ Response (Phase 2 – Add / Update / Delete Medicare Using MMA Response Processing)
• Monthly LTC Reconciliation Interface to MCOs
• 1095B Form Interface
Each of these is described in detail on the following pages.
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE SPECIFICATION
INPUT FILE
CPS ELIGIBILITY FILE INTERFACE
|Description: |
|The CPS (Child Protective Services) interface provides eligibility information on a daily basis about foster care children within the Child Protective Services Division of the Children, Youth,|
|and Families Department. It identifies individuals that are eligible for state-funded medical services. |
| |
|This interface also supplies a monthly reconciliation file in the same format as the daily file. |
|Source Files: |
|CPS daily eligibility file |
|CPS monthly eligibility reconciliation file |
|Target Tables: |
|B_DETAIL_TB |
|B _ADR_TB |
|B_COE_SPN_TB |
|B_ALT_ID_TB |
|B_PREV_NAM_TB |
|B_EXTRT_REQ_TB |
|B_SWIPE_CARD_TB |
|B_IFACE_ERR_TB |
|Reports: |
|RB010 – Possible Duplicate Client Report – Birth/Sex |
|RB020 – Possible Duplicate Client Report – SSN |
|RB080 – Eligibility Interface Audit Trail |
|RB400 – Unmatched Recon Records |
|RB410 – File Audit Report of Mismatches |
|RB060 – Interface Reformat Error Report |
|RB070 – Update Error Report |
|RB075 – Update State Error Report |
|Process Summaries |
|Remarks: |
|The daily CPS eligibility file and the monthly CPS eligibility reconciliation files are submitted in the same format and processed by the same programs in the MMIS. On the night when the |
|monthly CPS eligibility reconciliation file is processed, it will run immediately prior to the daily CPS eligibility file. This interface will accept a CPS specific eligibility record, apply|
|basic editing, and reformat the record into the ‘common interface format’, which is used for the two remaining legacy eligibility interfaces – CPS and CMS. A single eligibility update |
|program, NMMB1030, handles transactions in the common interface format. |
| |
|The State requested that certain errors encountered in the client eligibility update processing should not be printed on the update error reports (NMMB1050-RB070 and NMMB1050-RB075) but should|
|just be written out to a file. This was requested because at the time the volume of “bypass” errors was inflating the size of the update error reports. The file is in the format of the |
|RSERROR copybook. The following errors are written to the Bypass Error file: |
|Error 306 - INVALID CLOSURE TRANSACTION - UNABLE TO FIND OPEN ELIG |
|Error 400 - ELIGIBILITY SEGMENT BYPASSED - COMPARABLE ELIG ON FILE |
|Error 501 - LIABILITY SEGMENT BYPASSED - SEGMENT ALREADY COVERED |
| |
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE LAYOUT
INPUT FILE
CPS ELIGIBILITY FILE INTERFACE
*01 RS-ELIG-INTFC-RECORD.
* 05 RS-INTERFACE-INFO.
10 RS-INTERFACE-SOURCE PIC X(5).
88 RS-INTFC-SOURCE-ISD2 VALUE 'ISD2 '.
88 RS-INTFC-SOURCE-ISD2R VALUE 'RISD2'.
88 RS-INTFC-SOURCE-SDX VALUE 'SDX '.
88 RS-INTFC-SOURCE-SDXR VALUE 'RSDX '.
88 RS-INTFC-SOURCE-CMS VALUE 'CMS '.
88 RS-INTFC-SOURCE-CMSR VALUE 'RCMS '.
88 RS-INTFC-SOURCE-CPS VALUE 'CPS '.
88 RS-INTFC-SOURCE-CPSR VALUE 'RCPS '.
10 RS-INTERFACE-DATE.
15 RS-INTERFACE-DATE-CENTURY PIC X(2).
15 RS-INTERFACE-DATE-YEAR PIC X(2).
15 RS-INTERFACE-DATE-MONTH PIC X(2).
15 RS-INTERFACE-DATE-DAY PIC X(2).
10 RS-INTERFACE-SEQ-NUMB PIC X(6).
10 RS-INTERFACE-TYPE PIC X.
88 RS-INTFC-TYPE-ADD VALUE 'A'.
88 RS-INTFC-TYPE-CLOSE VALUE 'C'.
88 RS-INTFC-TYPE-UPDATE VALUE 'U'.
88 RS-INTFC-TYPE-RECON VALUE 'R'.
10 RS-ELIG-INTFC-IDENTIFIER.
15 RS-ELIG-INTFC-WHATSIT PIC X(5).
15 RS-ELIG-INTFC-WHOSIT PIC X(9).
05 RS-ISD2-CLIENT-INTRN-ID PIC X(9).
05 RS-ISD2-CASE-INTRN-ID PIC X(9).
05 RS-CASE-NUMBER.
10 RS-CASE-WHATSIT PIC X(5).
10 RS-CASE-WHOSIT PIC X(9).
05 RS-CLIENT-NAME.
10 RS-CLIENT-LAST-NAME PIC X(20).
10 RS-CLIENT-FIRST-NAME PIC X(15).
10 RS-CLIENT-MIDL-INIT PIC X.
10 RS-CLIENT-NAME-SUFFIX PIC XXX.
05 RS-REPRESENTATIVE-NAME.
10 RS-REP-LAST-NAME-LONG PIC X(70).
10 RS-REP-FIRST-NAME PIC X(15).
10 RS-REP-MIDL-INIT PIC X.
10 RS-REP-NAME-SUFFIX PIC XXX.
05 RS-HEAD-OF-HOUSEHOLD-NAME.
10 RS-HOH-LAST-NAME PIC X(20).
10 RS-HOH-FIRST-NAME PIC X(15).
10 RS-HOH-MIDL-INIT PIC X.
10 RS-HOH-NAME-SUFFIX PIC XXX.
05 RS-CLIENT-RESIDENCE-ADDRESS.
10 RS-RES-ADDR-LINE1 PIC X(25).
10 RS-RES-ADDR-LINE2 PIC X(25).
10 RS-RES-CITY PIC X(20).
10 RS-RES-STATE PIC XX.
10 RS-RES-ZIP-CODE.
15 RS-RES-ZIP-FIRST5 PIC X(5).
15 RS-RES-ZIP-LAST4 PIC X(4).
10 RS-RES-CARRIER-RT PIC XX.
05 RS-CLIENT-MAILING-ADDRESS.
10 RS-MAIL-ADDR-LINE1 PIC X(25).
10 RS-MAIL-ADDR-LINE2 PIC X(25).
10 RS-MAIL-CITY PIC X(20).
10 RS-MAIL-STATE PIC XX.
10 RS-MAIL-ZIP-CODE.
15 RS-MAIL-ZIP-FIRST5 PIC X(5).
15 RS-MAIL-ZIP-LAST4 PIC X(4).
10 RS-MAIL-CARRIER-RT PIC XX.
05 RS-REPRESENTATIVE-ADDRESS.
10 RS-REP-ADDR-LINE1 PIC X(25).
10 RS-REP-ADDR-LINE2 PIC X(25).
10 RS-REP-CITY PIC X(20).
10 RS-REP-STATE PIC XX.
10 RS-REP-ZIP-CODE.
15 RS-REP-ZIP-FIRST5 PIC X(5).
15 RS-REP-ZIP-LAST4 PIC X(4).
10 RS-REP-CARRIER-RT PIC XX.
05 RS-CLIENT-PHONE-NUMBER.
10 RS-CLIENT-PHONE PIC X(10).
10 RS-CLIENT-PHONE-EXT PIC X(5).
05 RS-CLIENT-SSN PIC X(9).
05 RS-HIC-NUMB PIC X(12).
05 RS-MEDICARE-INDICATOR PIC X.
05 RS-GENDER-CODE PIC X.
05 RS-RACE-CODE PIC XX.
05 RS-TRIBE-CODE PIC XX.
05 RS-LANGUAGE-TYPE PIC XX.
05 RS-ON-RESVN-IND PIC X.
05 RS-DATE-OF-BIRTH.
10 RS-DOB-CENTURY PIC XX.
10 RS-DOB-YEAR PIC XX.
10 RS-DOB-MONTH PIC XX.
10 RS-DOB-DAY PIC XX.
05 RS-DATE-OF-DEATH.
10 RS-DOD-CENTURY PIC XX.
10 RS-DOD-YEAR PIC XX.
10 RS-DOD-MONTH PIC XX.
10 RS-DOD-DAY PIC XX.
05 RS-PREVIOUS-ID.
10 RS-PREV-WHATSIT PIC X(5).
10 RS-PREV-WHOSIT PIC X(9).
05 RS-MEDICAID-ELIG-BEGIN-DATE.
10 RS-MEDICAID-ELIG-BEGIN-CENTURY PIC XX.
10 RS-MEDICAID-ELIG-BEGIN-YEAR PIC XX.
10 RS-MEDICAID-ELIG-BEGIN-MONTH PIC XX.
10 RS-MEDICAID-ELIG-BEGIN-DAY PIC XX.
05 RS-MEDICAID-ELIG-END-DATE.
10 RS-MEDICAID-ELIG-END-CENTURY PIC XX.
10 RS-MEDICAID-ELIG-END-YEAR PIC XX.
10 RS-MEDICAID-ELIG-END-MONTH PIC XX.
10 RS-MEDICAID-ELIG-END-DAY PIC XX.
05 RS-CAT-OF-ELIG-CODE PIC XXX.
05 RS-FED-MATCH-CODE PIC X.
05 RS-GEO-COUNTY-CODE PIC XX.
05 RS-ADMIN-OFFICE-CODE.
10 FILLER PIC X.
10 RS-ADMIN-OFFICE-CD PIC XX.
05 RS-CMS-DIAG-ELIG-CODE PIC XX.
05 FILLER PIC X(16).
05 RS-MEDICAL-CR-AMOUNT PIC 9(7)V99.
05 RS-ISD2-MEMBER-STATUS PIC X(1).
88 RS-ISD2-MEM-STD-032-INC-DIS VALUE 'M'. P260417
88 RS-ISD2-MEM-EXP-032-INC-DIS VALUE 'Q'. P260417
88 RS-ISD2-MEM-STD-036-INC-DIS VALUE 'L'. P260417
88 RS-ISD2-MEM-EXP-036-INC-DIS VALUE 'R'. P260417
88 RS-ISD2-MEM-STD-071-INC-DIS VALUE 'C'. P260417
88 RS-ISD2-MEM-EXP-071-INC-DIS VALUE 'Y'. P260417
88 RS-ISD2-MEM-FAMILY-PLANNING VALUE 'Z'.
88 RS-ISD2-MEM-TWELVE-MO-EXTSN VALUE 'E'.
05 RS-ISD2-BGMS-CODE PIC X(1).
05 RS-ISD2-INST-CARE-STATUS PIC X(1).
05 RS-BENEFIT-MONTH.
10 RS-BEN-MONTH-CENTURY PIC X(2).
10 RS-BEN-MONTH-YEAR PIC X(2).
10 RS-BEN-MONTH-MONTH PIC X(2).
05 RS-ISD2-PCNT-POVERTY PIC S9(3) COMP-3. P250079B
05 RS-ISD2-CASE-STATUS PIC X(1).
05 RS-ISD2-GRANT-AMT PIC 9(5)V99 COMP-3.
05 RS-MCAID-ELIG-FLAG PIC X.
05 RS-RETRO-MCAID OCCURS 3 TIMES.
10 RETRO-MCAID-STATUS PIC X.
10 RETRO-MCAID-BENEFIT-MO PIC S9(5) COMP-3.
05 RS-REL-HEAD-HH-CD PIC X.
05 FILLER PIC X(01). P250079
05 RS-COPAY-MAX-AMT PIC S9(05) COMP-3. P250079
05 RS-PARENT-IND PIC X(01). P250079
05 RS-AFFL-CD PIC X(01). P250079
05 RS-MCO-CHOICE-CD PIC X(02). P250079
05 RS-RECERT-DATE PIC S9(4) COMP-3. P250497
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE EXHIBIT
INPUT FILE
CPS ELIGIBILITY FILE INTERFACE
|Source |Target |Target |Std | | | |Note |
|Field |Table |Column |Edit |Req |Def |Specifications |Ref |
|RS-INTERFACE-SOURCE |B_DETAIL_TB |B_DOD_UPD_BY_ID |N/A |A |N/A | |21 |
|RS-INTERFACE-DATE |B_SWIPE_CARD_TB |B_SWIPE_ISS_DT |D |A |N/A |File’s creation date by CPS. This field is posted on |23 |
| | | | | | |reports, as well as used to populate the swipe card | |
| | | | | | |issue date if necessary | |
|RS-INTERFACE-SEQ-NUMB |N/A |N/A |N |A |N/A | |1 |
|RS-INTERFACE-TYPE |N/A |N/A |V |A |N/A |Determines type of transaction. A= Add, C=Close, | |
| | | | | | |R=Recon, U=Uupdate. | |
|RS-ELIG-INTFC-IDENTIFIER |B_ALT_ID_TB |B_ALT_ID |N |A |N/A |Must not = Zeros. |14 |
| | | | | | |CPS – Cols 1-2 (COE) 3-4 (GEO CTY) 5 (5) 6-14 (CPS | |
| | | | | | |Recipient ID) | |
|RS-ISD2-CLIENT-INTRN-ID |N/A |N/A |N/A |N |N/A | | |
|RS-ISD2-CASE-INTRN-ID |N/A |N/A |N/A |N |N/A | | |
|RS-CASE-NUMBER |B_COE_SPN_TB |B_CASE_HH_NUM |N |A |N/A | |17, 24 |
|RS-CLIENT-LAST-NAME |B_DETAIL_TB |B_LAST_NAM |N/A |A |N/A |The first character must be an alphabetic character. |14, 24 |
|RS-CLIENT-FIRST-NAME |B_DETAIL_TB |B_FST_NAM |N/A |A |N/A |The first character must be an alphabetic character. |14, 24 |
|RS-CLIENT-MIDL-INIT |B_DETAIL_TB |B_MI_NAM |N/A |N |Spaces |If entered, must be an alphabetic character. | |
|RS-CLIENT-NAME-SUFFIX |B_DETAIL_TB |B_SFX_NAM |N/A |N |Spaces | | |
|RS-REP-LAST-NAME-LONG |B_DETAIL_TB |B_REP_LAST_NAM |N/A |N |Spaces |The first character must be an alphabetic character. |13 |
|RS-REP-FIRST-NAME |B_DETAIL_TB |B_REP_FST_NAM |N/A |N |Spaces |The first character must be an alphabetic character. |13 |
|RS-REP-MIDL-INIT |B_DETAIL_TB |B_REP_MI_NAM |N/A |N |Spaces |If entered, must be an alphabetic character. |13 |
|RS-REP-NAME-SUFFIX |B_DETAIL_TB |B_REP_SFX_NAM |N/A |N |Spaces | | |
|RS-HOH-LAST-NAME |B_DETAIL_TB |B_REP_LAST_NAM |N/A |C |Spaces |The first character must be an alphabetic character. |13 |
|RS-HOH-FIRST-NAME |B_DETAIL_TB |B_REP_FST_NAM |N/A |C |Spaces |The first character must be an alphabetic character. |13 |
|RS-HOH-MIDL-INIT |B_DETAIL_TB |B_REP_MI_NAM |N/A |N |Spaces |If entered, must be an alphabetic character. |13 |
|RS-HOH-NAME-SUFFIX |B_DETAIL_TB |B_REP_SFX_NAM |N/A |N |Spaces | | |
|RS-RES-ADDR-LINE1 |B_ADR_TB |B_LINE1_AD |N/A |C |N/A | |2, 3, |
| | | | | | | |19, 20, |
|RS-RES-ADDR-LINE2 |B_ADR_TB |B_LINE2_AD |N/A |N |N/A | |2, 3, |
| | | | | | | |19, 20, |
|RS-RES-CITY |B_ADR_TB |B_CITY_NAM |N/A |C |N/A |First character must be alphabetic |2, 3, |
| | | | | | | |19, 20, |
| | | | | | | |,22 |
|RS-RES-STATE |B_ADR_TB |B_ST_CD |V |C |N/A | |2, 3, |
| | | | | | | |19, 20, |
| | | | | | | |,22 |
|RS-RES-ZIP-FIRST5 |B_ADR_TB |B_ZIP5_CD |N |C |N/A | |2, 3, |
| | | | | | | |19, 20, |
|RS-RES-ZIP-LAST4 |B_ADR_TB |B_ZIP4_CD |N |C |N/A | |2, 3, |
| | | | | | | |19, 20, |
|RS-RES-CARRIER-RT |N/A |N/A |N/A |N |N/A | | |
|RS-MAIL-ADDR-LINE1 |B_ADR_TB |B_LINE1_AD |N/A |C |N/A | |4, 5, 20|
|RS-MAIL-ADDR-LINE2 |B_ADR_TB |B_LINE2_AD |N/A |N |N/A | |4, 5, 20|
|RS-MAIL-CITY |B_ADR_TB |B_CITY_NAM |N/A |C |N/A |First character must be alphabetic |4, 5, |
| | | | | | | |20,22 |
|RS-MAIL-STATE |B_ADR_TB |B_ST_CD |V |C |N/A | |4, 5, |
| | | | | | | |20,22 |
|RS-MAIL-ZIP-FIRST5 |B_ADR_TB |B_ZIP5_CD |N |C |N/A | |4, 5, 20|
|RS-MAIL-ZIP-LAST4 |B_ADR_TB |B_ZIP4_CD |N |C |N/A | |4, 5, 20|
|RS-MAIL-CARRIER-RT |N/A |N/A |N/A |N |N/A | | |
|RS-REP-ADDR-LINE1 |N/A |N/A |N/A |N |N/A | | |
|RS-REP-ADDR-LINE2 |N/A |N/A |N/A |N |N/A | | |
|RS-REP-CITY |N/A |N/A |N/A |N |N/A | | |
|RS-REP-STATE |N/A |N/A |N/A |N |N/A | | |
|RS-REP-ZIP-FIRST5 |N/A |N/A |N/A |N |N/A | | |
|RS-REP-ZIP-LAST4 |N/A |N/A |N/A |N |N/A | | |
|RS-REP-CARRIER-RT |N/A |N/A |N/A |N |N/A | | |
|RS-CLIENT-PHONE | B_ADR_TB |B_PHON_NUM |N |N |N/A | |19,20 |
|RS-CLIENT-PHONE-EXT |N/A |N/A |N/A |N |N/A | | |
|RS-CLIENT-SSN |B_DETAIL_TB |B_SSN_NUM |N |C |N/A | |6, 14 |
|RS-HIC-NUMB |N/A |N/A |N |N |N/A | |7 |
|RS-MEDICARE-INDICATOR |N/A |N/A |N/A |N |N/A | | |
|RS-GENDER-CODE |B_DETAIL_TB |B-GENDER-CD |V |A |Spaces | |14, 16 |
|RS-RACE-CODE |B_DETAIL_TB |B_RACE_CD |V |A |N/A | |11 |
| | |B_TRIBAL_AFFL_CD | | | | | |
|RS-TRIBE-CODE |N/A |N/A |N/A |N |N/A | | |
|RS-LANGUAGE-TYPE |N/A |N/A |N/A |N |N/A | | |
|RS-ON-RESVN-IND |N/A |N/A |N/A |N |N/A | | |
|RS-DATE-OF-BIRTH |B_DETAIL_TB |B_DOB_DT |D |A |N/A |Cannot be a future date. Cannot be greater than |14 |
| | | | | | |B_DOD_DT. | |
| | | | | | |Date of Birth is not required for clients with only CPS| |
| | | | | | |eligibility. | |
|RS-DATE-OF-DEATH |B_DETAIL_TB |B_DOD_DT |D |N |N/A | Date of Death cannot be a future date |15 |
|RS-PREVIOUS-ID |N/A |N/A |N/A |N |N/A | |14 |
|RS-MEDICAID-ELIG-BEGIN-DATE |B_COE_SPN_TB |B_COE_SPN_BEG_DT |D |C |N/A |Required for all but close transactions. |8 |
| |B_DETAIL-TB |B_COPAY_BEG_DT_ | | | | | |
| | |B_MC_PREF_BEG_DT | | | | | |
| | |B_APPL-DT | | | | | |
|RS-MEDICAID-ELIG-END-DATE |B_COE_SPN_TB |B_COE_SPN_END_DT |D |C |N/A |Required for all but close transactions. |9 |
| | | | | | | | |
|RS-CAT-OF-ELIG-CODE |B_COE_SPN_TB |B_COE_CD |V |A |N/A | |10 |
|RS-FED-MATCH-CODE |B_COE_SPN_TB |B_FED_MTCH_CD |V |N |N/A | |10, 17 |
|RS-GEO-COUNTY-CODE | B_ADR_TB |B_GEO_CNTY_CD |V |A |N/A | | |
|RS-ADMIN-OFFICE-CD | B_ADR_TB |B_ADMIN_CNTY_CD |V |C |N/A |Required for all transactions. | |
|RS-CMS-DIAG-ELIG-CODE |N/A |N/A |N/A |N |N/A | | |
|RS-MEDICAL-CR-AMOUNT |N/A |N/A |N |C |N/A | | |
|RS-ISD2-MEMBER-STATUS |N/A |N/A |N/A |N |N/A | | |
|RS-ISD2-BGMS-CODE |N/A |N/A |N/A |N |N/A | | |
|RS-ISD2-INST-CARE-STATUS |N/A |N/A |N/A |N |N/A | | |
|RS-BENEFIT-MONTH |N/A |N/A |D |C |N/A | | |
|RS-ISD2-PCNT-POVERTY | | |N/A |N |N/A |CPS puts zero in this field | |
| |B_COPAY_TB |B_FPL_PCT | | | | | |
|RS-ISD2-CASE-STATUS |N/A |N/A |N/A |N |N/A | | |
|RS-ISD2-GRANT-AMT |N/A |N/A |N/A |N |N/A | | |
|RS-MCAID-ELIG-FLAG |N/A |N/A |N/A |N |N/A | | |
|RETRO-MCAID-STATUS (1) |N/A |N/A |N/A |N |N/A | | |
|RETRO-MCAID-BENEFIT-MO (1) |N/A |N/A |N/A |N |N/A | | |
|RETRO-MCAID-STATUS (2) |N/A |N/A |N/A |N |N/A | | |
|RETRO-MCAID-BENEFIT-MO (2) |N/A |N/A |N/A |N |N/A | | |
|RETRO-MCAID-STATUS (3) |N/A |N/A |N/A |N |N/A | | |
|RETRO-MCAID-BENEFIT-MO (3) |N/A |N/A |N/A |N |N/A | | |
|RS-REL-HEAD-HH-CD | B_DETAIL_TB |B_REL_HEAD_HH_CD |V |A |N/A | |12, 17 |
|RS-COPAY-MAX-AMT | B_COPAY_TB |B_COPAY_MAX_AMT |N |C |N/A |CPS puts zero in this field . | |
|RS-PARENT-IND | B_MC_PREF_TB |B_PARENT_IND |V |C |N/A |CPS puts spaces in this field. | |
|RS-AFFL-CD | B_MC_PREF_TB |B_AFFL_CD |V |C |N/A |CPS puts spaces in this field. | |
|RS-MCO-CHOICE-CD | B_MC_PREF_TB |B_MCO_CHOICE_CD |V |C |N/A |CPS puts spaces in this field. | |
|RS-RECERT-DATE |B_DETAIL_TB |B_CERT_DT |V |N |N/A |Defaults to low date “0001-01-01” if not received. Only| |
| | | | | | |MMYY is received (packed) and padded with “20” for | |
| | | | | | |century and “01” for day. | |
Notes:
1. Used during error reporting to track an error to the specific input interface record that triggered it.
2. If one of the following is present, the rest of the following are required: Residential Address Line 1, Residential Address City, Residential Address State, Residential Address Zip Code.
3. If either Residential Address Line 2 or Residential Address Zip Code is present, the following are required: Residential Address Line 1, Residential Address City, Residential Address State.
4. If one of the following is present, the rest of the following are required: Mailing Address Line 1, Mailing Address City, Mailing Address State.
5. If either Mailing Address Line 2 or Mailing Address Zip Code is present, the following are required: Mailing Address Line 1, Mailing Address City, Mailing Address State.
6. Social security numbers beginning with 900 – 939 are considered invalid. Newborns must have an SSN of zero. Newborns are identified as: the first five digits of RS-ELIG-INTFC-IDENTIFIER equal to zero, and the next three digits are 940-949.
7. The RS-HIC-NUM is ignored for the CPS interface.
8. The date spans for certain COEs must begin on the first day of the month, the date spans for other COEs may begin on any day of the month. This is controlled by entries on the COE Edit table. On add transactions, the client application date is set to the incoming span begin date. The eligibility begin date should not be less than the client date of birth. However, if the client’s date of birth is in the same year/month of the eligibility begin date, the record is not rejected. The eligibility begin date should not be greater than 3 months in the future. If it is, the record is rejected.
9. End date must be greater than begin date. An end date of zero is assumed to be an open-ended span and will convert to 12/31/9999 on the client COE table. The date spans for certain COEs must end on the last day of the month; the date spans for other COEs may end on any day of the month. This is controlled by entries on the COE Edit table
10. The system will verify that the COE/FM combination entered is valid, based on information in the COE Edit table. See the COE Edit Table exhibit in the Exhibits section of this document. The system will determine the impact upon existing spans that overlap the dates in the new span according to rules also contained in the COE hierarchy table, and may cut and paste date spans as required. B_ACTION-CD on the COE hierarchy table determines if the new span can coexist, closes, or cannot coexist with the overlapping span on file. See the COE Hierarchy Table for COE Date Span Overlaps exhibit in the Exhibits section of this document.
11. The incoming race code will be used to determine the race and tribal affiliation codes on the client database. See the race/tribal affiliation exhibit in the Exhibits section of this document.
12. If the relationship to head of household code is spaces on the interface record, it will default to ‘A’ (Self) in Omnicaid . If this value is different than the value in the client detail table, the value on the client detail table will be overlaid.
13. The head of household name will be used to update the representative payee name on the client database.
14. When an input transaction is processed, the system tries to find a matching client on the database using all of the available identification fields on the transaction. The goal is to avoid adding a new client that is later determined to be a duplicate of a client already on file. During this process, the transaction is classified as an add or update transaction, an additional alternate ID may be added to the database, and suspect duplicate clients are identified. See the decision tables under Finding a Matching Client.
15. If the Omnicaid client detail table contains a valid Date of Death then it will not be overlaid by a Date of Death on the incoming input file. The only way the DOD can be updated after it is recorded is via the online Omnicaid Client Detail screen or the monthly interface from the Office of Vital Statistics
Finding A Matching Client
Definition of Fields Used in Decision Table
Field Description Field Name Source
Incoming Client ID RS-ELIG-INTD-IDENTIFIER State Elig. transaction
Incoming Previous ID RS-PREVIOUS-ID State Elig. Transaction
MMIS Client ID B-ALT-ID One of the IDs associated with the client in Omnicaid
There are several tables presented here. Start with table 1, which will either present a final outcome or direct you to either table 2 or 3 for additional logic, if necessary.
Table 1 - CPS Transactions
|Conditions |1 |2 |3 |4 |5 |6 |7 |
|Incoming Client ID exists as an MMIS Client id |Y |N |N |N |N |N |N |
|Incoming Previous ID is not spaces, and is different than the incoming Client ID |-- |Y |Y |Y |Y |N |N |
|Incoming Previous ID exists as an MMIS Client ID |-- |Y |Y |N |N |-- |-- |
|SSN on the MMIS Client is the same as the incoming SSN |-- |Y |N |-- |-- |-- |-- |
|Incoming SSN, prefixed by ‘00000’, exists as an MMIS Client id |-- |-- |-- |Y |N |Y |N |
|Actions | | | | | | | |
|Perform Table 3 - Verify-Match |X |X | |X | |X | |
|Perform Table 4 - Name-Search | | | | | | |X |
|Reject Transaction with error 302 - ‘Previous ID points to another SSN’ | | |X | | | | |
|Reject Transaction with error 303 - ‘CPS Client missing eligibility under Previous | | | | |X | | |
|ID’ | | | | | | | |
Table 2 - Verify-Match
|Conditions |
|Source Files: |
|CMS daily eligibility file |
|Target Tables: |
|B_DETAIL_TB |
|B _ADR_TB |
|B_COE_SPN_TB |
|B_ALT_ID_TB |
|B_PREV_NAM_TB |
|Reports: |
|NONE, only error file (input record + error message at the end of the record WFB10015) |
|Remarks: |
|. This interface will accept a DOH specific eligibility record, apply basic editing, and reformat the record into the ‘common interface format’, which is used for the two remaining legacy |
|eligibility interfaces – CPS and CMS. A single eligibility update program, NMMB1030, handles transactions in the common interface format. |
| |
|We will no longer be receiving a monthly reconciliation file and will not be doing an eligibility reconciliation for CMS |
| |
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE LAYOUT
INPUT FILE
CMS TO OMNICAID ELIGIBILITY FILE INTERFACE
COPY RSCMSIN.
000010****************************************************************
000020* R E C I P I E N T N E W M E X I C O *
000030* C M S I N T E R F A C E F I L E *
000040* FIXED LENGTH LAYOUT OF 150 BYTES *
000060****************************************************************
000090****************************************************************
000101* DATE PROGRAMMER PROJECT *
000102*--------------------------------------------------------------*
000104* *
000090****************************************************************
000120*
000130 01 RS-CMS-INTFC-HDR-RECORD.
000140*
000150 05 RS-CMS-HDR-REC-TYPE PIC X(02).
000160 88 RS-CMS-VALID-HEADER VALUE 'HD'
000210 05 RS-CMS-HDR-FILE-NAME PIC X(07).
000230 88 RS-CMS-VALID-FILE-NAME VALUE 'CMSELIG'.
000231 05 RS-CMS-HDR-INTFC-DATE PIC X(10).
000261 05 RS-CMS-HDR-SEQ-NUM PIC 9(06).
000262
000600 01 RS-CMS-INTFC-DTL-RECORD.
000700*
000800 05 RS-CMS-RECIP-ID PIC 9(14).
000900 05 RS-CMS-SSN PIC 9(09).
001000 05 RS-CMS-ACTION-CODE PIC X(01).
001100 05 RS-CMS-RECIP-LAST-NAME PIC X(21).
001200 05 RS-CMS-RECIP-FIRST-NAME PIC X(15).
001300 05 RS-CMS-RECIP-MI-NAME PIC X(01).
001400 05 RS-CMS-CVRG-BEGIN-DATE PIC X(10).
001500 05 RS-CMS-CVRG-END-DATE PIC X(10).
001600 05 RS-CMS-GENDER-CD PIC X(01).
001700 05 RS-CMS-RACE-CD PIC X(01).
001800 05 RS-CMS-DATE-OF-BIRTH PIC X(10).
001900 05 RS-CMS-DOH-PRIOR-ID PIC 9(14).
002000 05 FILLER PIC X(43).
002200 01 RS-CMS-INTFC-TRL-RECORD.
002300*
002400 05 RS-CMS-TRL-REC-TYPE PIC X(02).
002410 88 RS-CMS-VALID-TRAILER VALUE 'TR'.
002420 05 RS-CMS-TRL-CNT PIC 9(09).
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE EXHIBIT
INPUT FILE
CMS TO OMINICAID ELIGIBILITY FILE INTERFACE
|Source |Target |Target |Std | | | |Note |
|Field |File |Field |Edit |Req |Def |Specifications |Ref |
|RS-CMS-HDR-REC-TYPE |N/A |N/A |S |A |HD |Determine the record type, ‘HD’ - Header | |
|RS-CMS-HDR-FILE-NAME |N/A |N/A |S |A |CMSELIG |File’s name, CMS Eligibility | |
|RS-CMS-HDR-INTFC-DATE |N/A |N/A |S |A | |File’s creation date by CMS. This field is | |
| | | | | | |posted on reports, as well as used to populate the| |
| | | | | | |swipe card issue date if necessary | |
|RS-CMS-HDR-SEQ-NUM |N/A |N/A |S |A |N/A |File’s sequence number, should start with 1, if | 1 |
| | | | | | |more than one file per day then increase by one | |
| | | | | | |for each file. | |
|RS-CMS-INTFC-DTL-RECORD | | | | | | |2 |
|RS-CMS-RECIP-ID |BALTIDTB |B-ALT-ID |N |A |N/A |This is '07' followed by the 12 digit ACAMS client|3 |
| | | | | | |MPI. | |
|RS-CMS-SSN |BDTAILTB |B-SSN-NUM |N |A | |If not available ACAMS to pass '000000000' |4 |
| | | | | | |otherwise must contain a valid format. | |
|RS-CMS-ACTION-CODE |N/A |N/A |S |A |N/A |Determines type of transaction. ACAMS will pass | |
| | | | | | |'A' for Add, ‘U’ for Update or 'C’ for Close. | |
|RS-CMS-RECIP-LAST-NAME |BDTAILTB |B-LAST-NAM |N/A |A |N/A |DOH - Last Name will be truncated to 21 characters| |
| | | | | | |(program will convert lower case to upper case) | |
|RS-CMS-RECIP-FIRST-NAME |BDTAILTB |B-FST-NAM |N/A |A |N/A |DOH – First Name will be truncated to 15 | |
| | | | | | |characters (program will convert lower case to | |
| | | | | | |upper case) . | |
|RS-CMS-RECIP-MI-NAME |BDTAILTB |B-MI-NAM |N/A |A |N/A | | |
|RS-CMS-CVRG-BEGIN-DATE |BCOESPTB |B-COE-SPN-BEG-DT |D |A |N/A |Format CCYY-MM-DD, must be less than or equal to |2, 5 |
| | | | | | |RS-CMS-CVRG-END-DATE | |
|RS-CMS-CVRG-END-DATE |BCOESPTB |B-COE-SPN-END-DT | |A | |Format CCYY-MM-DD |6 |
|RS-CMS-GENDER-CD |BDTAILTB |B-GENDER-CD |D |N/A |N/A |Valid value are M or F : | |
| | | | | | |M – Male | |
| | | | | | |F – Female | |
|RS-CMS-RACE-CD |BDTAILTB |B--RACE-CD |N/A |N/A |N/A |DOH will send values 1-5, 9 which match to |7 |
| | | | | | |Omnicaid values 1-5, 9 | |
|RS-CMS-DATE-OF-BIRTH |BDTAILTB |B-DOB-DT |D |A |N/A |Format CCYY-MM-DD and cannot be a future date or | |
| | | | | | |after RS-CMS-CVRG-BEGIN-DATE. | |
|RS-CMS-DOH-PRIOR-ID |BALTIDTB |B-ALT-ID |N | |N/A |If not available, default to zeros. Must exist in |3 |
| | | | | | |Omnicaid table BALTIDTB. | |
|RS-CMS-INTFC-TRL-RECORD | | | | | | | |
|RS-CMS-TRL-REC-TYPE |N/A |N/A |S |A |TR |Determine the record type, ‘TR’ - Trailer | |
|RS-CMS-TRL-CNT |N/A |N/A |N |A |TR |Total detail record in the CMS Eligibility | |
| | | | | | |interface file. | |
Notes:
1. Used during error reporting to track an error to the specific input interface record that triggered it.
2. The DOH CMS Eligibility detail record was designed to be a very simple record, with a minimal number of fields. The following default values will be used in this interface:
• Set the Category of Eligibility and Fed Match Code to 007/2 (B_COE_CD = ‘007’ & B_FED_MTCH_CD = ‘2 on the BCOESPTB)
• Set the Relationship to Head of Household to Self (B_REL_HEAD_HH_CD on the BDTAILTB = ‘A’)
• Set the Geographic County to Santa Fe (B_GEO_CNTY_CD = ‘26’ on the BADDRSTB)
• Set the Administrative Office Code to Sante Fe (B_ADMIN_OFC_CD = ‘26’ on the BADDRSTB)
• Set the Client Case Number to spaces
• For new clients, set the client residential address to the following:
DOH:1190 ST FRANCIS DRIVE, SANTA FE, NM 85702
The begin date of the address will be set to RS-CMS-CVRG-BEGIN-DATE, the address end date will be open-ended
3. The Omnicaid interface program will read the client Alternate Id table, BALTIDTB, using the id in RS-CMS-RECIP-ID. If the id is found, it uses the SYS-ID found to update the client's information. If the RS-CMS-RECIP-ID does not exist, and RS-CMS-PRIOR-DOH-ID > zeros, it uses RS-CMS-PRIOR-DOH-ID to check if it exists on BALTIDTB. If use RS-CMS-PRIOR-DOH-ID doesn't exist, reject the input transaction. If it exists, add RS-CMS-RECIP-ID as an alternate client id to BALTIDTB using the SYS ID found. If the client doesn't exist and RS-CMS-PRIOR-DOH-ID is zeros, then the common eligibility update program NMMB1030 will attempt to identify the client using the client's demographic information or add the input client as a new client. The goal is to avoid adding a new client that is later determined to be a duplicate of a client already on file. During this process, the transaction is classified as an add or update transaction, an additional alternate ID may be added to the database, and suspect duplicate clients are identified. See the decision tables under Finding a Matching Client.
4. Social security numbers beginning with 900 – 939 are considered invalid. Newborns must have an SSN of zero. Newborns are identified as: the first five digits of RS-ELIG-INTFC-IDENTIFIER equal to zero, and the next three digits are 940-949.
5. The date spans for certain COEs must begin on the first day of the month, the date spans for other COEs may begin on any day of the month. This is controlled by entries on the COE Edit table. On add transactions, the client application date is set to the incoming span begin date. The eligibility begin date should not be less than the client date of birth. However, if the client’s date of birth is in the same year/month of the eligibility begin date, the record is not rejected. The eligibility begin date should not be greater than 3 months in the future. If it is, the record is rejected.
6. End date must be greater than begin date. An end date of zero is assumed to be an open-ended span and will convert to 12/31/9999 on the client COE table. The date spans for certain COEs must end on the last day of the month; the date spans for other COEs may end on any day of the month. This is controlled by entries on the COE Edit table
7. The CMS Race code valid values:
CMS Race Description
1 Caucasian
2 Hispanic
3 American Indian
4 Asian
5 Black
9 Unknown
Finding A Matching Client
Definition of Fields Used in Decision Table
Field Description Field Name Source
Incoming Client ID RS-ELIG-INTD-IDENTIFIER State Elig. transaction
Incoming Previous ID RS-PREVIOUS-ID State Elig. Transaction
MMIS Client ID B-ALT-ID One of the IDs associated with the client in Omnicaid
There are several tables presented here. First, determine the source of the input transaction and start with either table 1, or 2. Those tables will either present a final outcome or direct you to either table 3 or 4 for additional logic, if necessary.
Table 1 - CMS Transactions
|Conditions |1 |2 |3 |
|Incoming Client ID exists as an MMIS Client id |Y |N |N |
|Incoming SSN, prefixed by ‘00000’, exists as an MMIS Client id |-- |Y |N |
|Actions | | | |
|Perform Table 3 - Verify-Match |X |X | |
|Perform Table 4 - Name-Search | | |X |
Table 2 - Verify-Match
|Conditions |
|Source Files: |
|CMS daily eligibility file |
| |
|Output Files: |
|NEWM.PROD.BDCMSUSZ.DATA.ALLERRS(0) – This file contain Eligibility edit and update errors |
|Remarks: |
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE LAYOUT
INPUT FILE
OMNICAID TO CMS ELIGIBILITY FILE INTERFACE
000010****************************************************************
000020* R E C I P I E N T N E W M E X I C O *
000030* OMNICAID TO CMS INTERFACE FILE *
000040* FIXED LENGTH LAYOUT OF 200 BYTES *
000060****************************************************************
000090****************************************************************
000101* DATE PROGRAMMER PROJECT *
000102*--------------------------------------------------------------*
000104* *
000090****************************************************************
000120*
000130 01 WFB10015-OMNI-TO-CMS-ELIG-REC.
000140*
000800 05 WFB10015-CMS-RECIP-ID PIC 9(14).
000900 05 WFB10015-CMS-SSN PIC 9(09).
001000 05 WFB10015-CMS-ACTION-CODE PIC X(01).
001100 05 WFB10015-CMS-RECIP-LAST-NAME PIC X(21).
001200 05 WFB10015-CMS-RECIP-FIRST-NAME PIC X(15).
001300 05 WFB10015-CMS-RECIP-MI-NAME PIC X(01).
001400 05 WFB10015-CMS-CVRG-BEGIN-DATE PIC X(10).
001500 05 WFB10015-CMS-CVRG-END-DATE PIC X(10).
001600 05 WFB10015-CMS-GENDER-CD PIC X(01).
001700 05 WFB10015-CMS-RACE-CD PIC X(01).
001800 05 WFB10015-CMS-DATE-OF-BIRTH PIC X(10).
001900 05 WFB10015-CMS-DOH-PRIOR-ID PIC 9(14).
002000 05 FILLER PIC X(43).
002200 05 WFB10015-CMS-ELG-ERR-MSG PIC X(50).
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
OMNICAID TO CMS ELIGIBILITY FILE INTERFACE
|Target |Source File |Source column |Std | | | |Note |
|Field | | |Edit |Req |Def |Specifications |Ref |
|WFB10015-CMS-SSN |CMS to OMNICAID |RS-CMS-SSN |N |A | | | |
| |Eligibility Interface | | | | | | |
| |file | | | | | | |
|WFB10015-CMS-ACTION-CODE |CMS to OMNICAID |RS-CMS-ACTION-CODE |S |A |N/A | | |
| |Eligibility Interface | | | | | | |
| |file | | | | | | |
|WFB10015-CMS-RECIP-LAST-NAME |CMS to OMNICAID |RS-CMS-RECIP-LAST-NAME |N/A |A |N/A | | |
| |Eligibility Interface | | | | | | |
| |file | | | | | | |
|WFB10015-CMS-RECIP-FIRST-NAME |CMS to OMNICAID |RS-CMS-RECIP-FIRST-NAME|N/A |A |N/A | | |
| |Eligibility Interface | | | | | | |
| |file | | | | | | |
|WFB10015-CMS-RECIP-MI-NAME |CMS to OMNICAID |RS-CMS-RECIP-MI-NAME |N/A |A |N/A | | |
| |Eligibility Interface | | | | | | |
| |file | | | | | | |
|WFB10015-CMS-CVRG-BEGIN-DATE |CMS to OMNICAID |RS-CMS-CVRG-BEGIN-DATE |D |A |N/A |Format CCYY-MM-DD, | |
| |Eligibility Interface | | | | | | |
| |file | | | | | | |
|WFB10015-CMS-CVRG-END-DATE |CMS to OMNICAID |RS-CMS-CVRG-END-DATE | |A | |Format CCYY-MM-DD | |
| |Eligibility Interface | | | | | | |
| |file | | | | | | |
|WFB10015-CMS-GENDER-CD |CMS to OMNICAID |RS-CMS-GENDER-CD |D |N/A |N/A | | |
| |Eligibility Interface | | | | | | |
| |file | | | | | | |
| WFB10015-CMS-RACE-CD |CMS to OMNICAID |RS-CMS-RACE-CD |N/A |N/A |N/A | | |
| |Eligibility Interface | | | | | | |
| |file | | | | | | |
|WFB10015-CMS-DATE-OF-BIRTH |CMS to OMNICAID |RS-CMS-DATE-OF-BIRTH |D |A |N/A |Format CCYY-MM-DD | |
| |Eligibility Interface | | | | | | |
| |file | | | | | | |
|WFB10015-CMS-DOH-PRIOR-ID |CMS to OMNICAID |RS-CMS-DOH-PRIOR-ID |N | |N/A | | |
| |Eligibility Interface | | | | | | |
| |file | | | | | | |
|WFB10015-CMS-ELG-ERR-MSG |N/A |N/A |N/A |A |N/A |Error message (see Sysdoc\SysDoc Final\04 | |
| | | | | | |Client\ 04D-5exhb-C) for detail | |
______________________________________________________________________________________________________________
LEGEND: For Req: A = Always For Std Edits: D = Date Edit V = Valid Value Edit
C = Conditionally N = Numeric Edits S = System Generated
N = Never
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE SPECIFICATION
INPUT FILE
BENDEX INTERFACE
|Description: |
|The daily Bendex interface supports updates regarding Title XVIII (Medicare) entitlement. The Information Systems Bureau (ISB) of the Administrative Services Division (ASD) of the Human Services|
|Department (HSD) receives the BENDEX interface from the Social Security Administration. ISB runs the BENDEX interface and forwards a file to the MMIS Client Subsystem to update the MMIS client |
|database. |
|Source Files: |
|Bendex transactions received from the State |
|Target Tables: |
|B_DETAIL_TB |
|B_MCARE_SPN_TB |
|Reports: |
|RB450 BENDEX Transactions Not Applied Report |
|Process Summary |
|The RS-O-36-1 Medical Management Closure report is being discontinued. |
|BENDEX is processed by program NMMB2200. The BENDEX file has 3 key elements within the BENDEX Record used by NMMB2200. |
|First is the client identification information. This consists of the HICN(Medicare ID) and/or SSN, name and dob. |
|Second is a Part A begin and end date which on the Bendex record are the HOS-Entitle and HOS-Term dates. |
|Lastly is a Part B begin and end date which on the Bendex record are the SMI-ENTITLE and SMI-TERM dates. |
| |
|When NMMB2200 reads in a record it first goes through normal validations. Logical date spans, valid HICN and/or SSN, and duplicated records are all checked for. If the record fails any of these |
|NMMB2200 rejects the record and moves on to the next record. |
|NMMB2200 then tries to find the client in Omnicaid. If the client is not found, the record is rejected and NMMB2200 goes on to the next record. To find a client, it first searches by HICN. If |
|it finds the client using HICN, it then validates the name/dob to verify the client is the same as on the input transaction. The date of birth must match exactly. The first letter of the first |
|name must match. The first five characters of the last name must match, or the surname must pass the Russell Surname test. If the name/dob validation fails, the record is rejected and the next |
|record is read. (See client sysdoc exhibits for more details about the Russell Surname test.) |
|If the client is not found using HICN, then it tries again using SSN. In the event that the client is found using SSN, NMMB2200 does name/dob validation to verify that the client is the same as|
|the client in the input transaction. If the name/dob validation fails, the record is rejected and the next record is read. If it passed the name/dob validation, the program then checks to see |
|if and when the last time the Medicare ID was updated and by what source. To do this, it checks a field on the client detail table, B-HCFA-HIC-NUM-CD. If it is found that the client has not |
|been updated before or if the last update occurred as a result of a Bendex update, then the client’s Medicare ID is updated using the incoming Bendex HICN. If the Medicare ID was updated by Buyin|
|or online then NMMB2200 rejects the transaction and immediately goes on to the next Bendex record without updating the Medicare ID on the client detail table. In other words, if there is a valid|
|Medicare ID for a client that was added either through the Buyin process or through online, it won’t be overlaid by Bendex. One last point regarding HICN update The Medicare ID update logic |
|just discussed is independent of the Medicare date span validation and therefore if it is found that the client’s HICN needs to be updated, this update takes place whether the client’s Medicare |
|spans are subsequently changed or not. |
| |
|Once the Medicare ID update logic is completed, if the record has been rejected, then program NMMB2200 moves on to Medicare span validation. The incoming record will either have a Part A span, |
|a Part B span, or both. |
|If the Bendex record has a valid and logical Part A span, NMMB2200 then compares it to the most recent Part A span in Omnicaid and updates or inserts as follows: |
|If no Part A span exists in Omnicaid, then a new Part A span is inserted using the incoming Bendex record HOS-ENTITLE(begin date) and HOS-TERM(end-date). |
|If a span exists then the following rules are followed: |
|Rule 1. If the Bendex record begin date is less than the existing Part A span begin date, then the existing Part A span is updated. The begin and end dates are replaced by the HOS-ENTITLE and|
|HOS-TERM dates respectively. |
|Rule 2. If Rule 1 does not apply and the bendex record begin date is greater than the existing Part A span end date, then a new Part A span is inserted using the incoming Bendex record |
|HOS-ENTITLE(begin date) and HOS-TERM(end-date). |
|Rule 3. If neither Rule 1 or Rule 2 apply and the bendex record end date is greater than the existing Part A begin date, then the existing Part A span is updated. The end date is replaced by the |
|HOS-TERM date. |
| |
| |
|NMMB2200 repeats the process for Part B spans but uses SMI-ENTITLE and SMI-TERM dates from the Bendex record. |
| |
|If the Bendex record has a valid and logical Part B span, NMMB2200 then compares it to the most recent Part B span in Omnicaid and updates or inserts as follows: |
|If no Part B span exists in Omnicaid, then a new Part B span is inserted using the incoming Bendex record SMI-ENTITLE(begin date) and SMIS-TERM(end-date). |
|If a span exists then the following rules are followed: |
|Rule 1. If the Bendex record begin date is less than the existing Part B span begin date, then the existing Part B span is updated. The begin and end dates are replaced by the SMI-ENTITLE and |
|SMIS-TERM dates respectively. |
|Rule 2. If Rule 1 does not apply and the bendex record begin date is greater than the existing Part B span end date, then a new Part B span is inserted using the incoming Bendex record |
|SMI-ENTITLE(begin date) and SMI-TERM(end-date). |
|Rule 3. If neither Rule 1 or Rule 2 apply and the bendex record end date is greater than the existing Part B begin date, then the existing Part B span is updated. The end date is replaced by the |
|SMI-TERM date. |
| |
|Essentially, Bendex is adding a new Part A and/or Part B span in the event none exists or the new span is more recent and not contiguous to and/or overlapping of the current span. |
|If the new span overlaps the existing span, the existing span is updated according to 2 rules. If the new span begin date is less than the existing begin date then essentially the existing span |
|is replaced with the new span. Otherwise the existing span is updated by keeping the begin date but replacing the end date only. |
|The following change was added to NMMB2200 as per plog7303. |
|Change sections S410(Part B span evaluation) and S430(Part A span evaluation) in program NMMB2200 to first evaluate the most recent existing span and the most recent incoming bendex span. The |
|spans will be compared and reconciled in the following ways: |
|If incoming bendex span end date is less than the existing spans end date then no action will take place. |
|If incoming bendex span end date is greater than the existing spans end date and the incoming spans begin date begins before the existing spans end date, then the existing spans end date will be |
|updated with the incoming bendex span end date. In this case an overlap exists and so the existing span is simply being extended. |
|If incoming bendex span end date is greater than the existing spans end date and the incoming spans begin date begins after the existing spans end date, then the incoming bendex date will be |
|inserted. The clients most recent span will then be the new bendex span. In this scenario there is no overlap but rather 2 distinct spans. This is the scenario that caused the problem described |
|in the email above. |
|If there is no existing span, the incoming bendex span will simply be inserted. |
|Essentially, there will only be 1 of 2 key actions. |
|If the incoming span overlaps the existing span in such a way that the incoming end date is greater than the existing spans end date, then the end date will be updated to the date of the incoming|
|span. |
|If no span exists or if the new incoming span begins after the most recent existing span ends, then the new incoming span will be inserted. |
| |
|Note that Medicare Part A/B spans can also be added by the CMS MMA interface. In regards to that, there are several points to keep in mind: |
| |
|1. MMA records do not come in with a HIC number, so when we have Medicare segments from MMA these clients don't get their HIC updated. |
| |
|2. When we eventually get the Bendex update for an MMA-added client, we will add the HIC number from Bendex.. |
| |
|3. Bendex will also update the Part A and Part B segments added by MMA if appropriate based on the rules documented above. |
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE LAYOUT
INPUT FILE
BENDEX INTERFACE
000010*****************************************************************
000020* R E C I P I E N T N E W M E X I C O *
000030* B E N D E X F I L E *
000040* (RS-I-12) COPYBOOK RSBENDEX *
000050*****************************************************************
000060* 06/05/90 - ANDY MORRIS - MODIFIED FOR NEW MEXICO *
000070* 08/19/96 - CHRIS EDWARDS - MODIFIED TO 400 BYTE LAYOUT *
000080*****************************************************************
000090*
000100 01 BENDEX-TRANSACTION.
000110 05 BDX-CLAIM-NUMBER.
000120 10 BENEFICIARYS-SSN PIC X(09).
000130 10 BDX-CLAIM-POS-10 PIC X(01).
000140 10 FILLER PIC X(01).
000150 05 BDX-NAME.
000160 10 BDX-LAST-NAME PIC X(12).
000170 10 BDX-FIRST-NAME PIC X(07).
000180 10 BDX-INITIAL PIC X(01).
000190 05 BDX-SEX-CODE PIC X(01).
000200 05 FILLER PIC X(07).
000300 05 BDX-STATE-AGENCY-CODE PIC X(03).
000310 05 BDX-SOURCE-CODE PIC X(01).
000320 05 BDX-CAT-ASSISTANCE PIC X(01).
000330 05 BDX-DWI-CODE PIC X.
000340 05 FILLER PIC X.
000350 05 BDX-RCD-PROC-DATE.
000360 10 BDX-PROC-MM PIC X(02).
000370 10 BDX-PROC-DD PIC X(02).
000380 10 BDX-PROC-YY PIC X(02).
000390 05 BDX-STATE-CTL-DATA PIC X(12).
000400 05 BDX-IEVS-AGENCY-CODE PIC X(04).
000410 05 BDX-OLD-BIC PIC X(02).
000420 05 BDX-SOC-SEC-XREF PIC X(09).
000430 05 BDX-PAY-STATUS-CODE PIC X(02).
000440 05 FILLER PIC X.
000450 05 BDX-MTH-BENEFIT-AMT PIC 9999V99.
000460 05 BDX-ENTITLE-DATE.
000470 10 BDX-ENTITLE-MM PIC 9(02).
000480 10 BDX-ENTITLE-CC PIC 9(02).
000490 10 BDX-ENTITLE-YY PIC 9(02).
000500 05 BDX-COMM-CODE.
000510 10 BDX-COMM-CODE-A.
000520 15 BDX-COMM-CODE-A1 PIC X(03).
000530 15 BDX-COMM-CODE-A2 PIC X(01).
000540 10 BDX-COMM-CODE-B PIC X(04).
000550 05 BDX-GROSS-AMT-PAY PIC 9999V99.
000570 05 BDX-DOEC.
000580 10 BDX-DOEC-MM PIC X(2).
000590 10 BDX-DOEC-CC PIC X(2).
000600 10 BDX-DOEC-YY PIC X(2).
000610 05 BDX-NET-MONTH-AMT-PAY PIC 9999V99.
000620 05 BDX-BLUNG-ACCT-NO PIC X(09).
000630 05 BDX-BLIC PIC X(02).
000650 05 BDX-BLUNG-TERM-DATE.
000660 10 BDX-BLUNG-TERM-MM PIC X(2).
000670 10 BDX-BLUNG-TERM-CC PIC X(2).
000680 10 BDX-BLUNG-TERM-YY PIC X(2).
000690 05 BDX-BLK-LUNG-ENTITLE-STATUS PIC X(01).
000700 05 FILLER PIC X(01).
000710 05 BDX-BLUNG-IND-PAY-AMT PIC 999V99.
000730 05 BDX-SSI-TERM-DATE.
000740 10 BDX-SSI-TERM-MM PIC X(2).
000750 10 BDX-SSI-TERM-CC PIC X(2).
000760 10 BDX-SSI-TERM-YY PIC X(2).
000770 05 BDX-SISC PIC X(01).
000780 05 BDX-RR-CLAIM-NO PIC X(11).
000790 05 BDX-RRB-STATUS-CODE PIC X(01).
000800 05 BDX-MONTH-OVERPMT-DED-AMT PIC 999V99.
000820 05 BDX-QMB-INDICATOR PIC X.
000830 05 BDX-PARTA-PREM-PAYER PIC X(03).
000850 05 BDX-ENDDTE-OVERPMT-DED.
000860 10 BDX-ENDDTE-OVERPMT-MM PIC X(2).
000870 10 BDX-ENDDTE-OVERPMT-CC PIC X(2).
000880 10 BDX-ENDDTE-OVERPMT-YY PIC X(2).
000890 05 BDX-SMI-OPTION-CD PIC X(01).
000900 05 BDX-SMI-ENTITLE-DATE.
000910 10 BDX-SMI-ENTITLE-MM PIC X(02).
000920 10 BDX-SMI-ENTITLE-CC PIC X(02).
000930 10 BDX-SMI-ENTITLE-YY PIC X(02).
000940 05 BDX-SMI-PREM-AMT-COL PIC 999V99.
000950 05 BDX-SMI-PREM-PAYER PIC X(05).
000970 05 BDX-SMI-TERM-DATE PIC X(06).
000980 05 FILLER REDEFINES BDX-SMI-TERM-DATE.
000990 10 BDX-SMI-TERM-MM PIC X(02).
001000 10 BDX-SMI-TERM-CC PIC X(02).
001010 10 BDX-SMI-TERM-YY PIC X(02).
001020 05 BDX-HOS-INS-OPTION-CODE PIC X(01).
001040 05 BDX-HOS-INS-ENTITLE-DATE PIC X(06).
001050 05 FILLER REDEFINES BDX-HOS-INS-ENTITLE-DATE.
001060 10 BDX-HOS-INS-ENTITLE-MM PIC X(02).
001070 10 BDX-HOS-INS-ENTITLE-CC PIC X(02).
001080 10 BDX-HOS-INS-ENTITLE-YY PIC X(02).
001090 05 BDX-HOS-INS-PREM-AMT PIC 999V99.
001110 05 BDX-HOS-INS-TERM-DATE PIC X(06).
001120 05 FILLER REDEFINES BDX-HOS-INS-TERM-DATE.
001130 10 BDX-HOS-INS-TERM-MM PIC X(02).
001140 10 BDX-HOS-INS-TERM-CC PIC X(02).
001150 10 BDX-HOS-INS-TERM-YY PIC X(02).
001170 05 BDX-SMI-TPL-ENT-DATE.
001180 10 BDX-SMI-TPL-ENT-MM PIC X(02).
001190 10 BDX-SMI-TPL-ENT-CC PIC X(02).
001200 10 BDX-SMI-TPL-ENT-YY PIC X(02).
001220 05 BDX-SMI-TPL-TERM-DATE.
001230 10 BDX-SMI-TPL-TERM-MM PIC X(02).
001240 10 BDX-SMI-TPL-TERM-CC PIC X(02).
001250 10 BDX-SMI-TPL-TERM-YY PIC X(02).
001260 05 BDX-STATE-COUNTY-CODE.
001270 10 BDX-RESI-STATE PIC X(02).
001280 10 BDX-RESI-COUNTY PIC X(03).
001290 05 BDX-BENEFICIARYS-SSN PIC X(09).
001300 05 BDX-DUAL-ENTIT-SSN PIC X(09).
001310 05 BDX-DUAL-ENTIT-BIC PIC X(02).
001320 05 BDX-DUAL-ENTITLE-IND PIC X(01).
001330 05 BDX-TRIPLE-ENT-SSN PIC X(09).
001340 05 BDX-TRIPLE-ENT-BIC PIC X(02).
001360 05 BDX-DIS-ONSET-DATE PIC X(06).
001370 05 FILLER REDEFINES BDX-DIS-ONSET-DATE.
001380 10 BDX-DIS-ONSET-MM PIC X(02).
001390 10 BDX-DIS-ONSET-CC PIC X(02).
001400 10 BDX-DIS-ONSET-YY PIC X(02).
001410 05 BDX-ENRQ PIC X(01).
001420 05 FILLER PIC X(02).
001430 05 BDX-XREF-SSN PIC X(09).
001440 05 BDX-XREF-BIC PIC X(02).
001450 05 BDX-DDC PIC X(01).
001460 05 BDX-RECORD-PROCESS-DATE.
001470 10 BDX-RECORD-PROCESS-MM PIC X(02).
001480 10 BDX-RECORD-PROCESS-CC PIC X(02).
001490 10 BDX-RECORD-PROCESS-YY PIC X(02).
001500 05 BDX-PARTA-TERM-DATE.
001510 10 BDX-PARTA-TERM-MM PIC X(02).
001520 10 BDX-PARTA-TERM-CC PIC X(02).
001530 10 BDX-PARTA-TERM-YY PIC X(02).
001540 05 BDX-BIRTH-DATE PIC 9(08).
001550 05 FILLER REDEFINES BDX-BIRTH-DATE.
001560 10 BDX-BIRTH-MM PIC X(02).
001570 10 BDX-BIRTH-DD PIC X(02).
001580 10 BDX-BIRTH-CC PIC X(02).
001590 10 BDX-BIRTH-YY PIC X(02).
001600 05 FILLER REDEFINES BDX-BIRTH-DATE.
001620 10 BDX-BIRTH-DATE-MMDD PIC X(04).
001630 10 FILLER PIC X(04).
001640 05 BDX-BIRTH-DATE-PROOF PIC X(01).
001650 05 FILLER PIC X(02).
001660 05 BDX-PAYMENT-CYCLING-IND PIC X.
001670 05 FILLER PIC X.
001680 05 BDX-RETRO-PAYMENT-AMOUNT PIC 99999V99.
001690 05 FILLER PIC X.
001700 05 BDX-PARTA-TPL-ENT-DATE.
001710 10 BDX-PARTA-TPL-ENT-MM PIC X(02).
001720 10 BDX-PARTA-TPL-ENT-CC PIC X(02).
001730 10 BDX-PARTA-TPL-ENT-YY PIC X(02).
001740 05 FILLER PIC X(04).
001750 05 BDX-GARNISH-AMT-WITHHELD PIC 9999V99.
001760 05 FILLER PIC X.
001770 05 BDX-DRUG-ADDICTION-ALC-CDE PIC X.
001780 05 FILLER PIC X.
001790 05 BDX-DAA-BENEFIT-DATA PIC X(07).
001800 05 FILLER PIC X.
001810 05 BDX-DAA-CURR-INSTALL-PMT PIC 9999V99.
001820 05 FILLER PIC X.
001830 05 BDX-DACI PIC X.
001840 05 FILLER PIC X.
001850 05 BDX-UNDERPAYMENT-AMT PIC 99999V99.
001860 05 FILLER PIC X.
001870 05 BDX-DAA-UP-SPECIAL-NEEDS-PMT PIC 99999V99.
001880 05 FILLER PIC X(23).
001890 05 BDX-FOR-SSA-USE-ONLY PIC X(04).
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE EXHIBIT
INPUT FILE
BENDEX INTERFACE
|Source |Target |Target |Std | | | |Note |
|Field |Table |Column |Edit |Req |Def |Specifications |Ref |
|BDX-LAST-NAME |N/A |N/A |N/A |A |N/A |The first 5 characters of the last name found on the input |3, 4 |
| | | | | | |record must match the first 5 characters of the last name | |
| | | | | | |found on the matching client detail row. If the field is | |
| | | | | | |invalid, the record is reported on the Bendex Transactions | |
| | | | | | |Not Applied Report. | |
|BDX-FIRST-NAME |N/A |N/A |N/A |A |N/A |The first character of the first name found on the input |3, 4 |
| | | | | | |record must match the first character of the first name found| |
| | | | | | |on the matching client detail row. If the field is invalid, | |
| | | | | | |the record is reported on the Bendex Transactions Not Applied| |
| | | | | | |Report. | |
|BDX-INITIAL |N/A |N/A |N/A |N |N/A | | |
|BDX-SEX-CODE |N/A |N/A |N/A |N |N/A | | |
|BDX-STATE-AGENCY-CODE |N/A |N/A |N/A |N |N/A | | |
|BDX-SOURCE-CODE |N/A |N/A |N/A |N |N/A | | |
|BDX-CAT-ASSISTANCE |N/A |N/A |N/A |A |N/A | | |
|BDX-DWI-CODE |N/A |N/A |N/A |N |N/A | | |
|BDX-RCD-PROC-DATE |N/A |N/A |N/A |N |N/A | | |
|BDX-STATE-CTL-DATA |N/A |N/A |N/A |N |N/A | | |
|BDX-IEVS-AGENCY-CODE |N/A |N/A |N/A |N |N/A | | |
|BDX-OLD-BIC |N/A |N/A |N/A |N |N/A | | |
|BDX-SOC-SEC-XREF |N/A |N/A |N/A |N |N/A |This field is used as an alternate client identifier if the |3, 4 |
| | | | | | |client detail row cannot be located using the | |
| | | | | | |BDX-CLAIM-NUMBER. | |
|BDX-PAY-STATUS-CODE |N/A |N/A |N/A |N |N/A | | |
|BDX-MTH-BENEFIT-AMT |N/A |N/A |N/A |N |N/A | | |
|BDX-ENTITLE-DATE |N/A |N/A |N/A |N |N/A | | |
|BDX-COMM-CODE |N/A |N/A |N/A |N |N/A |Must not be “NO AUTH.” If it is, the record is reported on | |
| | | | | | |the Bendex Transactions Not Applied Report. | |
|BDX-GROSS-AMT-PAY |N/A |N/A |N/A |N |N/A | | |
|BDX-DOEC |N/A |N/A |N/A |N |N/A | | |
|BDX-NET-MONTH-AMT-PAY |N/A |N/A |N/A |N |N/A | | |
|BDX-BLUNG-ACCT-NO |N/A |N/A |N/A |N |N/A | | |
|BDX-BLIC |N/A |N/A |N/A |N |N/A | | |
|BDX-BLUNG-TERM-DATE |N/A |N/A |N/A |N |N/A | | |
|BDX-BLK-LUNG-ENTITLE-STATUS |N/A |N/A |N/A |N |N/A | | |
|BDX-BLUNG-IND-PAY-AMT |N/A |N/A |N/A |N |N/A | | |
|BDX-SSI-TERM-DATE |N/A |N/A |N/A |N |N/A | | |
|BDX-SISC |N/A |N/A |N/A |N |N/A | | |
|BDX-RR-CLAIM-NO |N/A |N/A |N/A |N |N/A | | |
|BDX-RRB-STATUS-CODE |N/A |N/A |N/A |N |N/A | | |
|BDX-MONTH-OVERPMT-DED-AMT |N/A |N/A |N/A |N |N/A | | |
|BDX-QMB-INDICATOR |N/A |N/A |N/A |N |N/A | | |
|BDX-PARTA-PREM-PAYER |N/A |N/A |N/A |N |N/A | | |
|BDX-ENDDTE-OVERPMT-DED |N/A |N/A |N/A |N |N/A | | |
|BDX-SMI-OPTION-CD |N/A |N/A |N/A |C |N/A |Must not equal space if BDX-SMI-ENTITLE-DATE is not zero. If | |
| | | | | | |this is the case, the record is reported on the Bendex | |
| | | | | | |Transactions Not Applied Report. | |
|BDX-SMI-ENTITLE-DATE |B_MCARE_SPN_TB |B_BUYIN_SPN_BEG_DT |D |C |N/A | |2 |
|BDX-SMI-PREM-AMT-COL |N/A |N/A |N/A |N |N/A | | |
|BDX-SMI-PREM-PAYER |B_MCARE_SPN_TB |B_BUYIN_PYR_CD |S |C |6 | |1 |
|BDX-SMI-TERM-DATE |B_MCARE_SPN_TB |B_BUYIN_SPN_END_DT |D |C |N/A |Must not be less than BDX-SMI-ENTITLE-DATE, if so, the record|2 |
| | | | | | |is reported on the Bendex Transactions Not Applied Report. | |
|BDX-HOS-INS-OPTION-CODE |N/A |N/A |N/A |N |N/A |Must not equal space if BDX-HOS-INS-ENTITLE-DATE is not zero.| |
| | | | | | |If this is the case, the record is reported on the Bendex | |
| | | | | | |Transactions Not Applied Report. | |
|BDX-HOS-INS-ENTITLE-DATE |B_MCARE_SPN_TB |B_BUYIN_SPN_BEG_DT |D |C |N/A | |2 |
|BDX-HOS-INS-PREM-AMT |N/A |N/A |N/A |N |N/A | | |
|BDX-HOS-INS-TERM-DATE |B_MCARE_SPN_TB |B_BUYIN_SPN_END_DT |D |C |N/A |Must not be less than BDX-HOS-INS-ENTITLE-DATE, if so, the |2 |
| | | | | | |record is reported on the Bendex Transactions Not Applied | |
| | | | | | |Report. | |
|BDX-SMI-TPL-ENT-DATE |N/A |N/A |N/A |N |N/A | | |
|BDX-SMI-TPL-TERM-DATE |N/A |N/A |N/A |N |N/A | | |
|BDX-RESI-STATE |N/A |N/A |N/A |N |N/A | | |
|BDX-RESI-COUNTY |N/A |N/A |N/A |N |N/A | | |
|BDX-BENEFICIARYS-SSN |N/A |N/A |N/A |N |N/A | | |
|BDX-DUAL-ENTIT-SSN |N/A |N/A |N/A |N |N/A | | |
|BDX-DUAL-ENTIT-BIC |N/A |N/A |N/A |N |N/A | | |
|BDX-DUAL-ENTITLE-IND |N/A |N/A |N/A |N |N/A | | |
|BDX-TRIPLE-ENT-SSN |N/A |N/A |N/A |N |N/A | | |
|BDX-TRIPLE-ENT-BIC |N/A |N/A |N/A |N |N/A | | |
|BDX-DIS-ONSET-DATE |N/A |N/A |N/A |N |N/A | | |
|BDX-ENRQ |N/A |N/A |N/A |N |N/A | | |
|BDX-XREF-SSN |N/A |N/A |N/A |N |N/A | | |
|BDX-XREF-BIC |N/A |N/A |N/A |N |N/A | | |
|BDX-DDC |N/A |N/A |N/A |N |N/A | | |
|BDX-RECORD-PROCESS-DATE |N/A |N/A |N/A |N |N/A | | |
|BDX-PARTA-TERM-DATE |N/A |N/A |N/A |N |N/A | | |
|BDX-BIRTH-DATE |N/A |N/A |N/A |N |N/A |The birth year found on the input record must match the birth|3, 4 |
| | | | | | |year on the matching client detail row. If it does not, the | |
| | | | | | |record is reported on the Bendex Transactions Not Applied | |
| | | | | | |Report. | |
|BDX-BIRTH-DATE-PROOF |N/A |N/A |N/A |N |N/A | | |
|BDX-PAYMENT-CYCLING-IND |N/A |N/A |N/A |N |N/A | | |
|BDX-RETRO-PAYMENT-AMOUNT |N/A |N/A |N/A |N |N/A | | |
|BDX-PARTA-TPL-ENT-DATE |N/A |N/A |N/A |N |N/A | | |
|BDX-GARNISH-AMT-WITHHELD |N/A |N/A |N/A |N |N/A | | |
|BDX-DRUG-ADDICTION-ALC-CDE |N/A |N/A |N/A |N |N/A | | |
|BDX-DAA-BENEFIT-DATA |N/A |N/A |N/A |N |N/A | | |
|BDX-DAA-CURR-INSTALL-PMT |N/A |N/A |N/A |N |N/A | | |
|BDX-DACI |N/A |N/A |N/A |N |N/A | | |
|BDX-UNDERPAYMENT-AMT |N/A |N/A |N/A |N |N/A | | |
|BDX-DAA-UP-SPECIAL-NEEDS-PMT |N/A |N/A |N/A |N |N/A | | |
|BDX-FOR-SSA-USE-ONLY |N/A |N/A |N/A |N |N/A | | |
Notes:
1. BDX-SMI-PREM-PAYER B_BUYIN_PAYOR_CD
320. 1
CIVIL 2
PRITP 3
RRB 4
SELF 5
Space 6
2. BDX-SMI-ENTITLE-DATE, BDX-SMI-TERM-DATE, BDX-HOS-INS-ENTITLE-DATE, BDX-HOS-INS-TERM-DATE, and BDX-SMI-PREM-PAYER must not all be zeroes/spaces. If this is the case, the record is reported on the Bendex Transactions Not Applied Report.
If BDX-HOS-INS-ENTITLE-DATE is valid, B_BUYIN_MCARE_CD on B_MCARE_SPN_TB is set to “A”, and a Medicare span is written using the BDX-HOS-INS-ENTITLE-DATE for B_BUYIN_SPN_BEG_DT AND BDX-HOS-INS-TERM-DATE for B_BUYIN_SPN_END_DT. If BDX-SMI-ENTITLE-DATE is valid, B_BUYIN_MCARE_CD on B_MCARE_SPN_TB is set to “B”, and a Medicare span is written using the BDX-SMI-ENTITLE-DATE for B_BUYIN_SPN_BEG_DT AND BDX-SMI-TERM-DATE for B_BUYIN_SPN_END_DT. If both BDX-HOS-INS-ENTITLE-DATE and BDX-SMI-ENTITLE-DATE are populated on the input record, two Medicare spans will be written, one for Part A and one for Part B.
3. The system attempts to find the client on the MMIS using the input Bendex transaction HICN number, contained in the field BDX-CLAIM-NUMBER. If a client is found on the MMIS with a Medicare Id that matches the incoming HICN number, then the system checks name and date of birth to confirm the match. If the date of birth, the first five characters of the client’s last name, and the first character of the client’s first name all match the data on the input transaction, then the client is considered to be a match, and the processing of the input transaction to update the client’s medicare span data continues. If the name and DOB data don’t match the input transaction, then the transaction is rejected and an appropriate error message is printed on the error report.
If the client cannot be found using the HICN, then the system attempts to locate the client using the SSN field BDX-SOC-SEC-XREF on the incoming transaction. If the system finds a match on SSN, and the date of birth, the first five characters of the client’s last name, and the first character of the client’s first name all match the data on the input transaction, then the client is considered to be a match, and the client’s Medicare ID on the client detail table will be updated with the HICN number on the input transaction and the processing of the input transaction to update the client’s medicare span data continues.
4. Once a client is found on the MMIS that matches the input transaction, the system checks the client’s Medicare span with the most recent end date. If that span was updated as a result of the Medicare Buyin process, then the input transaction is rejected with an appropriate error message.
_________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always
C = Conditionally
N = Never
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE SPECIFICATION
INPUT FILE
BUY-IN TO MMIS INTERFACE
|Description: |
|On a monthly basis, the State receives a file from the Social Security Administration (SSA) that contains information for clients that are receiving Medicare. The State performs the buy-in |
|process by which the State purchases Medicare Part A, Part B, or both for Medicaid clients who are entitled to the buy-in. The Information Systems Bureau (ISB) of the Administrative Services |
|Division (ASD) of the Human Services Department (HSD) handles buy-in processing (beginning and ending the buy-in and paying Medicare premiums to SSA) and forwards a client buy-in file to the |
|MMIS Client Subsystem to update the MMIS client database. This file is used to update the Client Medicare Span Table. |
|Source Files: |
|Tape input from ISB on a monthly basis |
|Target Tables: |
|B_MCARE_SPN_TB |
|Reports: |
|RB420 Buy-In Transactions Not Applied |
|RB430 Buy-In Financial Report |
|RB440 Buy-In Financial Detail Report |
|Process Summary |
|Remarks: |
|This process reads the input file that contains client Medicare buy-in information and edits the input for validity and consistency. If the input is valid, the client SSN on the input record |
|is used to access the client detail table to verify that the client is on the database. Based on eligibility segments and buy-in information currently on the table for the client, the program|
|updates an existing span or adds a new span to the B_MCARE_SPN_TB. |
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE LAYOUT
INPUT FILE
BUY-IN TO MMIS INTERFACE
*****************************************************************
* N E W M E X I C O *
* S S A B U Y - I N T R A N S A C T I O N *
* (RS-I-06) COPYBOOK RSBUYIN *
*****************************************************************
* 08/90 M. BURGOYNE - NEW MEXICO SPECIFICS *
* 08/93 J. PENA - REDEFINE SOC-SEC-NO, SO CAN DETERMINE IF *
* JP3223 FIRST BYTE IS EQUAL 'T'. THIS INDICATES *
* THAT RECORD IS TOTAL RECORD. *
*****************************************************************
01 BUYIN-RECORD.
*
05 BUYIN-CLAIM-NO.
10 BUYIN-SOC-SEC-NO PIC X(09).
10 BUYIN-SOC-SEC-NO-T REDEFINES BUYIN-SOC-SEC-NO.
15 BUYIN-SOC-SEC-NO-1 PIC X(01).
88 BUYIN-TOTAL-REC VALUE 'T'.
15 FILLER PIC X(08).
10 BUYIN-BIC PIC X(03).
05 BUYIN-DATA.
10 BUYIN-LAST-NAME PIC X(12).
10 BUYIN-FIRST-NAME PIC X(07).
10 BUYIN-INITIAL PIC X(01).
10 BUYIN-SEX PIC X(01).
10 BUYIN-BIRTH-DATE.
15 BUYIN-BIRTH-MM PIC X(02).
15 BUYIN-BIRTH-DD PIC X(02).
15 BUYIN-BIRTH-YY PIC X(02).
10 FILLER PIC X(07).
10 BUYIN-STATE-CODE PIC X(03).
10 BUYIN-ELIG-CODE PIC X(01).
10 FILLER PIC X(05).
10 BUYIN-PREM-DATE.
15 BUYIN-PREM-MM PIC X(02).
15 BUYIN-PREM-YY PIC X(02).
10 BUYIN-TRANS-CODE.
15 BUYIN-TRANS-CD-1 PIC X(02).
15 BUYIN-TRANS-CD-2 PIC X(02).
10 BUYIN-TRANS-DATE.
15 BUYIN-TRANS-MM PIC X(02).
15 BUYIN-TRANS-YY PIC X(02).
10 BUYIN-RECIP-ID PIC X(09).
10 FILLER PIC X(14).
10 BUYIN-PREM-AMT PIC 9(04)V99.
10 FILLER PIC X(04).
05 FILLER
REDEFINES BUYIN-DATA.
10 FILLER PIC X(21).
10 BUYIN-NEW-CLAIM-NO PIC X(12).
10 FILLER PIC X(10).
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE EXHIBIT
INPUT FILE
BUY-IN TO MMIS INTERFACE
|Source |Target |Target |Std | | | |Note |
|Field |Table |Column |Edit |Req |Def |Specifications |Ref |
|BUYIN-SOC-SEC-NO |N/A |N/A |N/A |N/A |N/A |This field is not currently used. | |
|BUYIN-BIC |N/A |N/A |N/A |N/A |N/A |This field is not currently used. | |
|BUYIN-LAST-NAME |N/A |N/A |N/A |N/A |N/A |First 3 characters of the field must match the first 3 |2 |
| | | | | | |characters of the client last name on the matching client | |
| | | | | | |detail row. If not, report the record on the Buy-In | |
| | | | | | |Transaction Not Applied report. | |
|BUYIN-FIRST-NAME |N/A |N/A |N/A |A |N |The first character of the field must match the first |2 |
| | | | | | |character of the client first name on the matching client | |
| | | | | | |detail row. If not, report the record on the Buy-In | |
| | | | | | |Transaction Not Applied report. | |
|BUYIN-INITIAL |N/A |N/A |N/A |N/A |N/A |This field is not currently used. | |
|BUYIN-SEX |N/A |N/A |N/A |N/A |N/A |This field is not currently used. | |
|BUYIN-BIRTH-DATE |N/A |N/A |D |A |N |Field must be equal to the birth date stored on the |2 |
| | | | | | |matching client detail row. If not, report the record on | |
| | | | | | |the Buy-In Transaction Not Applied report. | |
|BUYIN-STATE-CODE |N/A |N/A |N/A |A |N |The state code on the record must be equal to “320.” If | |
| | | | | | |not, display a message and terminate processing. | |
|BUYIN-ELIG-CODE |N/A |N/A |N/A |N/A |N |This field is only used for determining which monetary | |
| | | | | | |category on the Buy-In Financial Report to add the premium| |
| | | | | | |amount. | |
|BUYIN-PREM-DATE |B_MCARE_SPN_TB |B_BUYIN_PREM_DT |N |A |N |This field must be numeric. If greater than zero, the | |
| | | | | | |format of the field should be MMYY (month/year). The | |
| | | | | | |first two digits must be 01 – 12. Reformat the field into| |
| | | | | | |MMDDYY and set DD to 01. Convert the date to MMDDYYYY | |
| | | | | | |format so that is can be stored as a DB2 date. | |
|BUYIN-TRANS-CD-1 |B_MCARE_SPN_TB |B_BUYIN_SMITXN1_CD |V |A |N |Use the group level name BUYIN-TRANS-CODE to validate the |1 |
| | | | | | |code using copybook RSBUYCDT. If field is invalid, report| |
| | | | | | |the record on the Buy-In Transactions Not Applied report. | |
|BUYIN-TRANS-CD-2 |B_MCARE_SPN_TB |B_BUYIN_SMITXN1_CD |V |A |N |Use the group level name BUYIN-TRANS-CODE to validate the |1 |
| | | | | | |code using copybook RSBUYCDT. If field is invalid, report| |
| | | | | | |the record on the Buy-In Transactions Not Applied report. | |
|BUYIN-TRANS-MM |B_MCARE_SPN_TB |Month used for |N/A |N |Current |If this field is non-zero, combine it with the | |
| | |B_BUYIN_SPN_BEGIN_DT | | |Month |BUYIN-TRANS-YY field, use “01” as the day and convert to | |
| | | | | | |DB2 date. If not valid, default current date. | |
|BUYIN-TRANS-YY |B_MCARE_SPN_TB |Year used for |N/A |N |Current |If this field is non-zero, combine it with the | |
| | |B_BUYIN_SPN_BEG_DT | | |Year |BUYIN-TRANS-MM field, use “01” as the day and convert to | |
| | | | | | |DB2 date. If not valid, default current date. | |
|BUYIN-RECIP-ID |N/A |N/A |N |A |N |Field must be numeric. If not valid, report the record on|2 |
| | | | | | |the Buy-In Transactions Not Applied report. Used to | |
| | | | | | |identify the client by the SSN if the client is not found | |
| | | | | | |using the BUYIN-CLAIM-NO. | |
|BUYIN-PREM-AMT |B_MCARE_SPN_TB |B_BUYIN_PREM_AMT |N |A |N |Field must be numeric. If not valid, report the record on| |
| | | | | | |the Buy-In Transactions Not Applied report. | |
|BUYIN-NEW-CLAIM-NO |B_DETAIL_TB |B_MCARE_ID |N |C |N |If BUYIN-TRANS-CD-1 is equal to “23,” use | |
| | | | | | |BUYIN-NEW-CLAIM-NO to update B_MCARE_ID. | |
Notes:
1. The combination of BUYIN-TRANS-CD-1 and BUYIN-TRANS-CD-2 determines what type of action will be performed. The10th position of the HIC number on the input record determines whether the action is performed for Part A, Part B, or both. The types of action are as follows:
1 = ACCRETE ONGOING
2 = DELETE
3 = ACCRETE MODIFY
4 = DELETE MODIFY
5 = FUTURE ENTITLEMENT
6 = HICN CHANGE
The combination of BUYIN-TRANS-CD-1 and BUYIN-TRANS-CD-2 is translated to a type of action as follows:
|Combination of BUYIN-TRANS-CD-1 |TRANS-TYPE |
|and BUYIN-TRANS-CD-2 | |
|1125 |1 |
|1128 |1 |
|1161 |1 |
|1162 |1 |
|1163 |1 |
|1164 |1 |
|1165 |1 |
|1167 |1 |
|1172 |1 |
|1175 |1 |
|1180 |1 |
|1184 |1 |
|1185 |1 |
|1190 |1 |
|14 |2 |
|15 |2 |
|16 |2 |
|1728 |2 |
|1750 |2 |
|1751 |2 |
|1753 |2 |
|1759 |2 |
|1772 |2 |
|1776 |2 |
|1781 |2 |
|1787 |2 |
|2261 |5 |
|2262 |5 |
|2263 |5 |
|2284 |5 |
|23 |6 |
|2350 |6 |
|2351 |6 |
|2353 |6 |
|2361 |6 |
|2362 |6 |
|2363 |6 |
|2364 |6 |
|2375 |6 |
|2376 |6 |
|2381 |6 |
|2384 |6 |
|2399 |6 |
|41 |1 |
|4211 |3 |
|4214 |4 |
|4215 |4 |
|4216 |4 |
|4241 |1 |
|4267 |3 |
|4268 |3 |
|4269 |4 |
|4291 |1 |
|4368 |3 |
|4369 |4 |
|4399 |1 |
|91 |1 |
• If the buy-in-trans-type is equal to “1” (accrete ongoing) or “5” (future entitlement) and the10th position of the HIC number on the input record is equal to “K”, “J”, or “M” and there is no existing Part B row, then create a new Part B row. If the 10th position of the HIC number on the input record is not equal to “K,” “J,” or “M,” then create a new Part A row on the BUYIN_SPAN_TB for the client and create a new Part B row on the BUYIN_SPAN_TB for the client.
• If the buy-in-trans-type is equal to “1” (accrete ongoing) or “5” (future entitlement) and there is an existing Part B row, then update the matching row.
• If the buy-in-trans-type is equal to “2” (closure), then there must be at least one Part B row (open or close) on the BUYIN_SPAN_TB for the client. If the BUYIN_SPAN_END_DT is greater than zero (closed) and the buyin-trans-cd-1 field is equal to “14,” “15,” or “16,” then bypass the record and report the record with a message of “No Open B Mcare Seg For Closure Tran 14 15 or 16.” If the buyin-trans-cd-1 is not equal to “14,” “15,” or “16,” then update the matching row.
• If the buy-in-trans-type is equal to “2” (closure) and the matching Part B row is open and the buy-in-trans-date is less than the row begin date and the buy-in trans-cd-1 is equal to “14,” “15,” or “16,” then bypass the record and report the record with a message of “Trans Date < Begin Date For Closure 14, 15, or 16.” If the buyin-trans-cd-1 is not equal to “14,” “15,” or “16,” then close the row by moving the buy-in-trans-date to the row end date.
• If the buy-in-trans-type is equal to “2” (closure) and the matching Part B row is open and the buy-in-trans-date is greater than or equal to the row begin date and the buy-in trans-cd-1 is equal to “14,” “15,” or “16,” then close the row by moving the buy-in-trans-date to the row end date. If the buy-in trans-cd-1 is not equal to “14,” “15,” or “16,” then update the matching row.
• If the buy-in-trans-type is equal to “3” (accrete modify) and there are no matching BUYIN_SPAN_TB rows for the client and the 10th position of the Medicate claim number on the input buy-in record is equal to “J,” “K,” or “M,” then create a new Part B row for the client. If the claim number is not “J,” “K,” or “M,” then create a new Part A row and a new Part B row for the client.
• If the buy-in-trans-type is equal to “3” (accrete modify) and there is an open Part B row for the client and the update source for the row is “BENDX,” then update the Part B row with the trans-code, premium amount, and premium date from the input record and set the payor code to “1.” If the update source is not equal to “BENDX,” then update the trans-code, premium amount, and premium date from the input record, set the payor code to “1,” and if the buy-in-trans-date field is less than the BUYIN_SPAN_BEGIN_DT on the BUYIN_SPAN_TB row, move it to the BUYIN_SPAN_BEGIN_DT on the row. If the update source is not “BENDX” and the 10th position of the Medicate claim number on the input buy-in record is not equal to “J,” “K,” or “M,” then also create a new Part A row for the client.
• If the buy-in-trans-type is equal to “3” (accrete modify) and the current Part B row for the client is closed and the buy-in-trans-date is less than the BUYIN_SPAN_END_DT, and the update source for the row is “BENDX,” then update the closed row. If the update source is not “BENDX,” then open the row by moving zero to the MCRE_END_DT, update other fields on the row from the buy-in record, and if the buy-in-trans-date is less than the MCARE_BEGIN_DT on the row, move it to the MCARE_BEGIN_DT on the row.
• If the buy-in-trans-type is equal to “4” (closure modify), there must be at least one Part B row for the client. If not, bypass the record and report the record on the Buy-In Transactions Not Applied report with a message of “No Medicare Segment For Closure Trans.”
• If the buy-in-trans-type is equal to “4” (closure modify) and the current Part B row is closed and the buy-in-trans-date is less than the BUYIN_SPAN_BEGIN_DT on the row and the buy-in-trans-code is equal to “4215,” then close all Part A and Part B rows. If the buy-in-trans-cd is not “4215,” then update the matching Part B row.
• If the buy-in-trans-type is equal to “4” (closure modify) and the current Part B row is closed and the buy-in-trans-date is greater than the BUYIN_SPAN_BEGIN_DT on the row, bypass the record and report the record with an error message of “Trans Date > Begin Date For Open Closure.”
• If the buy-in-trans-type is equal to “4” (closure modify) and the current Part B row is open and the buy-in-trans-date is greater than the BUYIN_SPAN_BEGIN_DT on the row and the buy-in-trans-cd is equal to “4216,” then close all Part A and Part B rows. If the buy-in-trans-cd is not “4216,” then update the matching Part B row.
• If the buy-in-trans-type is equal to “4” (closure modify) and the current Part B row is open and the buy-in-trans-date is not greater than the BUYIN_SPAN_BEGIN_DT on the row, then bypass the record and report it with an error message of “TRANS DATE > BEGIN DATE FOR OPEN CLOSURE.”
2. The system attempts to find the client on the MMIS using the input Buyin transaction HICN number, contained in the field BUYIN-CLAIM-NO. If a client is found on the MMIS with a Medicare Id that matches the incoming HICN number, then the system checks name and date of birth to confirm the match. The system considers it a match if the following data on the MMIS match the input transaction:
1st 3 characters of last name, and 1st character of the first name, and the month/year of the DOB
OR
1st 3 characters of last name, and 1st character of the first name, and the year of the DOB
OR
1st 3 characters of last name, and 1st character of the first name, and the month of the DOB
OR
1st 3 characters of last name and the month/year of the DOB
OR
1st character of the first name, and the month/year of the DOB
If the client is considered to be a match, the processing of the input transaction to update the client’s medicare span data continues. If the name and DOB data don’t match the input transaction, then the transaction is rejected and an appropriate error message is printed on the error report.
If the client cannot be found using the HICN, then the system attempts to locate the client using the SSN field BUYIN-RECIP-ID on the incoming transaction. If the system finds a client based on SSN, then it performs the same name/DOB matching logic detailed above to verify the client.
_________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always For Std Edits: D = Date Edit V = Valid Value Edit
C = Conditionally N = Numeric Edits S = System Generated
N = Never
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE SPECIFICATION
OUPUT FILE
SWIPE CARD INTERFACE
|Description: |
|This external interface file is created on a daily basis to provide the swipe card vendor with new Medicaid eligible clients that need a new card and clients that have requested a replacement |
|card. |
|Source Tables: |
|B_DETAIL_TB |
|B_SWIPE_CARD_TB |
|B_EXTRT_REQ_TB |
|Target Files: |
|Daily swipe card extract |
|Reports: |
|RB090 – Swipe Card Request Error Report |
|Remarks: |
|The system issues swipe cards on a daily basis in the following situations: |
| |
|° The addition of a new Medicaid-eligible client |
|° The addition of Medicaid eligibility for a known client who was previously only eligible for state-funded services |
|° Online request for the replacement of a swipe card |
|° Change in the first three characters of the client's last name, or change in the first character of the client's first name, or change in the year portion of the date of birth |
| |
|In all of these cases, before generating a swipe card, the system checks to see if the client is in a COE that is eligible to receive a swipe card, and whether there is a valid address on file |
|for the client. In addition, the system will not send a swipe card if the client’s date of death is populated. As of October 2009, if a client doesn’t have a current coe that is swipe card |
|enabled (by virtue of the swipe card issuance indicator field on the COE edit table (BCOEEDTB) a swipe card will not be produced. |
| |
|RAT1401 instituted a hierarchical address search using the following order – Swipe Card Address, Authorized Rep, Payee, Mailing and Residential. |
| |
|RAT1140 – Before using the residence address for the extract file, check if LINE1 of the residence address is equal to one of the following default address. If it is, then treat it as ‘address |
|not found’, this means don’t populate the extract file with the default address. |
|Default addresses: |
|'DOH 1190 ST FRANCIS DRIVE' |
|'ISD 2009 SOUTH PACHECO ST' |
|'CYFD 205 MONTEZUMA ' |
|'UNKNOWN |
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE LAYOUT
OUPUT FILE
SWIPE CARD INTERFACE
000010**********************************************************
000020* *
000030* COPYBOOK: CARDVEND *
000040* *
000050**********************************************************
000060* CHANGE LOG *
000070* *
000080**********************************************************
000090* *
000100* DATE ANALYST PROJECT DESCRIPTION *
000110* -------------------------------------------------------*
000120* XX/XX/XX XXX 210013 NEW COPYBOOK FOR THE *
000130* ELIGIBILITY SWIPE CARD *
000140* PROJECT. *
000150* *
000160**********************************************************
000170* *
000180* *
000190* CARD VENDOR RECORD - SENT TO THE CARD VENDOR TO
000200* PRODUCE A SWIPE CARD. *
000210* *
000220* *
000230**********************************************************
000240*
000250 01 CARD-VENDOR-RECORD.
000260 05 CV-BIN-NUMBER PIC 9(06).
000270 05 CV-CARD-CNTRL-NUMBER PIC 9(08).
000280 05 CV-CURRENT-RECIP-ID PIC X(14).
000290 05 CV-RECIP-BIRTHDATE PIC X(10).
000300 05 CV-RECIP-NAME.
000310 10 CV-RECIP-LAST-NAME PIC X(21).
000320 10 CV-RECIP-FIRST-NAME PIC X(15).
000330 10 CV-RECIP-INITIAL PIC X(01).
05 CV-PAYEE-NAME.
10 CV-PAYEE-LAST-NAME PIC X(21).
10 CV-PAYEE-FIRST-NAME PIC X(15).
10 CV-PAYEE-INITIAL PIC X(01).
000340 05 CV-RECIP-MAIL-ADDRESS.
000350 10 CV-MAIL-ADDRESS-LINE-1 PIC X(25).
000360 10 CV-MAIL-ADDRESS-LINE-2 PIC X(25).
000370 10 CV-MAIL-ADDRESS-CITY PIC X(20).
000380 10 CV-MAIL-ADDRESS-STATE PIC X(02).
000390 10 CV-MAIL-ADDRESS-ZIP5 PIC X(05).
000400 10 CV-MAIL-ADDRESS-ZIP4 PIC X(04).
000410 05 CV-ISSUE-DATE PIC X(10).
000420 05 CV-SCI-IND PIC X(01).
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE EXHIBIT
OUPUT FILE
SWIPE CARD INTERFACE
|Source |Source |Target | | | |Note |
|Table |Column |Field |Req |Def |Specifications |Ref |
|N/A |N/A |CV-CARD-CNTRL-NUMBER |A |N/A |Sequential number unique to each card record. This number is| |
| | | | | |also maintained on the B_SWIPE_CARD_TB for the client | |
|B_DETAIL_TB |Program Generated |CV-CURRENT-RECIP-ID |A |N/A |The new swipe card ID is in the format of “00003” followed by| |
| | | | | |the client system ID, contained in field B_SYS_ID. | |
|B_DETAIL_TB |B_DOB_DT |CV-RECIP-BIRTHDATE |A |N/A | | |
|B_DETAIL_TB |B_LAST_NAM |CV-RECIP-LAST-NAME |A |N/A | | |
|B_DETAIL_TB |B_FST_NAM |CV-RECIP-FIRST-NAME |A |N/A | | |
|B_DETAIL_TB |B_MI_NAM |CV-RECIP-INITIAL |A |Spaces | | |
|B_DETAIL_TB |B_REP_LAST_NAM |CV-PAYEE-LAST-NAME |A |N/A | |2 |
|B_DETAIL_TB |B_REP_FST_NAM |CV-PAYEE-FIRST-NAME |A |N/A | |2 |
|B_DETAIL_TB |B_REP_MI_NAM |CV-PAYEE-INITIAL |A |Spaces | |2 |
|B_ADR_TB |B_LINE1_AD |CV-MAIL-ADDRESS-LINE-1 |A |N/A | |1 |
|B_ADR_TB |B_LINE2_AD |CV-MAIL-ADDRESS-LINE-2 |A |N/A | |1 |
|B_ADR_TB |B_CITY_NAM |CV-MAIL-ADDRESS-CITY |A |N/A | |1 |
|B_ADR_TB |B_ST_CD |CV-MAIL-ADDRESS-STATE |A |N/A | |1 |
|B_ADR_TB |B_ZIP5_CD |CV-MAIL-ADDRESS-ZIP5 |A |N/A | |1 |
|B_ADR_TB |B_ZIP4_CD |CV-MAIL-ADDRESS-ZIP4 |A |N/A | |1 |
|N/A |N/A |CV-ISSUE-DATE |A |Current Date | | |
|N/A |N/A |CV-SCI-IND |N |N/A |This field will be initialized to spaces for Swipe Cards but | |
| | | | | |will be used in the Privacy Notice file | |
Notes:
1. The rules to determine which address to use from among the various addresses maintained on a client are as follows:
Use the swipe card override address entered on the swipe card tab page if it exists. If it does not exist, use the authorized rep. If the authorized rep address is not found, use the payee address. If the payee address is not found use the client mailing address. If mailing address does not exist, use residential address.
2. CV-PAYEE-LAST-NAME, CV-PAYEE-FIRST-NAME, and CV-PAYEE-INITIAL will either be blank or contain REP-PAYEE information for client. When populated, REP-PAYEE will be used by INK Impressions as addressee instead of client. When blank, CV-RECIP-LAST-NAME, CV-RECIP-FIRST-NAME, and CV-RECIP-INITIAL will be used to populate addressee name field by INK Impressions.
_________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always
C = Conditionally
N = Never
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE SPECIFICATION
OUPUT FILE
PRIVACY NOTICE FILE INTERFACE
|Description: |
|This external interface file is created on a daily basis to provide the swipe card vendor with new Medicaid eligible clients that need a Privacy Notice letter sent. The same file format utilized |
|for the swipe card is used again for the privacy notice file. The Privacy Notice file is generated using “S” (swipe card) extract records from the Extract Request table (BEXTRTTB). A check is |
|made to the Client Auxiliary Data table (BAUXDTTB) to see if a card has already been sent before a request is generated. If a Client is eligible for Medicaid and has not had a notice already |
|sent, a request is generated. As of October 21, 2009, if a client doesn’t have a current coe that is swipe card enabled (by virtue of the swipe card issuance indicator field on the COE edit |
|table (BCOEEDTB) a swipe card will not be produced. |
| |
|Using the privacy notice extract file, the swipe card vendor creates a customized transmittal letter (notice) that is sent to the client along with the privacy notice. We shouldn’t be |
|generating a privacy notice extract for any client that doesn’t have a current COE that is swipe card enabled. See the sample transmittal notices in Exhibit C at the end of this chapter. |
|Source Tables: |
|B_DETAIL_TB |
|B_ADR_TB |
|B_COE_SPN_TB |
|B_AUX_DT_TB |
|Target Files: |
|Daily privacy notice file |
|Reports: |
|Remarks: |
|The file is sent to the swipe card vendor (currently Election People a.k.a. Ink Impressions) for letter creation and dissemination |
| |
|RAT1401 instituted a hierarchical address search using the following order – Swipe Card Address, Authorized Rep, Payee, Mailing and Residential. |
| |
|RAT1140 – Before using the residence address for the extract file, check if LINE1 of the residence address is equal to one of the following default address. If it is, then treat it as ‘address |
|not found’, this means don’t populate the extract file with the default address. |
|Default addresses: |
|'DOH 1190 ST FRANCIS DRIVE' |
|'ISD 2009 SOUTH PACHECO ST' |
|'CYFD 205 MONTEZUMA ' |
|'UNKNOWN |
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE LAYOUT
OUPUT FILE
PRIVACY NOTICE FILE INTERFACE
000240*
000250 01 CARD-VENDOR-RECORD.
000260 05 CV-BIN-NUMBER PIC 9(06).
000270 05 CV-CARD-CNTRL-NUMBER PIC 9(08).
000280 05 CV-CURRENT-RECIP-ID PIC X(14).
000290 05 CV-RECIP-BIRTHDATE PIC X(10).
000300 05 CV-RECIP-NAME.
000310 10 CV-RECIP-LAST-NAME PIC X(21).
000320 10 CV-RECIP-FIRST-NAME PIC X(15).
000330 10 CV-RECIP-INITIAL PIC X(01).
05 CV-PAYEE-NAME.
10 CV-PAYEE-LAST-NAME PIC X(21).
10 CV-PAYEE-FIRST-NAME PIC X(15).
10 CV-PAYEE-INITIAL PIC X(01).
000340 05 CV-RECIP-MAIL-ADDRESS.
000350 10 CV-MAIL-ADDRESS-LINE-1 PIC X(25).
000360 10 CV-MAIL-ADDRESS-LINE-2 PIC X(25).
000370 10 CV-MAIL-ADDRESS-CITY PIC X(20).
000380 10 CV-MAIL-ADDRESS-STATE PIC X(02).
000390 10 CV-MAIL-ADDRESS-ZIP5 PIC X(05).
000400 10 CV-MAIL-ADDRESS-ZIP4 PIC X(04).
000410 05 CV-ISSUE-DATE PIC X(10).
000420 05 CV-SCI-IND PIC X(01).
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE EXHIBIT
OUPUT FILE
PRIVACY NOTICE FILE INTERFACE
|Source |Source |Target | | | |Note |
|Table |Column |Field |Req |Def |Specifications |Ref |
|N/A |N/A |CV-CARD-CNTRL-NUMBER |N |N/A |Sequential number unique to each card record. This | |
| | | | | |number is also maintained on the B_SWIPE_CARD_TB for| |
| | | | | |the client | |
|B_DETAIL_TB |B_CURR_ID |CV-CURRENT-RECIP-ID |A |N/A | | |
|B_DETAIL_TB |B_DOB_DT |CV-RECIP-BIRTHDATE |N |N/A | | |
|B_DETAIL_TB |B_LAST_NAM |CV-RECIP-LAST-NAME |N |N/A | | |
|B_DETAIL_TB |B_FST_NAM |CV-RECIP-FIRST-NAME |N |N/A | | |
|B_DETAIL_TB |B_MI_NAM |CV-RECIP-INITIAL |N |Spaces | | |
|B_DETAIL_TB |B_REP_LAST_NAM |CV-PAYEE-LAST-NAME |A |N/A | |2 |
|B_DETAIL_TB |B_REP_FST_NAM |CV-PAYEE-FIRST-NAME |A |N/A | |2 |
|B_DETAIL_TB |B_REP_MI_NAM |CV-PAYEE-INITIAL |C |Spaces | |2 |
|B_ADR_TB |B_LINE1_AD |CV-MAIL-ADDRESS-LINE-1 |A |N/A | |1 |
|B_ADR_TB |B_LINE2_AD |CV-MAIL-ADDRESS-LINE-2 |A |N/A | |1 |
|B_ADR_TB |B_CITY_NAM |CV-MAIL-ADDRESS-CITY |A |N/A | |1 |
|B_ADR_TB |B_ST_CD |CV-MAIL-ADDRESS-STATE |A |N/A | |1 |
|B_ADR_TB |B_ZIP5_CD |CV-MAIL-ADDRESS-ZIP5 |A |N/A | |1 |
|B_ADR_TB |B_ZIP4_CD |CV-MAIL-ADDRESS-ZIP4 |A |N/A | |1 |
|N/A |N/A |CV-ISSUE-DATE |A |Current | | |
| | | | |Date | | |
|B_COE_SPN_TB |B_COE_CD |CV-SCI-IND |A |N/A |This indicator was used for the SCI program, which | |
| | | | | |is no longer active. The indicator now defaults to | |
| | | | | |‘N’. | |
Notes:
1. The rules to determine which address to use from among the various addresses maintained on a client are as follows:
Use the swipe card override address entered on the swipe card tab page if it exists. If it does not exist, use the authorized rep. If the authorized rep address is not found, use the payee address. If the payee address is not found use the client mailing address. If mailing address does not exist, use residential address.
2. CV-PAYEE-LAST-NAME, CV-PAYEE-FIRST-NAME, and CV-PAYEE-INITIAL should contain REP-PAYEE information for client. This will be used by INK Impressions as addressee instead of client.
_________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always
C = Conditionally
N = Never
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE SPECIFICATION
OUTPUT FILE
TPL HSD FILE INTERFACE COE 031/035 ONLY
OBSOLETE
|Description: |
|This external interface file is created on a weekly basis to provide HSD with a file containing a combination of client and TPL information for all recipients that have one or more eligibility |
|spans. The information for each recipient includes: |
|Demographic information |
|Eligibility spans |
|Patient liability spans |
|Medicare spans |
|TPL resource information |
|Lock-in spans |
|Source Tables: |
|B_DETAIL_TB |
|B_ADR_TB |
|B_COE_SPN_TB |
|B_LTC_PAT_LIAB_TB |
|B_MCARE_SPN_TB |
|B_LCKN_TB |
|P_PROV_TB |
|T_CVRG_CLNT_TB |
|T_CVRG_PLCY_TB |
|Target Files: |
|HSD Client/TPL download file |
|Reports: |
|Process Summary |
|Remarks: |
|This file contains records only for clients that have active COE spans 031 and 035. There are up to four COE spans reported for each client, so if a client has overlapping active spans, there |
|may be COEs other than 031 and 035 reported, as long as the client has at least one active 031/035 span. |
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE LAYOUT
OUTPUT FILE
TPL HSD FILE INTERFACE COE 031/035 ONLY
OBSOLETE
000010******************************************************************
000020* *
000030* WEEKLY FEED OF MMIS TO NEW MEXICO HSD - THE TPL & ELIGIBILITY *
000040* INTERFACE *
000050* *
000060******************************************************************
000070* --------- CSR CHANGES --------- *
000080* *
000090* CSR CHANGE ANALYST *
000100* NBR DATE NAME DESCRIPTION OF CHANGE *
000110* *
000120* 01/18/2001 R. FLEMING NEW COPYBOOK FOR OMNICAID *
000130* *
000140* 01/24/2002 J. SHERRY CHANGE TO SEND SIX CHARACTER *
000150* CARRIER ID. *
000160* *
000170******************************************************************
000180*
000190*
000200 01 ELIGIBILITY-EXTRACT-RECORD.
000210 05 EXT-RECIP-ID-NO PIC X(14).
000220 05 EXT-RECIP-NAME.
000230 10 EXT-RECIP-LAST-NAME PIC X(17).
000240 10 EXT-RECIP-FIRST-NAME PIC X(12).
000250 10 EXT-RECIP-INITIAL PIC X(01).
000260 05 EXT-MAILING-ADDRESS.
000270 10 EXT-MAIL-ADDRESS-LINE-1 PIC X(25).
000280 10 EXT-MAIL-ADDRESS-LINE-2 PIC X(25).
000290 10 EXT-MAIL-ADDRESS-CITY PIC X(15).
000300 10 EXT-MAIL-ADDRESS-STATE PIC X(02).
000310 10 EXT-MAIL-ADDRESS-ZIP-CODE PIC 9(05).
000320 05 EXT-RECIP-DATE-OF-BIRTH PIC 9(06).
000330 05 EXT-RECIP-SEX PIC X(01).
000340 05 EXT-SOC-SEC-NO PIC X(09).
000350 05 EXT-SOC-SEC-CLAIM-NO PIC X(12).
000360 05 EXT-PREV-RECIP-ID-NO PIC X(14).
000370 05 EXT-RECIP-DATE-OF-DEATH PIC 9(06).
000380 05 EXT-ABSENT-PARENT-SSN-1 PIC S9(09) COMP-3.
000390 05 EXT-ABSENT-PARENT-SSN-2 PIC S9(09) COMP-3.
000400 05 EXT-ABSENT-PARENT-LNAME PIC X(05).
000410 05 EXT-ABSENT-PARENT-DOB PIC S9(07) COMP-3.
000420 05 EXT-ELIG-SEG-IND PIC X(01).
000430 05 EXT-LIAB-SEG-IND PIC X(01).
000440 05 EXT-TPL-SEG-IND PIC X(01).
000450 05 EXT-LOCK-IN-SEG-IND PIC X(01).
000460 05 EXT-BUY-IN-SEG-IND PIC X(01).
000470 05 EXT-MEDICARE-SEG-IND PIC X(01).
000480*
000490 05 EXT-ELIG-HISTORY-DATA
000500 OCCURS 4 TIMES.
000510*
000520 10 EXT-ELIG-BEGIN-DATE PIC 9(06).
000530 10 EXT-ELIG-END-DATE PIC 9(06).
000540 10 EXT-ELIG-CAT PIC X(03).
000550 10 EXT-ELIG-GEO-CNTY PIC X(02).
000560 10 EXT-ELIG-ADM-CNTY PIC X(02).
000570 10 EXT-ELIG-FEDERAL-MATCH PIC X(01).
000580*
000590 05 EXT-LIABILITY-DATA.
000600 10 EXT-LIAB-BEGIN-DATE PIC 9(06).
000610 10 EXT-LIAB-END-DATE PIC 9(06).
000620 10 EXT-LIAB-AMT PIC S9(05)V99 COMP-3.
000630*
000640 05 EXT-TPL-DATA
000650 OCCURS 2 TIMES.
000660 10 EXT-TPL-POLICY-HLD-NAME.
000670 15 EXT-TPL-LAST-NAME PIC X(17).
000680 15 EXT-TPL-FIRST-NAME PIC X(12).
000690 15 EXT-TPL-INITIAL PIC X(01).
000700 10 EXT-TPL-SSN PIC X(09).
000710****** 10 EXT-TPL-CARRIER-NUM PIC X(04).
000720 10 EXT-TPL-CARRIER-NUM PIC X(06). JS020102
000730 10 EXT-TPL-COVERAGE-TYPE PIC X(03).
000740 10 EXT-TPL-POLICY-NUM PIC X(16).
000750 10 EXT-TPL-GROUP-NUM PIC X(16).
000760 10 EXT-TPL-BEGIN-DATE PIC 9(06).
000770 10 EXT-TPL-END-DATE PIC 9(06).
000780 10 FILLER PIC X(01).
000790*
000800 05 EXT-LOCKIN-DATA.
000810 10 EXT-LK-TYPE PIC X(01).
000820 10 EXT-LK-PROV-ID PIC X(09).
000830 10 EXT-LK-PROV-NAME PIC X(30).
000840 10 FILLER PIC X(09).
000850 10 FILLER PIC X(30).
000860*
000870 05 EXT-MCARE-A-BEGIN-DATE PIC 9(06).
000880 05 EXT-MCARE-A-END-DATE PIC 9(06).
000890 05 EXT-MCARE-B-BEGIN-DATE PIC 9(06).
000900 05 EXT-MCARE-B-END-DATE PIC 9(06).
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
TPL HSD FILE INTERFACE COE 031/035 ONLY
OBSOLETE
|Source |Source |Target | | | |Note |
|Table |Column |Field |Req |Def |Specifications |Ref |
|B_DETAIL_TB |B_LAST_NAM |EXT-RECIP-LAST-NAME |A |N/A | | |
|B_DETAIL_TB |B_FST_NAM |EXT-RECIP-FIRST-NAME |A |N/A | | |
|B_DETAIL_TB |B_MI_NAM |EXT-RECIP-INITIAL |N |Spaces | | |
|B_ADR_TB |B_LINE1_AD |EXT-MAIL-ADDRESS-LINE-1 |A |N/A | |4 |
|B_ADR_TB |B_LINE2_AD |EXT-MAIL-ADDRESS-LINE-2 |A |N/A | |4 |
|B_ADR_TB |B_CITY_NAM |EXT-MAIL-ADDRESS-CITY |A |N/A | |4 |
|B_ADR_TB |G_ST_CD |EXT-MAIL-ADDRESS-STATE |A |N/A | |4 |
|B_ADR_TB |B_ZIP5_CD, B_ZIP4_CD |EXT-MAIL-ADDRESS-ZIP-CODE |A |N/A | |4 |
|B_DETAIL_TB |B_DOB_DT |EXT-RECIP-DATE-OF-BIRTH |A |N/A |MMDDYY | |
|B_DETAIL_TB |B_GENDER_CD |EXT-RECIP-SEX |A |N/A | | |
|B_DETAIL_TB |B_SSN_NUM |EXT-SOC-SEC-NO |A |Zero | | |
|B_DETAIL_TB |B_MCARE_ID |EXT-SOC-SEC-CLAIM-NO |N |Spaces | | |
| B_DETAIL_TB | B-ORIG-ID |EXT-PREV-RECIP-ID-NO |N |Spaces |Use the ID with the earliest date added | |
|B_DETAIL_TB |B_DOD_DT |EXT-RECIP-DATE-OF-DEATH |N |Zero |MMDDYY | |
|N/A |N/A |EXT-ABSENT-PARENT-SSN-1 |N |Spaces | | |
|N/A |N/A |EXT-ABSENT-PARENT-SSN-2 |N |Spaces | | |
|N/A |N/A |EXT-ABSENT-PARENT-LNAME |N |Spaces | | |
|N/A |N/A |EXT-ABSENT-PARENT-DOB |N |Spaces | | |
|N/A |N/A |EXT-ELIG-SEG-IND |A |N/A |This is a count of the number of eligibility | |
| | | | | |spans reported on the extract. Up to four | |
| | | | | |spans may be put on the extract. | |
|N/A |N/A |EXT-LIAB-SEG-IND |A |N/A | This is an indicator that specifies whether | |
| | | | | |the client has liability segments or not | |
| | | | | |(Y/N). | |
|N/A |N/A |EXT-TPL-SEG-IND |N |Zero |This is a count of the number of TPL spans | |
| | | | | |reported on the extract. Up to two spans may | |
| | | | | |be put on the extract. | |
|N/A |N/A |EXT-LOCK-IN-SEG-IND |A |N |If any non-voided lockin spans are open then | |
| | | | | |set to Y, otherwise set to N. | |
|N/A |N/A |EXT-BUY-IN-SEG-IND |A |N |Set to Y if there are any spans on the Buyin | |
| | | | | |table for this client where B_BUYIN_SMITXN1_CD| |
| | | | | |= “11,” “41” or “91,” or B_BUYIN_SMITXN2_CD = | |
| | | | | |“11.” | |
|N/A |N/A |EXT-MEDICARE-SEG-IND |A |N |Set to Y if there are any spans on the | |
| | | | | |Medicare Span table for this client. | |
|B_COE |B_COE_SPN_BEG_DT |EXT-ELIG-BEGIN-DATE |A |Zero |MMDDYY |1 |
|_SPN_TB | | | | | | |
|B_COE_SPN_TB |B_COE_SPN_END_DT |EXT-ELIG-END-DATE |A |Zero |MMDDYY |1 |
|B_COE_SPN_TB |B_COE_CD |EXT-ELIG-CAT |A |Spaces | |1 |
|B_COE_SPN_TB |B_GEO_CNTY_CD |EXT-ELIG-GEO-CNTY |A |Spaces | |1 |
|B_COE_SPN_TB |B_ADMIN_CNTY_CD |EXT-ELIG-ADM-CNTY |A |Spaces | |1 |
|B_COE_SPN_TB |B_FED_MTCH_CD |EXT-ELIG-FEDERAL-MATCH |A |Spaces | |1 |
|B_LTC_PAT_LIAB_TB |B_LIAB_SPAN_BEG_DT |EXT-LIAB-BEGIN-DATE |N |Zero |MMDDYY | |
|B_LTC_PAT_LIAB_TB |B_LIAB_SPAN_END_DT |EXT-LIAB-END-DATE |N |Zero |MMDDYY | |
|B_LTC_PAT_LIAB_TB |B_LTC_LIAB_AMT |EXT-LIAB-AMT |N |Zero | | |
|T_CVRG_PLCY_TB |T_PLCYHLD_LST_NAM |EXT-TPL-LAST-NAME |N |Spaces | |3 |
|T_CVRG_PLCY_TB |T_PLCYHLD_FST_NAM |EXT-TPL-FIRST-NAME |N |Spaces | |3 |
|T_CVRG_PLCY_TB |T_PLCYHLD_MI_NAM |EXT-TPL-INITIAL |N |Spaces | |3 |
|T_CVRG_PLCY_TB |T_PLCYHLD_SSN_NUM |EXT-TPL-SSN |N |Spaces | |3 |
|T_CVRG_CLNT_TB |T_CARR_ID |EXT-TPL-CARRIER-NUM |N |Spaces | |3 |
|To be defined |To be defined |EXT-TPL-COVERAGE-TYPE |N |Spaces | |3 |
|T_CVRG_CLNT_TB |T_ PLCY_NUM |EXT-TPL-POLICY-NUM |N |Spaces | |3 |
|T_CVRG_PLCY_TB |T_PLCY_GRP_ID |EXT-TPL-GROUP-NUM |N |Spaces | |3 |
|T_CVRG_CLNT_TB |T_CVRG_CLNT_BEG_DT |EXT-TPL-BEGIN-DATE |N |Zero |MMDDYY |3 |
|T_CVRG_CLNT_TB |T_CVRG_CLNT_END_DT |EXT-TPL-END-DATE |N |Zero |MMDDYY |3 |
|B_LOCKIN_TB |B_LCKN_TY_CD |EXT-LK-TYPE |N |Spaces | |2, 6, 7 |
|B_LOCKIN_TB |P_ID |EXT-LK-PROV-ID |N |Spaces | |2 |
|P_PROV_TB |P_NAM |EXT-LK-PROV-NAME |N |Spaces | |2 |
|B_MCARE_SPN_TB |B_BUYIN_SPN_BEG_DT |EXT-MCARE-A-BEGIN-DATE |N |Zero |MMDDYY, From span where B_BUYIN_MCARE_CD = “A”|5 |
|B_MCARE_SPN_TB |B_BUYIN_SPN_END_DT |EXT-MCARE-A-END-DATE |N |Zero |MMDDYY, From span where B_BUYIN_MCARE_CD = “A”|5 |
|B_MCARE_SPN_TB |B_BUYIN_SPN_BEG_DT |EXT-MCARE-B-BEGIN-DATE |N |Zero |MMDDYY, From span where B_BUYIN_MCARE_CD = “B”|5 |
|B_MCARE_SPN_TB |B_BUYIN_SPN_END_DT |EXT-MCARE-B-END-DATE |N |Zero |MMDDYY, From span where B_BUYIN_MCARE_CD = “B”|5 |
Notes:
1. Can occur up to four times. Only data from eligibility spans that are open at the time the extract is created is included, that is, EXT-ELIG-BEGIN-DATE BEGIN DATE |The care coordination end date from the input file (WFB46050-CARE-COORD-END-DT) |
| | | |cannot be less than the care coordination begin date from the input file |
| | | |(WFB46050-CARE-COORD-EFF-DT). The end date must be equal to or greater than the |
| | | |effective date. |
|24 |Critical |HEALTH HOME END DATE NOT > BEGIN DATE |The home health end date from the input file (WFB46050-HLTH-HOME-END-DT) must be |
| | | |greater than the home health effective date from the input file |
| | | |(WFB46050-HLTH-HOME-EFF-DT). |
|25 |Critical |LTC END DATE MUST BE > LTC BEGIN DATE |The long term care end date from the input file (WFB46050-NF-LVL-CARE-END-DT must|
| | | |be greater than the long term care end date from the input file |
| | | |(WFB46050-NF-LVL-CARE-EFF-DT). |
|27 |Critical |PCP ASSIGN EFFECTIVE DATE INVALID |The PCP assign date from the input file (WFB46050-PCP-ASSIGN-EFF-DT) is not a |
| | | |valid date. |
|28 |Critical |CC ASSESS DATE REQUIRED FOR ASSESS TYPE |The care coordination type ((WFB46050-CARE-COORD-TY) is specified on the input |
| | | |record, but the care coordination assessment date (WFB46050-CARE-COORD-DT) is not|
| | | |specified. Both fields are required if one of the fields is specified. |
|29 |Critical |CC ASSESS TYPE REQUIRED FOR ASSESS DATE |The care coordination type ((WFB46050-CARE-COORD-TY) is not specified on the |
| | | |input record, but the care coordination assessment date (WFB46050-CARE-COORD-DT) |
| | | |is specified. Both fields are required if one of the fields is specified. |
|30 |Critical |CC LEVEL, CC EFF/END DATES REQUIRED |The care coordination level (WFB46050-CARE-COORD-LVL – values 1 thru 7) is |
| | | |specified, but either the care coordination effective date |
| | | |(WFB46050-CARE-COORD-EFF-DT) or the care coordination end date |
| | | |(WFB46050-CARE-COORD-END-DT) is not specified. |
|32 |Critical |CC BEG/END, CC ASSESS DATE REQUIRED |The care coordination level (WFB46050-CARE-COORD-LVL – values 1, 2, 3, 6, 7) is |
| | | |specified, and the care coordination date from the input file |
| | | |(WFB46050-CARE-COORD-DT) is not specified, and no assessment date can be found on|
| | | |the B_CARE_COORD_TB for the client. |
|33 |Critical |CC LEVEL & CC END DATE REQUIRED |The care coordination effective date (WFB46050-CARE-COORD-EFF-DT) is specified, |
| | | |but either the care coordination level (WFB46050-CARE-COORD-LVL) or the care |
| | | |coordination end date (WFB46050-CARE-COORD-END-DT) is not specified. |
|34 |Critical | SETNG OF CARE PROV NOT ON FILE OR BLANK | The LTC provider id from the input file (WFB46050-CARE-SETTING-ID) is |
| | | |specified, and is not “99999998”. If the WFB46050-CARE-SETTING-ID is an NPI , it|
| | | |cannot be found on the P_NPI_XMTCH_TB table.. If the WFB46050-CARE-SETTING-ID is |
| | | |a Medicaid provider id , it cannot be found on the P_PROV_TB table. |
|35 |Critical |PROVIDER NPI NOT ON FILE |The provider NPI (WFB46050-PROVIDER-NPI) is specified but cannot be found on the |
| | | |P_NPI_XMTCH_TB table. |
|36 |Critical |LTC ASSESS DATE REQD FOR LTC BEG/END |The LTC assessment date (WFB46050-LTC-ASSESS-DT) is not specified on the input |
| | | |file, but either the level of care effective date (WFB46050-NF-LVL-CARE-EFF-DT) |
| | | |or the level of care end date (WFB46050-NF-LVL-CARE-END-DT) is specified. |
|37 |Critical |NO ASSESS DATE FOUND FOR COORD INSERT |No care coordination assessment date was present on the input file AND no |
| | | |B_CC_ASSESS_DT could be found on the B_CARE_COORD_TB. |
|38 |Critical |INVALID DISABILITY TYPE END DATE |Disability Type end date must be a valid date. |
|39 |Critical |DISABIL END DATE MUST BE => EFF DATE |Disability Type end date must be greater than the effective date. |
|40 |Critical |NO UPDATES MADE TO OMNICAID |The record was processed, but no updates were made to Omnicaid. Critical errors |
| | | |can post to the error file, but the error 40 may not appear on the error report. |
| | | |This happens when there is data for more than 1 table (ex: home health and care |
| | | |coordination) in the record, but edits prevented one of updates from occurring,|
| | | |but the data for the other passed all edits and OMNICAID updated. |
| | | | |
|41 |Critical |INVALID RECORD TYPE |The record type on the record is not ‘H’, ‘D’, or ‘T’ (Header, Detail, or |
| | | |Trailer). The entire record will be rejected and no further edits will be done. |
|42 |Critical |DISABIL DATE REQUIRED FOR DISABIL TYPE |If a disability type is received, disability dates must be provided as well. |
|43 |Critical |DISABIL TYPE REQUIRED FOR DISABIL DATE |If disability dates are provided, there must be a disability type provided. |
|44 |Critical | DISABIL EFF DATE MUST => CC ENROLL DATE | If the client has a disability type, then the disability begin date must be |
| | | |provided and it must be >= the client’ s Centennial Care first enrollment date. |
|45 |Critical |RETRO COMMNTY BENEFIT ENROLL NOT ALLOWED |LTC Level Of Care = NFL and LTC Setting Of Care = ‘ANW’ or ‘ADB or ‘SNW’ or ‘SDB’|
| | | |and LTC Begin Date is less than first of the upcoming month. |
|46 |Critical |CLIENT HAS OVERLAPPING CARELINK HHM SPAN |Client has existing open health home span with type ‘C’. MCO source transactions|
| | | |cannot overlay this span. |
|47 |Critical |CLIENT HAS OVERLAPPING CARELINK CC SPAN |Client has existing overlapping health home span with type C and care |
| | | |coordination level ‘6’ or ‘7’. MCO source transactions cannot overlay this span.|
NEW MEXICO OMNICAID MMIS MANAGED CARE SUBSYSTEM
INTERFACE SPECIFICATION
OUTPUT FILE
DAILY HSD TO MCO INTERFACE ERROR FILE
|Description: |
|The MCO to HSD interface jobs that are run for each Centennial Care MCO may result reject some of the input transactions for various error conditions. These errors are written to an error |
|file and transmitted to the MCO. More than one error may be posted for a given input transaction record, and a portion of the input transaction may be rejected while a separate portion is |
|accepted and used to update Omnicaid. For example, a client’s LTC span data may be updated even if the Care Coordination dates are rejected as being invalid. |
|Source Files: |
|B4600SA – MCO to HSD Interface file |
|Source Tables: |
|B_DETAIL_TB |
|B_CARE_COORD_TB |
|B_HEALTH_HOME_TB |
|B_LTC_SPN_TB |
|B_ALT_ID_TB |
|P_NPI_XMTCH_TB |
|P_ENROL_STAT_TB |
|P_PROV_TB |
|Target Tables: |
|B_DETAIL_TB |
|B_CARE_COORD_TB |
|B_HEALTH_HOME_TB |
|B_LTC_SPN_TB |
|B_EXTRT_REQ_TB |
|B_AUX_DAT_TB |
|Target Files: |
|B4600SB – Edit Error File |
|Reports: |
|N/A |
|Remarks: |
|There will be four files processed daily. The files will be from Blue Cross/Blue Shield, Presbyterian, Molina, and United HealthCare. An error file is generated by this interface and posted |
|to the MCO on DMZ, a formatted error report is not created. See the end of this interface for a list of errors. |
NEW MEXICO OMNICAID MMIS MANAGED CARE SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
DAILY HSD TO MCO INTERFACE ERROR FILE
01 WFB46051-ERROR-RECORD.
*
05 WFB46051-DATA PIC X(264).
*
05 WFB46051-HEADER-RECD REDEFINES WFB46051-DATA.
10 WFB46051-HEADER-REC PIC X(01).
88 WFB46051-088-HEADER VALUE 'H'.
10 WFB46051-MCO-ID PIC X(08).
10 FILLER PIC X(02).
10 WFB46051-FILE-CREATE-DT PIC X(08).
10 FILLER PIC X(245).
*
05 WFB46051-DETAIL-RECD REDEFINES WFB46051-DATA.
10 WFB46051-DETAIL-REC PIC X(01).
88 WFB46051-088-DETAIL VALUE 'D'.
10 WFB46051-DTL-FILE-CREATE-DT PIC X(08).
10 WFB46051-MCO-PROV-ID PIC X(08).
10 FILLER PIC X(02).
10 WFB46051-ERR-NUM PIC X(02).
10 WFB46051-ERR-MSG PIC X(40).
10 WFB46051-MEDICAID-SWIPE-ID PIC X(14).
10 WFB46051-B-FST-NAM PIC X(15).
10 WFB46051-B-LAST-NAM PIC X(21).
10 WFB46051-B-DOB-DT PIC X(08).
10 WFB46051-CARE-COORD-DT PIC X(08).
10 WFB46051-CARE-COORD-TY PIC X(01).
10 WFB46051-CARE-COORD-LVL PIC X(01).
10 WFB46051-CARE-COORD-EFF-DT PIC X(08).
10 WFB46051-CARE-COORD-END-DT PIC X(08).
10 WFB46051-PROVIDER-NPI PIC X(10).
10 WFB46051-PCP-ASSIGN-EFF-DT PIC X(08).
10 WFB46051-LTC-ASSESS-DT PIC X(08).
10 WFB46051-NF-LVL-CARE PIC X(03).
10 WFB46051-NF-LVL-CARE-EFF-DT PIC X(08).
10 WFB46051-NF-LVL-CARE-END-DT PIC X(08).
10 WFB46051-CARE-SETTING PIC X(03).
10 WFB46051-CARE-SETTING-ID PIC X(10).
10 WFB46051-HLTH-HOME-TY-CD PIC X(01).
10 WFB46051-HLTH-HOME-NPI PIC X(10).
10 WFB46051-HLTH-HOME-EFF-DT PIC X(08).
10 WFB46051-HLTH-HOME-END-DT PIC X(08).
10 WFB46051-COPAY-AMT-TO-DT PIC 9(5)V99.
10 WFB46051-COPAY-AMT-TO-DT-X REDEFINES
WFB46051-COPAY-AMT-TO-DT PIC X(07).
10 WFB46051-COPAY-PD-THRU-DT PIC X(08).
10 WFB46051-DISABIL-TY-CD PIC X(03).
88 WFB4651-088-PHYSICAL VALUE 'PH '.
88 WFB4651-088-MENTAL VALUE 'ME '.
10 WFB46051-DISABIL-EFF-DT PIC X(08).
10 WFB46051-DISABIL-END-DT PIC X(08).
*
05 WFB46051-TRAILER-RECD REDEFINES WFB46051-DATA.
10 WFB46051-TRAILER-REC PIC X(01).
88 WFB46051-088-TRAILER VALUE 'T'.
10 WFB46051-TRLR-RECD-CNT PIC 9(05).
10 FILLER PIC X(258).
*
NEW MEXICO OMNICAID MMIS MANAGED CARE SUBSYSTEM
INTERFACE SPECIFICATION
INPUT FILE
DAILY CARELINK NM TO HSD INTERFACE
|Description: |
|The daily file from CareLink NM is used to update the Client Health Home and Care Coordination tables. There are several distinct sections or types of data in the input file: demographic |
|data to identify the client, data to update the Health Home table. Each of these sections of data used to update Omnicaid are subject to their own sets of validation edits, and data that in |
|invalid in one section will not cause valid data to be ignored in another section. For example, a client’s LTC span data may be updated even if the Care Coordination dates are rejected as |
|being invalid. |
| |
|In general, the input record data will take precedence over what is on Omnicaid. The date overlap logic for the Health Home and Care Coordination tables needs to take into consideration the |
|fact that the incoming date span can possibly overlap zero to many existing spans on the existing date span table. The overall goal is to apply all the incoming span to the Omnicaid table. |
|At a high level, the program looks at the incoming span and overlays any existing span data with overlapping date periods. If the incoming span does not overlap any existing span, then the |
|incoming span is simply added to Omnicaid. If the existing span overlaps the incoming span, but the begin date of the existing span is earlier than the incoming span, then it terminates the |
|existing span one day prior to the incoming span. If the incoming begin date matches an existing begin date, then it simply replaces the existing span with the incoming span. If the existing|
|span is open-ended, and the incoming span is not, it does not keep the ongoing portion of the existing span. The assumption is that CareLink NM is terminating the open span. If they want to |
|keep an ongoing span they need to submit an ongoing span. Existing spans will be voided in order to maintain a history of the span activity. |
| |
|Since the incoming span could overlap multiple existing spans, the process will be iterative. See the Exhibits for further details on the date span processing CareLink NM to HSD Care |
|Coordination / Health Home Span Date Overlap Logic. |
|Source Files: |
|B4605SA – CareLink NM to HSD Interface file |
|Source Tables: |
|B_DETAIL_TB |
|B_CARE_COORD_TB |
|B_HEALTH_HOME_TB |
|B_ALT_ID_TB |
|P_NPI_XMTCH_TB |
|P_PROV_TB |
|Target Tables: |
|B_CARE_COORD_TB |
|B_HEALTH_HOME_TB |
|B_EXTRT_REQ_TB |
|Target Files: |
|B4605SB – Edit Error File |
|Reports: |
|Process Summary |
|Remarks: |
|There will be one CareLink NM file processed daily. The file will be from Falling Colors, the IT contractor for the State Behavioral Health Services Division’s STAR system which is used by |
|CareLink NM to track Health Home enrollments. An error file is generated by this interface and posted to the CareLink NM folder on DMZ. A formatted error report is not created. See the end |
|of this interface for a list of errors. |
NEW MEXICO OMNICAID MMIS MANAGED CARE SUBSYSTEM
INTERFACE LAYOUT
INPUT FILE
DAILY CARELINK NM TO HSD INTERFACE
001500 01 WFB46550-INPUT-RECORD.
001600*
001700 05 WFB46550-DATA PIC X(100).
001800*
001900 05 WFB46550-DATA-X REDEFINES WFB46550-DATA.
002000 10 WFB46550-RECORD-TYPE PIC X(01).
002100 10 WFB46550-INPUT-DATA PIC X(99).
002200*
002300 05 WFB46550-HEADER-RECD REDEFINES WFB46550-DATA.
002400 10 WFB46550-HEADER-REC PIC X(01).
002500 10 WFB46550-TXN-SOURCE PIC X(08).
002600 10 WFB46550-FILE-CREATE-DATE PIC X(08).
002610 10 FILLER PIC X(83).
002700*
002800 05 WFB46550-DETAIL-RECD REDEFINES WFB46550-DATA.
002900 10 WFB46550-DETAIL-REC PIC X(01).
003000 10 WFB46550-MEDICAID-SWIPE-ID PIC X(14).
003100 10 WFB46550-B-FST-NAM PIC X(15).
003200 10 WFB46550-B-LAST-NAM PIC X(21).
003300 10 WFB46550-B-DOB-DT PIC X(08).
003400 10 WFB46550-CARE-COORD-LVL PIC X(01).
003500 10 WFB46550-HLTH-HOME-TY-CD PIC X(01).
003600 10 WFB46550-HLTH-HOME-NPI PIC X(10).
003700 10 WFB46550-HLTH-HOME-EFF-DT PIC X(08).
003800 10 WFB46550-HLTH-HOME-END-DT PIC X(08).
003810 10 FILLER PIC X(13).
003900*
004000 05 WFB46550-TRAILER-RECD REDEFINES WFB46550-DATA.
004100 10 WFB46550-TRAILER-REC PIC X(01).
004200 10 WFB46550-TRLR-RECD-CNT PIC 9(05).
004300 10 FILLER PIC X(94).
NEW MEXICO OMNICAID MMIS MANAGED CARE SUBSYSTEM
INTERFACE EXHIBIT
INPUT FILE
DAILY CARELINK NM TO HSD INTERFACE
|Source |Target |Target |Std | | | |Note |
|Field |Table |Column |Edit |Req |Def |Specifications |Ref |
|WFB46550-HEADER-REC |N/A |N/A |V |A |X(01) |Must be an “H”. | |
|WFB46550-TXN-SOURCE |N/A |N/A |V |A |X(08) |Must be constant value = ‘STAR ‘ | |
|WFB46550-FILE-CREATE-DATE |N/A |N/A |D |A |X(08) |This the date the file was created. It is | |
| | | | | | |required and must be in CCYYMMDD format. | |
|WFB46550-DETAIL-RECD | | | | | | | |
|WFB46550-MEDICAID-SWIPE-ID|B_ALT_ID_TB |B_ALT_ID | |C |X(14) |This is used to obtain the B_SYS_ID of the |1 |
| | | | | | |client. If the last 4 characters are spaces, | |
| | | | | | |the swipe id is reformatted as 4 spaces and | |
| | | | | | |then the first 10 characters of the swipe id. | |
|WFB46550-B-FST-NAM |B_DETAIL_TB |B_LAST_NAM | |C |X(15) |Must be specified for all detail records. |2 |
|WFB46550-B-LAST-NAM |B_DETAIL_TB |B_FST_NAM | |C |X(21) |Must be specified for all detail records. |2 |
|WFB46550-B-DOB-DT |B_DETAIL_TB |B_DOB_DT |D |C |X(08) |Must be specified for all detail records. |2 |
|WFB46550-CARE-COORD-LVL |B_CARE_COORD_TB |B_CC_LVL_CD |V |C |X(01). |Must be ‘6’ or ‘7’. | |
|WFB46550-HLTH-HOME-TY-CD |B_HEALTH_HOME_TB |B_HHM_LVL_CD |V |C |X(01) |Must be ‘C’. | |
|WFB46550-HLTH-HOME-NPI |B_HEALTH_HOME_TB |B_HHM_NPI_ID | |C |X(10) |Must be a valid NPI number in Omnicaid, that | |
| | | | | | |is, it must exist on the Provider NPI Cross | |
| | | | | | |Reference table. There must be at least one | |
| | | | | | |provider associated with the NPI on the Health| |
| | | | | | |Home effective date whose Health Home | |
| | | | | | |indicator = ‘Y’. | |
|WFB46550-HLTH-HOME-EFF-DT |B_HEALTH_HOME_TB |B_HHM_BEG_DT | |C |X(08) |Effective date of Home Health/Care |3, 4 |
| |B_CARE_COORD_TB |B_CC_BEG_DT | | | |Coordination service. This is required. Must | |
| | | | | | |be a valid date in CCYYMMDD format. Care | |
| | | | | | |Coordination effective date is also populated | |
| | | | | | |from this field. | |
|WFB46550-HLTH-HOME-END-DT |B_HEALTH_HOME_TB |B_HHM_END_DT | |C |X(08) |End date of Home Health/Care Coordination |4 |
| |B_CARE_COORD_TB |B_CC_END_DT | | | |service. | |
| | | | | | |This is required. Open ended date is | |
| | | | | | |99991231. Home Health end date must be on or | |
| | | | | | |after the Home Health effective date. Care | |
| | | | | | |Coordination end date is also populated from | |
| | | | | | |this field. | |
|WFB46550-TRAILER-RECD | | | | | | | |
|WFB46550-TRAILER-REC |N/A |N/A |V |A |X(01) |Must be “T” | |
|WFB46550-TRLR-RECD-CNT |N/A |N/A |N |A |9(05) |Must be equal to the number of detail records | |
| | | | | | |in the file. | |
Notes:
1) If the B_SYS_ID cannot be determined from the reformatted swipe id, an error condition results and no subsequent edits will be done.
2) The first name, last name, and date of birth are required for each detail record. If any of these are missing, an error condition results, and no subsequent edits are done. The program then verifies the client is correct by comparing last name and DOB. If either of these match, then the client is considered to be verified. For the last name verification, the last name is only checked up to the first space. For example, if the Last Name field in Omnicaid contains ‘SMITH JR’, only ‘SMITH’ is used in the comparison. The birth day from the input file (CCYYMMDD) is reformatted and compared to the B_DOB_DT from Omnicaid. If neither of these fields match, an error condition exists and no subsequent errors will be done.
3) This date must be on or after the start date of the CareLink NM program which is stored on Client subsystem system parameter 1100. The recipient must be Medicaid COE eligible on this date. A Medicaid COE span is defined as COE is not equal to ‘029’, '041', '042', '045', '048', '054', '062', '063', or '064', and fed match is equal to '1', '3', '4', '5', '6', '7', '8', or 'X'.
4) The Health Home effective and end dates are not allowed to overlap those same dates on any other incoming transaction for the same recipient. In cases where these dates overlap on multiple transactions for the same recipient, all of the transactions with overlapping dates are errored off before any other editing occurs.
_________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always For Std Edits: D = Date Edit V = Valid Value Edit
C = Conditionally N = Numeric Edits S = System Generated
N = Never
NEW MEXICO OMNICAID MMIS MANAGED CARE SUBSYSTEM
INTERFACE EXHIBIT
EDIT ERRORS
The CareLink NM interface can result in edit errors. These errors prevent the update or insertion of rows into the Client Health Home and Care Coordination tables. The following is a list of errors generated by the CareLink NM interface.
|Error Num |Critical/Non-Critic|Error Message |Meaning |
| |al | | |
|00 |Critical |NO UPDATES MADE TO OMNICAID |The record was processed, but no updates were made to Omnicaid. This happens |
| | | |when the transaction data matches data that is already on file, so no updates |
| | | |were necessary. |
|01 |Critical |INVALID RECORD TYPE |The record type on the record is not ‘H’, ‘D’, or ‘T’ (Header, Detail, or |
| | | |Trailer). The entire record will be rejected and no further edits will be done. |
|02 |Critical |CLIENT NOT FOUND |The client was not found in OMNICAID. The swipe card id is used to read the |
| | | |B_ALT_ID_TB. If the B_SYS_ID is not found for the swipe card id, the error will |
| | | |be posted. This error is Fatal, and will cause the transaction to be rejected |
| | | |without any further editing. All remaining edits are considered Critical, |
| | | |meaning any of them will ultimately cause the transaction to be rejected, but |
| | | |will not cause any of the other edits below to be bypassed. |
|03 |Critical |CLIENT ID NAME OR DATE OF BIRTH MISMATCH |The full last name or the date of birth from the input record does not match that|
| | | |of the data returned from the client (B_DETAIL_TB) table. The entire record will|
| | | |be rejected and no further edits will be done. |
|04 |Critical |CLIENT NOT MEDICAID ELIGIBLE ON HH EFFECTIVE DT |Health home effective date must be covered by a Medicaid COE span. Medicaid COE |
| | | |span is defined as COE is not equal to ‘029’, '041', '042', '045', '048', '054', |
| | | |'062', '063', or '064', and |
| | | |Fed Match is equal to '1', '3', '4', '5', '6', '7', '8', or 'X'. |
|05 |Critical |OVERLAPPING DATES ON TXNS FOR SAME CLIENT NOT ALLOWED |There is overlap of WFB46550-HLTH-HOME-EFF-DT and WFB46550-HLTH-HOME-END-DT |
| | | |across two or more transactions for the same client. All transactions with |
| | | |overlapping dates for the same client are rejected. |
|06 |Critical |INVALID HEALTH HOME TYPE |The home health level code from the input record (WFB46550-HLTH-HOME-TY-CD) can |
| | | |only be ‘C’ (CareLink). |
|07 |Critical |HEALTH HOME EFFECTIVE DATE IS NOT VALID |The home health effective date from the input file (WFB46550-HLTH-HOME-EFF-DT) is|
| | | |not a valid date. |
|08 |Critical |HH EFFECTIVE DT MUST BE ON OR AFTER CARELINK START DT |Health home effective date (WFB46550-HLTH-HOME-EFF-DT) is prior to the CareLink |
| | | |NM start date. |
|09 |Critical |HEALTH HOME END DATE IS NOT VALID |The home health end date from the input file (WFB46550-HLTH-HOME-END-DT) is not a|
| | | |valid date. Open ended (99991231) dates are allowed. |
|10 |Critical |HEALTH HOME END DATE NOT > BEGIN DATE |The home health end date from the input file (WFB46550-HLTH-HOME-END-DT) must be |
| | | |greater than the home health effective date from the input file |
| | | |(WFB46550-HLTH-HOME-EFF-DT). |
|11 |Critical |HEALTH HOME NPI NOT ON FILE |An NPI was specified in the WFB46550-HLTH-HOME-NPI field of the input record, but|
| | | |the NPI could not be found on the Provider NPI Cross Match table |
| | | |(P_NPI_XMTCH_TB). |
|12 |Critical |NPI NOT ASSOCIATED WITH A HEALTH HOME PROVIDER |At least one of the providers associated with the incoming health home NPI |
| | | |(WFB46550-HLTH-HOME-NPI) must have the health home indicator on the Provider |
| | | |Table set to ‘Y’ (P_HLTH_HM_IND of PROVDRTB). |
|13 |Critical |INVALID CARE COORDINATION LEVEL |The care coordination level from the input file (WFB46550-CARE-COORD-LVL) is |
| | | |missing or is not equal to ‘6’ (Health Home CC level 2) or ‘7’ (Health Home CC |
| | | |level 3). |
NEW MEXICO OMNICAID MMIS MANAGED CARE SUBSYSTEM
INTERFACE SPECIFICATION
OUTPUT FILE
DAILY HSD TO MCO INTERFACE ERROR FILE
|Description: |
|The CareLink NM to HSD interface job may result in rejection of some of the input transactions for various error conditions. These errors are written to an error file and transmitted to |
|Falling Colors, the IT contractor for CareLink NM. More than one error may be posted for a given input transaction record. If an error condition occurs, no updates will be made to either the |
|Health Home or the Care Coordination tables. |
|Source Files: |
|B4605SA – CareLink NM to HSD Interface file |
|Source Tables: |
|B_DETAIL_TB |
|B_CARE_COORD_TB |
|B_HEALTH_HOME_TB |
|B_ALT_ID_TB |
|P_NPI_XMTCH_TB |
|P_PROV_TB |
|Target Tables: |
|B_DETAIL_TB |
|B_CARE_COORD_TB |
|B_HEALTH_HOME_TB |
|B_EXTRT_REQ_TB |
|Target Files: |
|B4605SB – Edit Error File |
|Reports: |
|N/A |
|Remarks: |
|An error file is generated by this interface and posted to the CareLink NM folder on DMZ, a formatted error report is not created. See the end of the Daily CareLink NM to HSD interface above |
|for a list of errors. |
NEW MEXICO OMNICAID MMIS MANAGED CARE SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
DAILY HSD TO MCO INTERFACE ERROR FILE
001500 01 WFB46551-ERROR-RECORD.
001600*
001700 05 WFB46551-DATA PIC X(160).
002200*
002300 05 WFB46551-HEADER-RECD REDEFINES WFB46551-DATA.
002400 10 WFB46551-HEADER-REC PIC X(01).
002410 88 WFB46551-088-HEADER VALUE 'H'.
002500 10 WFB46551-TXN-SOURCE PIC X(08).
002600 10 WFB46551-FILE-CREATE-DT PIC X(08).
002610 10 FILLER PIC X(143).
002700*
002800 05 WFB46551-DETAIL-RECD REDEFINES WFB46551-DATA.
002900 10 WFB46551-DETAIL-REC PIC X(01).
002910 88 WFB46551-088-DETAIL VALUE 'D'.
002920 10 WFB46551-DTL-FILE-CREATE-DT PIC X(08).
002930 10 WFB46551-DTL-TXN-KEY PIC X(10).
002950 10 WFB46551-ERR-NUM PIC X(02).
002960 10 WFB46551-ERR-MSG PIC X(40).
003000 10 WFB46551-MEDICAID-SWIPE-ID PIC X(14).
003100 10 WFB46551-B-FST-NAM PIC X(15).
003200 10 WFB46551-B-LAST-NAM PIC X(21).
003300 10 WFB46551-B-DOB-DT PIC X(08).
003400 10 WFB46551-CARE-COORD-LVL PIC X(01).
003500 10 WFB46551-HLTH-HOME-TY-CD PIC X(01).
003600 10 WFB46551-HLTH-HOME-NPI PIC X(10).
003700 10 WFB46551-HLTH-HOME-EFF-DT PIC X(08).
003800 10 WFB46551-HLTH-HOME-END-DT PIC X(08).
003810 10 FILLER PIC X(13).
003900*
004000 05 WFB46551-TRAILER-RECD REDEFINES WFB46551-DATA.
004100 10 WFB46551-TRAILER-REC PIC X(01).
004110 88 WFB46551-088-TRAILER VALUE 'T'.
004200 10 WFB46551-TRLR-RECD-CNT PIC 9(05).
004300 10 FILLER PIC X(154).
NEW MEXICO OMNICAID MMIS MANAGED CARE SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
DAILY HSD TO MCO INTERFACE ERROR FILE – HEADER
|Source |Source |Target | | | |Note |
|Table |Column |Field |Req |Def |Specifications |Ref |
|WFB46550-HEADER-RECD |WFB46550-TXN-SOURCE |WFB46551-TXN-SOURCE |A |STAR | | |
|WFB46550-HEADER-RECD |WFB46550-FILE-CREATE-DATE |WFB46551-FILE-CREATE-DATE |A | | | |
_________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always For Def: H = Header
C = Conditionally
N = Never
NEW MEXICO OMNICAID MMIS MANAGED CARE SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
DAILY HSD TO MCO INTERFACE ERROR FILE – DETAIL
|Source |Source |Target | | | |Note |
|Table |Column |Field |Req |Def |Specifications |Ref |
|WFB46550-HEADER-RECD |WFB46550-FILE-CREATE-DATE |WFB46551-DTL-FILE-CREATE-DT |A | | | |
|WFB46550-HEADER-RECD |WFB46550-MEDICAID-SWIPE-ID |WFB46551-DTL-TXN-KEY |A | | | |
|System Generated |System Generated |WFB46551-ERR-NUM |A | |See CareLink NM Edit Errors table above. | |
|System Generated |System Generated |WFB46551-ERR-MSG-KEY |A | |See CareLink NM Edit Errors table above. | |
|WFB46550-DETAIL-RECD |WFB46550-B-FST-NAM |WFB46551-B-FST-NAM |C | | | |
|WFB46550-DETAIL-RECD |WFB46550-B-LAST-NAM |WFB46551-B-LAST-NAM |C | | | |
|WFB46550-DETAIL-RECD |WFB46550-B-DOB-DT |WFB46551-B-DOB-DT |C | | | |
|WFB46550-DETAIL-RECD |WFB46550-CARE-COORD-LVL |WFB46551-CARE-COORD-LVL |C | | | |
|WFB46550-DETAIL-RECD |WFB46550-HLTH-HOME-TY-CD |WFB46551-HLTH-HOME-TY-CD |C | | | |
|WFB46550-DETAIL-RECD |WFB46550-HLTH-HOME-NPI |WFB46551-HLTH-HOME-NPI |C | | | |
|WFB46550-DETAIL-RECD |WFB46550-HLTH-HOME-EFF-DT |WFB46551-HLTH-HOME-EFF-DT |C | | | |
|WFB46550-DETAIL-RECD |WFB46550-HLTH-HOME-END-DT |WFB46551-HLTH-HOME-END-DT |C | | | |
_________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always For Def: TR = Trailer
C = Conditionally
N = Never
NEW MEXICO OMNICAID MMIS MANAGED CARE SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
DAILY HSD TO MCO INTERFACE ERROR FILE – TRAILER
|Source |Source |Target | | | |Note |
|Table |Column |Field |Req |Def |Specifications |Ref |
|System Generated |System Generated |WFB46551-TRLR-RECD-CNT |A |9(05) |Count of all error detail records written to | |
| | | | | |the output file. | |
_________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always For Def: TR = Trailer
C = Conditionally
N = Never
NEW MEXICO OMNICAID MMIS MANAGED CARE SUBSYSTEM
INTERFACE SPECIFICATION
INPUT FILE
DAILY ELIGIBILITY VOID REINSTATEMENT INTERFACE
|Description: |
|The State requested this interface because of the number of voids occurring on OmniCaid as a result of ASPEN eligibility not coming across as designed and the negative impact on provider and |
|clients. This interface is envisioned as a short term fix to add back COE spans that have been voided unintentionally due to the way the spans are coming across from ASPEN. It will be an |
|ongoing process that we run at least weekly until a long term fix can be implemented that stops the voids from occurring in the first place. |
|Source Files: |
|B3125SA – COE Void Reinstatement Interface file |
|Source Tables: |
|B_DETAIL_TB |
|B_COE_SPN_TB |
|Target Tables: |
|B_COE_SPN_TB |
|B_EXTRT_REQ_TB |
|Target Files: |
|B3125SB – Audit Trail File |
|Reports: |
|Process Summary |
|Remarks: |
|This program will insert coe spans into the BCOESPTB table from the input file. For each record on the input file do the following: |
| |
|• Read the client detail table for the input MCI. |
|• If the MCI does not exist, format an error message to the audit trail file and continue to the next input record |
|• If MCI is found |
|o Look for an overlapping non-voided span on the BCOESPTB with the same COE/FM as the input record. The overlap date check should be: Input span begin date = BCOESPTB span begin date |
|o If there are overlaps, format an error message to the audit trail file and continue to the next input record |
|o If no overlaps, insert the input span, populating the table columns with the corresponding field from the input record. B_ELIG_VOID_IND and B_COE_TERM_RSN_CD should be set to spaces. |
|MMB3125 is the audit user id. Write a span inserted message to the audit trail file. Add a row to the B_EXTRT_REQ_TB for trigger type E and another row for trigger type M, clone code |
|S520-000-INSERT-TRIGGER from NMMB3120. |
|• At end of file, if no input records then set return code to 2. |
| |
|The state will create a .txt file and put it on DMZ with file name VOIDINST for production processing in folder /Distribution / NM Operations / State of NM / To ACS. The input file will be |
|put on the mainframe automatically via MOVEIT to NEWM.PROD.B3125SA.DATA(+1). |
NEW MEXICO OMNICAID MMIS MANAGED CARE SUBSYSTEM
INTERFACE LAYOUT
INPUT FILE
DAILY ELIGIBILITY VOID REINSTATEMENT INTERFACE
01 WFB31250-VOID-REINSTATE-REC.
05 WFB31250-B-SYS-ID PIC X(09).
05 FILLER PIC X(01).
05 WFB31250-B-ASPEN-MCI-ID PIC X(09).
05 FILLER PIC X(01).
05 WFB31250-B-COE-SPN-BEG-DT PIC X(10).
05 FILLER PIC X(01).
05 WFB31250-B-COE-SPN-END-DT PIC X(10).
05 FILLER PIC X(01).
05 WFB31250-B-MAJ-PROG-CD PIC X(01).
05 FILLER PIC X(01).
05 WFB31250-B-COE-CD PIC X(03).
05 FILLER PIC X(01).
05 WFB31250-B-FED-MTCH-CD PIC X(01).
05 FILLER PIC X(01).
05 WFB31250-B-FED-CAT-CD PIC X(01).
05 FILLER PIC X(01).
05 WFB31250-B-MONEY-CD PIC X(01).
05 FILLER PIC X(01).
05 WFB31250-B-CASE-HH-NUM PIC X(09).
05 FILLER PIC X(17).
NEW MEXICO OMNICAID MMIS MANAGED CARE SUBSYSTEM
INTERFACE EXHIBIT
INPUT FILE
DAILY ELIGIBILITY VOID REINSTATEMENT INTERFACE
|Source |Target |Target |Std | | | |Note |
|Field |Table |Column |Edit |Req |Def |Specifications |Ref |
|WFB31250-B-SYS-ID |B_COE_SPN_TB |B_SYS_ID | |A |X(09) |Must be numeric. |1, 2 |
|WFB31250-B-ASPEN-MCI-ID |B_DETAIL_TB |N/A | |A |X(09) |Must be specified. Used to verify the client | |
| | | | | | |MCI is on Omnicaid. | |
|WFB31250-B-COE-SPN-BEG-DT |B_COE_SPN_TB |B-COE-SPN-BEG-DT |D |A |X(10) | |1,2 |
|WFB31250-B-COE-SPN-END-DT |B_DETAIL_TB |B-COE-SPN-END-DT |D |A |X(10) | |1,2 |
|WFB31250-B-MAJ-PROG-CD |B_COE_SPN_TB |B-MAJ-PROG-CD | |A |X(01) | | |
|WFB31250-B-COE-CD |B_COE_SPN_TB |B-COE-CD | |A |X(03) | |1,2 |
|WFB31250-B-FED-MTCH-CD |B_COE_SPN_TB |B-FED-MTCH-CD | |A |X(01). | |1,2 |
|WFB31250-B-FED-CAT-CD |B_COE_SPN_TB |B-FED-CAT-CD | |A |X(01). | | |
|WFB31250-B-MONEY-CD |B_COE_SPN_TB |B-MONEY-CD | |A |X(01). | | |
|WFB31250-B-CASE-HH-NUM |B_COE_SPN_TB |B-CASE-HH-NUM | |A |X(09). | | |
|N/A |B_COE_SPN_TB |B-ELIG-VOID-IND | | |X(01). |Set to spaces | |
|N/A |B_COE_SPN_TB |B-COE-TERM-RSN-CD | | |X(03). |Set to spaces | |
|N/A |B_COE_SPN_TB |G-AUD-ADD-USER-ID | | |X(07). |Set to MMB3125 | |
|N/A |B_COE_SPN_TB |G-AUD-ADD-DT | | |X(10). |Set to current date | |
|N/A |B_COE_SPN_TB |G-AUD-ADD-TM | | |X(08). |Set to current time | |
|N/A |B_COE_SPN_TB |G-AUD-USER-ID | | |X(07). |Set to MMB3125 | |
|N/A |B_COE_SPN_TB |G-AUD-DT | | |X(10). |Set to current date | |
|N/A |B_COE_SPN_TB |G-AUD-TM | | |X(08). |Set to current time | |
| | | | | | | | |
Notes:
1) If the fields fail the edits, then the record is rejected and an appropriate error message is written to the audit trail file.
2) If there are overlaps with existing spans for the same client and for the same COE/FM, then the record is rejected and an appropriate error message is written to the audit trail file.
3) If there are no errors, then the fields on the input record are used to format a row on the BCOESPTB, and an appropriate row inserted message is written to the audit trail file. Trigger records will also be written to the BEXTRTTB.
_________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always For Std Edits: D = Date Edit V = Valid Value Edit
C = Conditionally N = Numeric Edits S = System Generated
N = Never
NEW MEXICO OMNICAID MMIS MANAGED CARE SUBSYSTEM
INTERFACE SPECIFICATION
INPUT FILE
ON REQUEST MCI ID UPDATE INTERFACE
|Description: |
|The State requested this interface to fix the MCI Id on BDTAILTB because of the clients having been incorrectly entered manually by staff entering eligibility online in Omnicaid. This program |
|may need to be run on a periodic basis to create such corrections as the field can’t be corrected online. |
|Source Files: |
|B3126SA – Fix MCI Id Interface file |
|Source Tables: |
|B_DETAIL_TB |
|Target Tables: |
|B_DETAIL_TB |
|B_EXTRT_REQ_TB |
|Target Files: |
|B3126SB – Audit Trail File |
|Reports: |
|Process Summary |
|Remarks: |
|This program will update the MCI Id on the BDTAILTB table with the correct MCI ID from the input file. For each record on the input file do the following: |
| |
|Read the client detail table for the input INCORRECT MCI. |
|If the MCI does not exist, format an error message to the audit trail file and continue to the next input record |
|If MCI is found |
|Validate the format of the input SYS ID and compare with the INCORRECT MCI’s SYS ID, if invalid SYS ID or it’s not the same as the INCORRECT MCI’s SYS ID, format an error message to the audit |
|trail file and continue to the next input record. |
| |
|Read client detail table for the input CORRECT MCI |
|If the correct MCI already exists on the client detail table, format an error message to the audit trail file and continue to the next input record |
|If the correct MCI does not exist on the client detail table |
|Update the client detail row for the INCORRECT MCI by setting B_ASPEN_MCI_ID to the CORRECT MCI from the input file |
|Write a client cmi updated message to the audit trail file. Add a row to the B_EXTRT_REQ_TB for trigger type E and another row for trigger type M. |
|At end of file, if no input records then set return code to 2. |
NEW MEXICO OMNICAID MMIS MANAGED CARE SUBSYSTEM
INTERFACE LAYOUT
INPUT FILE
ON REQUEST MCI ID UPDATE INTERFACE
01 NMMB3126-MCI-CORRECTION-REC.
05 NMMB3126-SYS-ID PIC X(09).
05 FILLER PIC X(01).
05 NMMB3126-INCORRECT-MCI PIC X(09).
05 FILLER PIC X(01).
05 NMMB3126-CORRECT-MCI PIC X(09).
05 FILLER PIC X(01).
05 NMMB3126-ADD-SOURCE PIC X(07).
05 FILLER PIC X(01).
05 NMMB3126-NAME PIC X(42).
NEW MEXICO OMNICAID MMIS MANAGED CARE SUBSYSTEM
INTERFACE EXHIBIT
INPUT FILE
ON REQUEST MCI ID UPDATE INTERFACE
|Source |Target |Target |Std | | | |Note |
|Field |Table |Column |Edit |Req |Def |Specifications |Ref |
|NMMB3126-SYS-ID |B_DETAIL_TB |B_SYS_ID | |A |X(09) |Must be numeric. |1, 2 |
|NMMB3126-INCORRECT-MCI |B_DETAIL_TB |N/A | |A |X(09) |Must be specified. Used to verify the client |3 |
| | | | | | |MCI is on Omnicaid. | |
|NMMB3126-CORRECT-MCI |B_DETAIL_TB |B_ASPEN_MCI_ID | |A |X(09) |Must be specified. Used to update the client |4 |
| | | | | | |MCI ID on Omnicaid. | |
|NMMB3126-ADD-SOURCE |N/A |N/A | |A |X(07) | | |
|NMMB3126-NAME |N/A |N/A | |A |X(42) | | |
Notes:
5) If the fields fail the edits, then the record is rejected and an appropriate error message is written to the audit trail file.
6) If not match with the Incorrect MCI Id’s Sys Id, then the record is rejected and an appropriate error message is written to the audit trail file.
7) If it’s not on BDTAILTB, then the record is rejected and an appropriate error message is written to the audit trail file.
8) If it’s on BDTAILTB, then the record is rejected and an appropriate error message is written to the audit trail file.
9) If there are no errors, then the correct MCI Id on the input record is used to update the MCI Id on BDTAILTB, and an appropriate row updated message is written to the audit trail file. Trigger records will also be written to the BEXTRTTB.
_________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always For Std Edits: D = Date Edit V = Valid Value Edit
C = Conditionally N = Numeric Edits S = System Generated
N = Never
NEW MEXICO OMNICAID MMIS MANAGED CARE SUBSYSTEM
INTERFACE SPECIFICATION
INPUT FILE
ON REQUEST BATCH COE SPANS UPDATE INTERFACE
|Description: |
| |
|Preliminary TMSIS Eligibility files indicate problems with data that requires a fix in order not to be reported incorrectly to CMS. There are COEs that are pregnancy related, but the client is|
|male. A new program, NMMB3127, has been created to take in a flat file of Client COE corrections and void the original COE span with COE CD equal 035/300/301. For each void COE span, insert a|
|COE span with COE CD equal 029 (family planning) , and Fed Match Code of 1. |
|Source Files: |
| |
|Normally, the flat file of Client COE corrections will be created by unloading data from the COE span table that have following criteria: |
| |
|SELECT DTAIL.B_SYS_ID |
|,DTAIL.B_GENDER_CD |
|,COESP.B_COE_SPN_BEG_DT |
|,COESP.B_COE_CD |
|,COESP.B_FED_MTCH_CD |
|,COESP.B_ELIG_VOID_IND |
|,COESP.B_COE_SPN_END_DT |
|,COESP.B_FED_CAT_CD |
|,COESP.B_MONEY_CD |
|,COESP.B_CASE_HH_NUM |
|,COESP.B_MAJ_PROG_CD |
|,COESP.B_COE_TERM_RSN_CD |
|FROM NMTEST.BDTAILTB AS DTAIL |
|,NMTEST.BCOESPTB AS COESP |
|WHERE DTAIL.B_SYS_ID = COESP.B_SYS_ID |
|AND DTAIL.B_GENDER_CD = 'M' |
|AND COESP.B_ELIG_VOID_IND IN (' ','N') |
|AND COESP.B_COE_CD IN ('035','300','301') |
|AND (COESP.B_COE_SPN_END_DT >= CURRENT_DATE - 3 YEARS |
| |
| |
|However the State can send us a flat file with the same format generated from the data warehouse. In that case we will skip the unload step. We should prepare a DLA/DLE for this request, but |
|a formal Response or Test Results letter is not required. The BA’s will verify the results before we run them. |
| |
|The data should match the following format (B3127SA) |
| |
|01 NMMB3127-COE-CORRECTION-REC. |
|05 NMMB3127-SYS-ID PIC X(09). |
|05 NMMB3127-GENDER-CD PIC X(01). |
|05 NMMB3127-COE-SPN-BEG-DT PIC X(10). |
|05 NMMB3127-COE-CD PIC X(03). |
|05 NMMB3127-FED-MTCH-CD PIC X(01). |
|05 NMMB3127-ELIG-VOID-IND PIC X(01) |
|05 NMMB3127-COE-SPN-END-DT PIC X(10). |
|05 NMMB3127-FED-CAT-CD PIC X(01). |
|05 NMMB3127-MONEY-CD PIC X(01). |
|05 NMMB3127-CASE-HH-NUM PIC X(09). |
|05 NMMB3127-MAJ-PROG-CD PIC X(01). |
|05 NMMB3127-COE-TERM-RSN-CD PIC X(03). |
|Source Tables: |
|B_COE_SPN_TB |
|Target Tables: |
|B_COE_SPN_TB |
|B_EXTRT_REQ_TB |
|Target Files: |
|B3127SB – Audit Trail File |
|Reports: |
|Process Summary |
|Remarks: |
|This program will read the input file (created by the download or by the State). For each record read, the program will validate the input data, if invalid, the input transaction will be |
|rejected. If valid, the program will void the COE span on file and add a new COE span with COE code 029 (family planning) and Fed Match Code 1for the same date span. In both cases, an audit |
|record will be showed on the audit report. |
NEW MEXICO OMNICAID MMIS MANAGED CARE SUBSYSTEM
INTERFACE LAYOUT
INPUT FILE
ON REQUEST BATCH COE SPANS UPDATE INTERFACE
01 NMMB3127-COE-CORRECTION-REC.
05 NMMB3127-SYS-ID PIC X(09).
05 NMMB3127-GENDER-CD PIC X(01).
05 NMMB3127-COE-SPN-BEG-DT PIC X(10).
05 NMMB3127-COE-CD PIC X(03).
05 NMMB3127-FED-MTCH-CD PIC X(01).
05 NMMB3127-ELIG-VOID-IND PIC X(01)
05 NMMB3127-COE-SPN-END-DT PIC X(10).
05 NMMB3127-FED-CAT-CD PIC X(01).
05 NMMB3127-MONEY-CD PIC X(01).
05 NMMB3127-CASE-HH-NUM PIC X(09).
05 NMMB3127-MAJ-PROG-CD PIC X(01).
05 NMMB3127-COE-TERM-RSN-CD PIC X(03).
NEW MEXICO OMNICAID MMIS MANAGED CARE SUBSYSTEM
INTERFACE EXHIBIT
INPUT FILE
ON REQUEST BATCH COE SPANS UPDATE INTERFACE
|Source |Target |Target |Std | | | |Note |
|Field |Table |Column |Edit |Req |Def |Specifications |Ref |
|NMMB3127-SYS-ID |B_DETAIL_TB |B_SYS_ID | |A |X(09) |Must exist on BDTAILTB table. |1 |
|NMMB3127-GENDER-CD |B_DETAIL_TB |N/A | |A |X(01) |Must equal ‘M’ (male) and match with the |2 |
| | | | | | |client’s gender on BDTAILTB table. | |
|NMMB3127-COE-SPN-BEG-DT |B_COE_SPN_TB |B_COE_SPN_BEG_DT | |A |X(10) |Must be a valid date and exist on BCOESPTB. |3,4,5 |
|NMMB3127-COE-CD |B_COE_SPN_TB |B_COE_CD | |A |X(03) |Must exist on BCOESPTB. |4,5 |
|NMMB3127-FED-MTCH-CD |B_COE_SPN_TB |B_FED_MTCH_CD | |A |X(01) |Must exist on BCOESPTB. |4,5 |
|NMMB3127-ELIG-VOID-IND |B_COE_SPN_TB |B_ELIG_VOID_IND | |A |X(01) |Must equal |4,5 |
| | | | | | |WV-B2670-C-NOT-VOIDED | |
|NMMB3127-COE-SPN-END-DT |B_COE_SPN_TB |B_COE_SPN_END_DT | |A |X(10) |Must be a valid date and exist on BCOESPTB. |3,4,5 |
|NMMB3127-FED-CAT-CD |N/A |N/A | |N |X(01) | | |
|NMMB3127-MONEY-CD |N/A |N/A | |N |X(01) | | |
|NMMB3127-CASE-HH-NUM |N/A |N/A | |N |X(09) | | |
|NMMB3127-MAJ-PROG-CD |N/A |N/A | |N |X(01) | | |
|NMMB3127-COE-TERM-RSN-CD |N/A |N/A | |N |X(03) | | |
Notes:
1) If the SYS ID is not on BDTAILTB, then the record is rejected and an appropriate error message is written to the audit trail file.
2) If not ‘M’ or not match with the client’s gender on BDTAILTB table, then the record is rejected and an appropriate error message is written to the audit trail file.
3) If data is invalid, then the record is rejected and an appropriate error message is written to the audit trail file.
4) A COE span with matching SYS ID/COE CD/FED MATCH/BEG DT/END DT/VOID IND must exist on BCOESPTB, if not then the record is rejected and an appropriate error message is written to the audit trail file. If a COE span with COE 029 already exists that overlaps the incoming span, the record will be rejected with an appropriate error message.
5) If there are no errors, then the matching COE span will be voided and the same COE span with COE code 029 (family planning) and Fed Match Code 1 will be inserted to the BCOESPTB table. In both cases an appropriate row updated message is written to the audit trail file. Trigger records will also be written to the BEXTRTTB.
_________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always For Std Edits: D = Date Edit V = Valid Value Edit
C = Conditionally N = Numeric Edits S = System Generated
N = Never
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE SPECIFICATION
OUTPUT FILE
CMS TBQ INQUIRE INTERFACE
|Description: |
|This interface allows New Mexico to request Medicare/Medicaid eligibility information from the CMS Medicare Beneficiary Database Suite of Systems (MBDSS). CMS refers to this interface as the TBQ |
|exchange. There is no constant set of criteria that is used to choose clients to send to CMS, the State will need to identify the clients and supply us with a list. Job NMBR7030 accepts the |
|State file as input and creates the TBQ inquiry records in the format required by CMS. It also verifies the data in the State file as part of the process. It then FTPs the inquiry file to the |
|State, which then sends the file to CMS. The reason the State is involved in the transmittal process is because CMS requires that the TBQ transmittal process be the same as the MMA transmittal |
|process, and the State actually communicates with CMS for the MMA file. |
|Source Tables: |
|Target Files: |
|NEWM.PROD.NDM.TBQ.REQUEST(+1) |
|Reports: |
|N/A |
|Remarks: |
| |
|References – We used the CMS document titled Medicare Beneficiary Database Suite of Systems (MBDSS), Interface Control Document (ICD) For Territory Beneficiary Query (TBQ) available on the |
|following CMS website address – |
| |
TBQ Header Record
Field Name Position Len Type
TBQ-RECORD-REC-ID 1 7 A
TBQ Detail Record
Field Name Position Len Type
TBQ-REC-TYPE 1 3 A (alphanumeric)
TBQ-SSN 4 9 A
TBQ-FIRST-NAM 13 15 A
TBQ-LAST-NAM 28 20 A
TBQ-MI 48 1 A
TBQ-DOB 49 8 A
TBQ-GENDER 57 1 A
TBQ-FAMILY-ID 58 11 A
TBQ-MBR-SUFFIX 69 2 A
TBQ-MPI 71 13 A
TBQ-FILLER 84 17 A
TBQ Trailer Record
Field Name Position Len Type
TBQ-RECORD-REC-ID 1 7 A
TBQ-RECORD-TLR-CNT 9 9 N
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE HEADER RECORD
CMS TBQ INTERFACE
|Source |Source |Target | | | |Note |
|Table |Column |Field |Req |Def |Specifications |Ref |
_________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always
C = Conditionally
N = Never
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE DETAIL RECORD
CMS TBQ INTERFACE
|Source |Source |Target | | | |Note |
|Table |Column |Field |Req |Def |Specifications |Ref |
|N/A | N/A |TBQ-SSN |A | |Cannot be spaces or zero |1 |
|N/A | N/A |TBQ-FIRST-NAM |A | |Cannot be spaces |1 |
|N/A | N/A |TBQ-LAST-NAM |A | |Cannot be spaces |1 |
|N/A | N/A |TBQ-MI |A | | |1 |
|N/A | N/A |TBQ-DOB |A | |Cannot be spaces |1 |
|N/A | N/A |TBQ-GENDER |A | |Cannot be spaces |1 |
|N/A | N/A |TBQ-FAMILY-ID |A |Spaces | | |
|N/A | N/A |TBQ-MBR-SUFFIX |A |Spaces | | |
|N/A | N/A |TBQ-MPI |A | |Cannot be spaces |1 |
|N/A | N/A |TBQ-FILLER |A |Spaces | | |
Notes:
1. Populated from State input file
_________________________________________________________________________________________________________________________________LEGEND: For Req: A = Always
C = Conditionally
N = Never
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE TRAILER RECORD
CMS TBQ INTERFACE
|Source |Source |Target | | | |Note |
|Table |Column |Field |Req |Def |Specifications |Ref |
|N/A | N/A |TBQ-RECORD-TLR-CNT |A | |The job calculates the number of | |
| | | | | |records on the file. Only detail | |
| | | | | |records are counted. | |
_________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always
C = Conditionally
N = Never
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE SPECIFICATION
INPUT FILE
Close Open Medicare (Phase 1)
|Description: |
|This interface is received within a few days of transmitting the TBQ Inquiry file to CMS. Job NMBR7040 is used to process this file. The State actually receives the file and sends it to Xerox |
|via NDM. The phase 1 version of the TBQ response processor will only close open-ended Medicare spans for clients where the incoming Medicare data is closed. This version of the interface will |
|still be available on request even when phase 2 of this project is implemented. |
|Source Files: |
|NEWM.PROD.NDM.TBQ.RESPONSE(0) |
|Target Tables: |
|B_MCARE_SPN_TB |
|B_EXTRT_REQ_TB |
|Reports: |
|Remarks: |
| |
|The header and trailer records on the response file from CMS are bypassed during Omnicaid processing. Since this is an on-request process, the staff member assigned to run this job will review |
|the file prior to submitting. |
| |
|References – We used the CMS document titled Medicare Beneficiary Database Suite of Systems (MBDSS), Interface Control Document (ICD) For Territory Beneficiary Query (TBQ) available on the |
|following CMS website address – |
| |
| |
|Processing of Response File |
| |
|Read input file until EOF. For each record, do the following |
|Read the Omnicaid client detail table using the client sysid from the MPI field in the response record. If found, continue processing, otherwise bypass the input record. It is possible that the|
|client will not be found if the client sysid was merged between the time that the TBQ request record was created and sent to CMS and when we received and processed the CMS response. |
|Check the CMS Processed flag (values listed below) |
|If the Processed Flag = 00 or 08 |
|Read most recent Omnicaid part A Medicare span. If closed, skip to part B processing. |
|Check dates on response record for part A, if closed then update the Omnicaid Medicare span A with the end date from the response file, if that date is after the Omnicaid span begin date. If it |
|is not, then close the client’s Medicare Part A span using the last day of the month of the Premium date from that span. If there is no premium date available, which does happen, then close it |
|as of the last day of the month of the audit date on the span. If the audit date is prior to the begin date on the span, then use the last day of the month of the begin date to close the span |
|Do the same for Part B |
|If the Processed flag is 07 |
|Read most recent Omnicaid part A Medicare span. If closed, skip to part B processing. |
|Close the clients Medicare Part A span, using the last day of the month of the Premium date from that span. If there is no premium date available, which does happen, then close it as of the last|
|day of the month of the audit date on the span. If the audit date is prior to the begin date on the span, then use the last day of the month of the begin date to close the span |
|Do the same for Part B |
|If the Processed flag is 09 |
|Write a record to a file for manual research |
|If the Processed flag is 01 – 06 (shouldn’t happen, since we will be controlling the data sent to CMS, but just in case there is an issue) |
|Write a record to a file for manual research |
| |
| |
|The possible values for the Processed flag are: |
|00 = Successfully Processed |
|01 = Detail Record Identifier not ‘DTL’ |
|02 = SSN Missing |
|03 = First Name Missing |
|04 = Last Name Missing |
|05 = Gender Code Missing |
|06 = Date of Birth Missing |
|07 = Beneficiary Not Found |
|08 = Successfully processed, but beneficiary not entitled to Part A and/or Part B |
|09 = More than One Beneficiary Found |
| |
| |
000010***************************************************************
000020* *
000030* COPYBOOK: WFB74050 - CMS TBQ RESPONSE RECORD *
000040* *
000050***************************************************************
000060* CHANGE LOG *
000070* *
000080***************************************************************
000090* *
000100* DATE ANALYST PROJECT DESCRIPTION *
000110* ------------------------------------------------------------*
000120* 02/13/15 JMS OMNICAID FILE LAYOUT FOR THE CMS *
000130* TBQ RESPONSE FILE. *
006000*
006000 01 WFB74050-CMS-TBQ-RESP-RECORD.
006000 05 WFB74050-CMS-TBQ-REQ-RECORD.
006100 10 WFB74050-REQ-REC-ID-CD PIC X(03).
006600 10 WFB74050-REQ-SSN PIC 9(09).
006800 10 WFB74050-REQ-FIRST-NAME PIC X(15).
006900 10 WFB74050-REQ-LAST-NAME PIC X(20).
007000 10 WFB74050-REQ-MID-NAME PIC X(01).
007300 10 WFB74050-REQ-DOB.
006100 15 WFB74050-REQ-DOB-CC PIC 9(02).
006300 15 WFB74050-REQ-DOB-YY PIC 9(02).
007400 15 WFB74050-REQ-DOB-MM PIC 9(02).
007500 15 WFB74050-REQ-DOB-DD PIC 9(02).
007200 10 WFB74050-REQ-GENDER PIC X(01).
007100 10 WFB74050-REQ-FAMILY-ID PIC X(11).
007100 10 WFB74050-REQ-SUFFIX PIC X(02).
007100 10 WFB74050-REQ-MPI PIC X(13).
006000 05 WFB74050-CMS-TBQ-RESP-DTL.
006300 10 WFB74050-RESP-PROC-FLAG PIC X(02).
007200 10 FILLER PIC X(151).
006200 10 WFB74050-BENE-CLAIM-ACCT PIC 9(09).
006300 10 WFB74050-BENE-ID-CD PIC 9(02).
007300 10 WFB74050-BENE-DOB.
007400 15 WFB74050-BENE-DOB-MM PIC 9(02).
007500 15 WFB74050-BENE-DOB-DD PIC 9(02).
006100 15 WFB74050-BENE-DOB-CC PIC 9(02).
006300 15 WFB74050-BEND-DOB-YY PIC 9(02).
007300 10 WFB74050-BENE-DOD.
007400 15 WFB74050-BENE-DOD-MM PIC 9(02).
007500 15 WFB74050-BENE-DOD-DD PIC 9(02).
006100 15 WFB74050-BENE-DOD-CC PIC 9(02).
006300 15 WFB74050-BEND-DOD-YY PIC 9(02).
007200 10 WFB74050-BENE-GENDER PIC X(01).
006800 10 WFB74050-BENE-FIRST-NAME PIC X(30).
007000 10 WFB74050-BENE-MID-NAME PIC X(01).
006900 10 WFB74050-BENE-LAST-NAME PIC X(40).
006200 10 WFB74050-XREF-NUMBERS OCCURS 10 TIMES.
006200 15 WFB74050-XREF-CLAIM-ACCT PIC 9(09).
006300 15 WFB74050-XREF-ID-CD PIC 9(02).
006200 10 WFB74050-SSN-NUMBERS OCCURS 05 TIMES.
006200 15 WFB74050-SSN PIC 9(09).
007600 10 WFB74050-MBD-MAIL-ADDRS-LN1 PIC X(40).
10 WFB74050-MBD-MAIL-ADDRS-LN2 PIC X(40).
10 WFB74050-MBD-MAIL-ADDRS-LN3 PIC X(40).
10 WFB74050-MBD-MAIL-ADDRS-LN4 PIC X(40).
10 WFB74050-MBD-MAIL-ADDRS-LN5 PIC X(40).
10 WFB74050-MBD-MAIL-ADDRS-LN6 PIC X(40).
10 WFB74050-MBD-MAIL-ADDRS-CITY PIC X(40).
10 WFB74050-MBD-MAIL-ADDRS-STATE PIC X(02).
10 WFB74050-MBD-MAIL-ADDRS-ZIP PIC X(09).
10 WFB74050-MBD-MAIL-ADDRS-CHG-DT PIC 9(08).
10 WFB74050-MBD-RESD-ADDRS-LN1 PIC X(40).
10 WFB74050-MBD-RESD-ADDRS-LN2 PIC X(40).
10 WFB74050-MBD-RESD-ADDRS-LN3 PIC X(40).
10 WFB74050-MBD-RESD-ADDRS-LN4 PIC X(40).
10 WFB74050-MBD-RESD-ADDRS-LN5 PIC X(40).
10 WFB74050-MBD-RESD-ADDRS-LN6 PIC X(40).
10 WFB74050-MBD-RESD-ADDRS-CITY PIC X(40).
10 WFB74050-MBD-RESD-ADDRS-STATE PIC X(02).
10 WFB74050-MBD-RESD-ADDRS-ZIP PIC X(09).
10 WFB74050-MBD-RESD-ADDRS-CHG-DT PIC 9(08).
10 WFB74050-MBD-BENE-REP-PAYEE-SW PIC X(01).
007600 10 WFB74050-PRTA-NENTLMNT-STAT PIC X(01).
007600 10 WFB74050-PRTB-NENTLMNT-STAT PIC X(01).
007600*
007600 10 WFB74050-MBD-ENTMNT-REASON OCCURS 05 TIMES.
007600 15 WFB74050-ENT-RSN-CD-CHG-DT PIC 9(08).
007600 15 WFB74050-MBD-ENT-RSN-CD PIC X(04).
007600*
007600 10 WFB74050-PARTA-ENTITLEMENT OCCURS 05 TIMES.
007600 15 WFB74050-BENE-PTA-ENTMT-BEG-DT PIC 9(08).
007600 15 WFB74050-BENE-PTA-ENTMT-END-DT PIC 9(08).
007600 15 WFB74050-BENE-PTA-ENROL-RSN-CD PIC X(01).
007600 15 WFB74050-BENE-PTA-ENTMT-STA-CD PIC X(01).
007600*
007600 10 WFB74050-PARTB-ENTITLEMENT OCCURS 05 TIMES.
007600 15 WFB74050-BENE-PTB-ENTMT-BEG-DT PIC 9(08).
007600 15 WFB74050-BENE-PTB-ENTMT-END-DT PIC 9(08).
007600 15 WFB74050-BENE-PTB-ENROL-RSN-CD PIC X(01).
007600 15 WFB74050-BENE-PTB-ENTMT-STA-CD PIC X(01).
007600*
007600 10 WFB74050-MBD-HOSPICE-CVRGE OCCURS 05 TIMES.
007600 15 WFB74050-BENE-HSPC-CVRG-BEG-DT PIC 9(08).
007600 15 WFB74050-BENE-HSPC-CVRG-END-DT PIC 9(08).
007600*
007600 10 WFB74050-MBD-DISAB-INSUR OCCURS 03 TIMES.
007600 15 WFB74050-BENE-DISB-ENTL-BEG-DT PIC 9(08).
007600 15 WFB74050-BENE-DISB-ENTL-END-DT PIC 9(08).
007600 15 WFB74050-BENE-DISB-ENTL-JUS-CD PIC X(01).
007600*
007600 10 WFB74050-MBD-GRP-HLTH-ORG OCCURS 10 TIMES PL9092
007601 INDEXED BY GHO-IDX. PL9092
007600 15 WFB74050-BENE-GHO-ENROL-BEG-DT PIC 9(08).
007600 15 WFB74050-BENE-GHO-ENROL-END-DT PIC 9(08).
007600 15 WFB74050-BENE-GHO-CNTRACT-NUM PIC X(05).
007600*
007600 10 WFB74050-MBD-PLAN-BEN-PKG-ELCN OCCURS 10 TIMES PL9092
INDEXED BY PBP-IDX. PL9092
007600 15 WFB74050-MBD-GHP-ENROL-EFF-DT PIC 9(08).
007600 15 WFB74050-MBD-PBP-BEG-DT PIC 9(08).
007600 15 WFB74050-MBD-PBP-END-DT PIC 9(08).
007600 15 WFB74050-MBD-PBP-NUM PIC X(03).
007600 15 WFB74050-MBD-PBP-CVRGE-TY-CD PIC X(02).
007600*
007600 10 WFB74050-ESRD-CVGE-BEG-DT PIC 9(08).
007600 10 WFB74050-ESRD-CVGE-END-DT PIC 9(08).
007600 10 WFB74050-ESRD-TRMNTN-RSN-CD PIC X(01).
007600 10 WFB74050-ESRD-DIALYS-BEG-DT PIC 9(08).
007600 10 WFB74050-ESRD-DIALYS-END-DT PIC 9(08).
007600 10 WFB74050-ESRD-TRPLNT-BEG-DT PIC 9(08).
007600 10 WFB74050-ESRD-TRPLNT-END-DT PIC 9(08).
007600*
007600 10 WFB74050-TP-PARTA-HISTORY OCCURS 05 TIMES.
007600 15 WFB74050-BENE-PTA-TP-BEG-DT PIC 9(08).
007600 15 WFB74050-BENE-PTA-TP-PRMPYR-CD PIC X(03).
007600 15 WFB74050-BENE-PTA-TP-END-DT PIC 9(08).
007600 15 WFB74050-BENE-PTA-TP-BUYIN-CD PIC X(01).
007600*
007600 10 WFB74050-TP-PARTB-HISTORY OCCURS 05 TIMES.
007600 15 WFB74050-BENE-PTB-TP-BEG-DT PIC 9(08).
007600 15 WFB74050-BENE-PTB-TP-PRMPYR-CD PIC X(03).
007600 15 WFB74050-BENE-PTB-TP-END-DT PIC 9(08).
007600 15 WFB74050-BENE-PTB-TP-BUYIN-CD PIC X(01).
007600*
007600 10 WFB74050-BENE-FST-ELG-PARTD-DT PIC 9(08).
007600 10 WFB74050-BENE-AFF-DECL-IND PIC X(01).
007600*
007600 10 WFB74050-BENE-COPAY-HISTORY OCCURS 10 TIMES.
007600 15 WFB74050-BENE-LIS-TYPE PIC X(01).
007600 15 WFB74050-BENE-COPAY-LEVEL PIC X(01).
007600 15 WFB74050-BENE-COPAY-BEG-DT PIC 9(08).
007600 15 WFB74050-BENE-COPAY-END-DT PIC 9(08).
007600*
007600 10 WFB74050-BENE-PTD-PLN-BEN-PKG OCCURS 10 TIMES.
007200 15 WFB74050-BENE-CONTRACT-NUM PIC X(05).
007200 15 WFB74050-PTD-PBP-ENRL-BEG-DT PIC 9(08).
007200 15 WFB74050-PTD-PBP-ENRL-END-DT PIC 9(08).
007400 15 WFB74050-BENE-PTD-PBP-PLAN-ID PIC X(03).
007500 15 WFB74050-BENE-ENROLL-TYPE-IND PIC X(01).
007600*
007600 10 WFB74050-PTC-ORGANIZATION-NAME PIC X(55).
007600 10 WFB74050-PTC-PLAN-NAME PIC X(50).
007600 10 WFB74050-PTD-ORGANIZATION-NAME PIC X(55).
007600 10 WFB74050-PTD-ORG-PLAN-NAME PIC X(50).
007600 10 WFB74050-PTD-ORG-PLAN-BENE PIC X(01).
007600 10 WFB74050-BENE-LANGUAGE-IND PIC X(01).
007600*
007600 10 WFB74050-SPN-INDICATOR OCCURS 10 TIMES.
007200 15 WFB74050-SPN-IND PIC X(01).
007600*
007600 10 WFB74050-INCARCERATION-BEG-DT PIC 9(08).
007600 10 WFB74050-INCARCERATION-END-DT PIC 9(08).
007600*
007600 10 FILLER PIC X(14).
007600*
007600 10 WFB74050-RDS-COVERAGE-PERIODS OCCURS 05 TIMES.
007200 15 WFB74050-RDS-BEG-DT PIC 9(08).
007200 15 WFB74050-RDS-END-DT PIC 9(08).
007600*
007600 10 FILLER PIC X(01).
007600*
007600 10 WFB74050-PTD-ELIG-DATES OCCURS 05 TIMES.
007200 15 WFB74050-PTD-ELIG-BEG-DT PIC 9(08).
007200 15 WFB74050-PTD-ELIG-END-DT PIC 9(08).
007600*
007600 10 WFB74050-BENE-SUBSIDY-INFO OCCURS 10 TIMES.
007200 15 WFB74050-BENE-SUBSIDY-LVL PIC 9(03).
007200 15 WFB74050-LIS-DEEM-SRCE-CD PIC X(02).
007600*
007600 10 WFB74050-ESRD-DIALYS-BEG-DT-2 PIC 9(08). 121852
007600 10 WFB74050-ESRD-DIALYS-END-DT-2 PIC 9(08). 121852
007600 10 WFB74050-ESRD-DIALYS-BEG-DT-3 PIC 9(08). 121852
007600 10 WFB74050-ESRD-DIALYS-END-DT-3 PIC 9(08). 121852
007600 10 WFB74050-ESRD-DIALYS-BEG-DT-4 PIC 9(08). 121852
007600 10 WFB74050-ESRD-DIALYS-END-DT-4 PIC 9(08). 121852
007600 10 WFB74050-ESRD-DIALYS-BEG-DT-5 PIC 9(08). 121852
007600 10 WFB74050-ESRD-DIALYS-END-DT-5 PIC 9(08). 121852
007600 10 WFB74050-ESRD-DIALYS-BEG-DT-6 PIC 9(08). 121852
007600 10 WFB74050-ESRD-DIALYS-END-DT-6 PIC 9(08). 121852
007600* 121852
007600 10 FILLER PIC X(01). 121852
007600 10 WFB74050-MMP-OPT-OUT-IND PIC X(01). 121852
007600* 121852
007600 10 FILLER PIC X(205). 121852
007600*
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE EXHIBIT
INPUT FILE DETAIL RECORD
CMS TBQ RESPONSE FILE INTERFACE
Close Open Medicare (Phase 1)
|Source |Target |Target |Std | | | |Note |
|Field |Table |Column |Edit |Req |Def |Specifications |Ref |
|WFB74050-CMS-TBQ-REQ-RECORD |Group level | | | | | |1 |
|WFB74050-REQ-SSN | |N/A | |A | | |1 |
| |N/A | | | | | | |
|WFB74050-REQ-FIRST-NAME | |N/A | |A | | |1 |
| |N/A | | | | | | |
|WFB74050-REQ-LAST-NAME | |N/A | |A | | |1 |
| |N/A | | | | | | |
|WFB74050-REQ-MID-NAME | |N/A | |A | | |1 |
| |N/A | | | | | | |
|WFB74050-REQ-DOB | |N/A | |A | | |1 |
| |N/A | | | | | | |
|WFB74050-REQ-GENDER | |N/A | |A | | |1 |
| |N/A | | | | | | |
|WFB74050-REQ-FAMILY-ID | |N/A | |A | | |1 |
| |N/A | | | | | | |
|WFB74050-REQ-SUFFIX | |N/A | |A | | |1 |
| |N/A | | | | | | |
|WFB74050-REQ-MPI |B_DETAIL_TB |B_SYS_ID | |A | | |1, 2 |
|WFB74050-CMS-TBQ-RESP-DTL |Group level | | | | | | |
|WFB74050-RESP-PROC-FLAG | |N/A | |A | |CMS valid values 00 |3 |
| |N/A | | | | |through 09 | |
|WFB74050-BENE-CLAIM-ACCT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-ID-CD | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-DOB | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-DOD | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-GENDER | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-FIRST-NAME | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-MID-NAME | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-LAST-NAME | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-XREF-NUMBERS OCCURS 10 TIMES |Group level | | | | | | |
|WFB74050-XREF-CLAIM-ACCT | | | | | | | |
|WFB74050-XREF-ID-CD | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-SSN-NUMBERS OCCURS 05 TIMES |Group level | | | | | | |
|WFB74050-SSN | |N/A | |A | | | |
| |N/A | | | | | | |
| | | | | | | | |
|WFB74050-MBD-MAIL-ADDRS-LN1 | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-MBD-MAIL-ADDRS-LN2 | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-MBD-MAIL-ADDRS-LN3 | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-MBD-MAIL-ADDRS-LN4 | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-MBD-MAIL-ADDRS-LN5 | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-MBD-MAIL-ADDRS-LN6 | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-MBD-MAIL-ADDRS-CITY | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-MBD-MAIL-ADDRS-STATE | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-MBD-MAIL-ADDRS-ZIP | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-MBD-MAIL-ADDRS-CHG-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-MBD-RESD-ADDRS-LN1 | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-MBD-RESD-ADDRS-LN2 | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-MBD-RESD-ADDRS-LN3 | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-MBD-RESD-ADDRS-LN4 | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-MBD-RESD-ADDRS-LN5 | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-MBD-RESD-ADDRS-LN6 | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-MBD-RESD-ADDRS-CITY | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-MBD-RESD-ADDRS-STATE | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-MBD-RESD-ADDRS-ZIP | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-MBD-RESD-ADDRS-CHG-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-MBD-BENE-REP-PAYEE-SW | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-PRTA-NENTLMNT-STAT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-PRTB-NENTLMNT-STAT | |N/A | |A | | | |
| |N/A | | | | | | |
| | | | | | | | |
|WFB74050-MBD-ENTMNT-REASON OCCURS 05 |Group level | | | | | | |
|TIMES | | | | | | | |
|WFB74050-ENT-RSN-CD-CHG-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-MBD-ENT-RSN-CD | |N/A | |A | | | |
| |N/A | | | | | | |
| | | | | | | | |
|WFB74050-PARTA-ENTITLEMENT OCCURS 05 |Group level | | | | | | |
|TIMES | | | | | | | |
|WFB74050-BENE-PTA-ENTMT-BEG-DT | |N/A |D |A | |MMDDCCYY |4 |
| |N/A | | | | |Must be zeroes or a valid | |
| | | | | | |date. If valid date, must| |
| | | | | | |be less than the end date | |
|WFB74050-BENE-PTA-ENTMT-END-DT |B- MCARE- SPN-TB |B-BUYIN-SPN-END-DT |D |A | |MMDDCCYY |4 |
| | | | | | |Must be zeroes, nines, or | |
| | | | | | |a valid date. If valid | |
| | | | | | |date, must be greater than| |
| | | | | | |the begin date | |
|WFB74050-BENE-PTA-ENROL-RSN-CD | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-PTA-ENTMT-STA-CD | |N/A | |A | | | |
| |N/A | | | | | | |
| | | | | | | | |
|WFB74050-PARTB-ENTITLEMENT OCCURS 05 |Group level | | | | | | |
|TIMES | | | | | | | |
|WFB74050-BENE-PTB-ENTMT-BEG-DT | |N/A |D |A | |MMDDCCYY |4 |
| |N/A | | | | |Must be zeroes or a valid | |
| | | | | | |date. If valid date, must| |
| | | | | | |be less than the end date | |
|WFB74050-BENE-PTB-ENTMT-END-DT |B- MCARE- SPN-TB |B-BUYIN-SPN-END-DT |D |A | |MMDDCCYY |4 |
| | | | | | |Must be zeroes, nines, or | |
| | | | | | |a valid date. If valid | |
| | | | | | |date, must be greater than| |
| | | | | | |the begin date | |
|WFB74050-BENE-PTB-ENROL-RSN-CD | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-PTB-ENTMT-STA-CD | |N/A | |A | | | |
| |N/A | | | | | | |
| | | | | | | | |
|WFB74050-MBD-HOSPICE-CVRGE OCCURS 05 |Group level | | | | | | |
|TIMES | | | | | | | |
|WFB74050-BENE-HSPC-CVRG-BEG-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-HSPC-CVRG-END-DT | |N/A | |A | | | |
| |N/A | | | | | | |
| | | | | | | | |
|WFB74050-MBD-DISAB-INSUR OCCURS 03 |Group level | | | | | | |
|TIMES | | | | | | | |
|WFB74050-BENE-HSPC-CVRG-BEG-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-HSPC-CVRG-END-DT | |N/A | |A | | | |
| |N/A | | | | | | |
| | | | | | | | |
|WFB74050-MBD-GRP-HLTH-ORG OCCURS 10 |Group level | | | | | | |
|TIMES | | | | | | | |
|WFB74050-BENE-GHO-ENROL-BEG-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-GHO-ENROL-END-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-GHO-CNTRACT-NUM | | | | | | | |
| | | | | | | | |
|WFB74050-MBD-PLAN-BEN-PKG-ELCN OCCURS 10 |Group level | | | | | | |
|TIMES | | | | | | | |
|WFB74050-MBD-GHP-ENROL-EFF-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-MBD-PBP-BEG-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-MBD-PBP-END-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-MBD-PBP-NUM | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-MBD-PBP-CVRGE-TY-CD | |N/A | |A | | | |
| |N/A | | | | | | |
| | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-ESRD-CVGE-BEG-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-ESRD-CVGE-END-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-ESRD-TRMNTN-RSN-CD | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-ESRD-DIALYS-BEG-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-ESRD-DIALYS-END-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-ESRD-TRPLNT-BEG-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-ESRD-TRPLNT-END-DT | |N/A | |A | | | |
| |N/A | | | | | | |
| | | | | | | | |
|WFB74050-TP-PARTA-HISTORY OCCURS 05 |Group level | | | | | | |
|TIMES | | | | | | | |
|WFB74050-BENE-PTA-TP-BEG-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-PTA-TP-PRMPYR-CD | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-PTA-TP-END-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-PTA-TP-BUYIN-CD | |N/A | |A | | | |
| |N/A | | | | | | |
| | | | | | | | |
|WFB74050-TP-PARTB-HISTORY OCCURS 05 |Group level | | | | | | |
|TIMES | | | | | | | |
|WFB74050-BENE-PTB-TP-BEG-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-PTB-TP-PRMPYR-CD | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-PTB-TP-END-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-PTB-TP-BUYIN-CD | |N/A | |A | | | |
| |N/A | | | | | | |
| | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-FST-ELG-PARTD-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-AFF-DECL-IND | |N/A | |A | | | |
| |N/A | | | | | | |
| | | | | | | | |
|WFB74050-BENE-COPAY-HISTORY OCCURS 10 |Group level | | | | | | |
|TIMES | | | | | | | |
|WFB74050-BENE-LIS-TYPE | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-COPAY-LEVEL | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-COPAY-BEG-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-COPAY-END-DT | |N/A | |A | | | |
| |N/A | | | | | | |
| | | | | | | | |
|WFB74050-BENE-PTD-PLN-BEN-PKG OCCURS 10 |Group level | | | | | | |
|TIMES | | | | | | | |
|WFB74050-BENE-CONTRACT-NUM | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-PTD-PBP-ENRL-BEG-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-PTD-PBP-ENRL-END-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-PTD-PBP-PLAN-ID | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-ENROLL-TYPE-IND | |N/A | |A | | | |
| |N/A | | | | | | |
| | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-PTC-ORGANIZATION-NAME | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-PTC-PLAN-NAME | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-PTD-ORGANIZATION-NAME | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-PTD-ORG-PLAN-NAME | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-PTD-ORG-PLAN-BENE | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-BENE-LANGUAGE-IND | |N/A | |A | | | |
| |N/A | | | | | | |
| | | | | | | | |
|WFB74050-SPN-INDICATOR OCCURS 10 |Group level | | | | | | |
|TIMES | | | | | | | |
|WFB74050-SPN-IND | |N/A | |A | | | |
| |N/A | | | | | | |
| | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-INCARCERATION-BEG-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-INCARCERATION-END-DT | |N/A | |A | | | |
| |N/A | | | | | | |
| | | | | | | | |
|WFB74050-RDS-COVERAGE-PERIODS OCCURS 05 |Group level | | | | | | |
|TIMES | | | | | | | |
|WFB74050-RDS-BEG-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-RDS-END-DT | |N/A | |A | | | |
| |N/A | | | | | | |
| | | | | | | | |
|WFB74050-PTD-ELIG-DATES OCCURS 05 |Group level | | | | | | |
|TIMES | | | | | | | |
|WFB74050-PTD-ELIG-BEG-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-PTD-ELIG-END-DT | |N/A | |A | | | |
| |N/A | | | | | | |
| | | | | | | | |
|WFB74050-BENE-SUBSIDY-INFO OCCURS 10 |Group level | | | | | | |
|TIMES | | | | | | | |
|WFB74050-PTD-ELIG-BEG-DT | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-PTD-ELIG-END-DT | |N/A | |A | | | |
| |N/A | | | | | | |
| | | | | | | | |
|WFB74050-BENE-SUBSIDY-INFO OCCURS 10 |Group level | | | | | | |
|TIMES | | | | | | | |
|WFB74050-BENE-SUBSIDY-LVL | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-LIS-DEEM-SRCE-CD | |N/A | |A | | | |
| |N/A | | | | | | |
| | | | | | | | |
|WFB74050-ESRD-DIALYS-BEG-DT-2 | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-ESRD-DIALYS-END-DT-2 | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-ESRD-DIALYS-BEG-DT-3 | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-ESRD-DIALYS-END-DT-3 | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-ESRD-DIALYS-BEG-DT-4 | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-ESRD-DIALYS-END-DT-4 | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-ESRD-DIALYS-BEG-DT-5 | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-ESRD-DIALYS-END-DT-5 | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-ESRD-DIALYS-BEG-DT-6 | |N/A | |A | | | |
| |N/A | | | | | | |
|WFB74050-ESRD-DIALYS-END-DT-6 | |N/A | |A | | | |
| |N/A | | | | | | |
| | | | | | | | |
|WFB74050-MMP-OPT-OUT-IND | |N/A | |A | | | |
| |N/A | | | | | | |
| | | | | | | | |
Notes:
15. CMS populates this field from the inquiry request record sent to CMS
16. The MPI field contains the Omnicaid client sysid from the inquiry request record sent to CMS
17. The values for the Processed Flag from CMS are:
00 = Successfully Processed
01 = Detail Record Identifier not ‘DTL’
02 = SSN Missing
03 = First Name Missing
04 = Last Name Missing
05 = Gender Code Missing
06 = Date of Birth Missing
07 = Beneficiary Not Found
08 = Successfully processed, but beneficiary not entitled to Part A and/or Part B
09 = More than One Beneficiary Found
4. Zeroes in the entitlement dates means the client is not entitled for that coverage. All nines in the entitlement end date means the client has open-ended coverage.
_________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always
C = Conditionally
N = Never
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE SPECIFICATION
INPUT FILE
CMS TBQ RESPONSE FILE INTERFACE
Add / Update / Delete Medicare Using MMA Response Processing (Phase 2)
|Description: |
|On request job NMBR7041 will handle the TBQ response file from CMS. This version of the interface will update Omnicaid Medicare spans to match the incoming Medicare data by doing add / update / |
|delete processing. Since the TBQ response record has the same enrollment data as the MMA response data, and we already have MMA response file process in place (record layout WFB70054), this job |
|will just reformat TBQ response file (record layout WFB74050) to the same format as MMA response, and then feed that record into the MMA response file processor, NMMB7011, to update Omnicaid |
|Medicare data. |
|Only TBQ records with response flags of 00 - Successful would be formatted for the MMA program to process. |
|TBQ records with response flags of 08-Successful Not Entitled will be processed through the phase 1 program, NMMB7040, to close the applicable Part A / B span. |
|Source Files: |
|NEWM.PROD.NDM.TBQ.RESPONSE(0) |
|Target Tables: |
|B_MCARE_SPN_TB |
|B_EXTRT_REQ_TB |
|Reports: |
|Remarks: |
| |
|The header and trailer records on the response file from CMS are bypassed during Omnicaid processing. Since this is an on-request process, the staff member assigned to run this job will review |
|the file prior to submitting. |
| |
|References – We used the CMS document titled Medicare Beneficiary Database Suite of Systems (MBDSS), Interface Control Document (ICD) For Territory Beneficiary Query (TBQ) available on the |
|following CMS website address – |
| |
| |
|Processing of Response File |
| |
|Same As MMA response file process (NMMB7011) |
| |
NEW MEXICO OMNICAID MMIS CLIENT SUBSYSTEM
INTERFACE SPECIFICATION
INPUT FILE
CMS TBQ RESPONSE FILE INTERFACE
Add / Update / Delete Medicare Using MMA Response Processing (Phase 2)
|Source |
|Field |
|Source Files: |
| |
|None – data is pulled from the Omnicaid database. |
| |
|Source Tables: |
|B_LOCKIN_TB |
|B_LTC_SPN_TB |
|B_COE_SPN_TB |
|Target Tables: |
|None |
|Target Files: |
|M7620SB – UHC extract file |
|M7620SC – Molina extract file |
|M7620SD – Presbyterian extract file |
|M7620SE – BCBS extract file |
|Reports: |
|None |
|Remarks: |
|The extracts files are produced by joining the Client Lockin and LTC tables with the the Client COE span table. |
NEW MEXICO OMNICAID MMIS MANAGED CARE SUBSYSTEM
INTERFACE LAYOUT
OUTPUT FILE
LTC RECONCILIATION INTERFACE
01 HEADER-RECORD.
05 HEADER-TYPE PIC X(02).
05 FILLER PIC X(01).
05 HEADER-MCO PIC X(30).
05 FILLER PIC X(03).
05 HEADER-DATE PIC X(8).
05 FILLER PIC X(01).
05 HEADER-DESC PIC X(14.
05 FILLER PIC X(59).
01 DETAIL.
05 SYS-ID PIC 9(9).
05 MCO-P-ID PIC X(8).
05 LTC-SPN-BEG-DT PIC X(10).
05 LTC-SPN-END-DT PIC X(10).
05 LTC-P-ID PIC X(8).
05 LOC PIC X(3).
05 LAST-ASSESS-DT PIC X(10).
05 SOC PIC X(03).
05 LTC-ADD-USER PIC X(07).
05 LTC-ADD-DT PIC X(10).
05 LTC-UPD-USER PIC X(07).
05 LTC-UPD-DT PIC X(10).
05 COE-SPN-BEG-DT PIC X(10).
05 FILLER PIC X(01).
05 COE-SPN-END-DT PIC X(10).
05 FILLER PIC X(01).
05 COE-CD PIC X(03).
01 TRAILER-RECORD.
05 TRAILER-TYPE PIC X(2).
05 FILLER PIC X(1).
05 TRAILER-COUNT PIC 9(9).
05 FILLER PIC X(106).
NEW MEXICO OMNICAID MMIS MANAGED CARE SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
LTC RECONCILIATION INTERFACE
|Source |Source |Target |Std | | | |Note |
|Field |Table |Field |Edit |Req |Def |Specifications |Ref |
|P_ID |B_LOCKIN_TB |MCO-P-ID | |A |X(09) | | |
|B_LTC_SPN_BEG_DT |B_LTC_SPN_TB |LTC-SPN-BEG-DT | |A |X(01) | | |
|B_LTC_SPN_END_DT |B_LTC_SPN_TB |LTC-SPN-END-DT | |A |X(10) | | |
|P_ID |B_LTC_SPN_TB |LTC-P-ID | |A | | | |
|B_LEVEL_OF_CARE_CD |B_LTC_SPN_TB |LOC | |A | | | |
|B_LAST_ASSESS_DT |B_LTC_SPN_TB |LAST-ASSESS-DT | |A | | | |
|B_SETNG_OF_CARE_CD |B_LTC_SPN_TB |SOC | |A | | | |
|G_AUD_ADD_USER_ID |B_LTC_SPN_TB |LTC-ADD-USER | |A | | | |
|G_AUD_ADD_DT |B_LTC_SPN_TB |LTC-ADD-DT | |A | | | |
|G_AUD_USER_ID |B_LTC_SPN_TB |LTC-UPD-USER | |A | | | |
|G_AUD_DT |B_LTC_SPN_TB |LTC-UPD-DT | |A | | | |
|B_COE_SPN_BEG_DT |B_COE_SPN_TB |COE-SPN-BEG-DT | |C | | |1 |
|B_COE_SPN_END_DT |B_COE_SPN_TB |COE-SPN-END-DT | |C | | | |
|B_COE_CD |B_COE_SPN_TB |COE-CD | |C | | | |
Notes:
1) The COE data will only appear if the recipient had a COE of 095/096 and was enrolled with a NFL level of care for the overlapping time.
_________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always For Std Edits: D = Date Edit V = Valid Value Edit
C = Conditionally N = Numeric Edits S = System Generated
N = Never
NEW MEXICO OMNICAID MMIS MANAGED CARE SUBSYSTEM
INTERFACE SPECIFICATION
OUTPUT FILE
1095-B FORM INTERFACE
|Description: |
|The Affordable Care Act requires that all nonexempt individuals either have minimum essential coverage (MEC), or pay the individual shared responsibility payment. To enable Medicaid clients |
|to meet this requirement, beginning with tax year 2015, State Medicaid agencies are required to report MEC for all its non-exempt individuals on a 1095-B form documenting months of coverage |
|for the prior tax year and provide to the IRS an electronic file 1095-B documenting all the individuals for whom a 1095-B form was created. |
| |
|This extract supports both the 1095-B print vendor interface, and the IRS 1095-B file transmission process maintained by the web portal. |
|Source Files: |
| |
|None – data is pulled from the Omnicaid database. |
| |
|Source Tables: |
|B_DETAIL_TB |
|B_ADR_TB |
|B_COE_SPN_TB |
|B_IRS_SUMB_TB |
|Target Tables: |
|B_CVRG_YR_TB |
|Target Files: |
|1095-B Print Vendor Files |
|Reports: |
|None |
|Remarks: |
|This interface will run annually to create the 1095-B form history for the prior tax year and generate the 1095-B print vendor extract to the selected print vendors. It will also run |
|quarterly to create corrections to the 1095-B form history for the prior tax year and generate the 1095-B print vendor extracts for those corrections. Finally, it will run daily or weekly to |
|transmit on demand reprint extracts resulting from reprint requests entered online into Omnicaid, and also to create corrections to the 1095-B form history resulting from correction requests |
|entered online into Omnicaid, and generate the 1095-B print vendor extracts for those corrections. |
| |
|Important Design Considerations |
| |
|Responsible Individuals and Covered Individuals |
|The IRS 1095-B form contains a ‘Responsible Individual’ with one to many ‘Covered Individuals’. (See the IRS 1095 tax form exhibit in the exhibit section of the client system documentation |
|for details about the form along with a sample form, or see ). In order to determine the Responsible Individual, the system uses a combination of the|
|head of household name on the client detail table along with the address, chosen by the standard address hierarchy. It groups clients as Covered Individuals under the same Responsible |
|Individual if there are multiple clients with the same head of household name and address. A Responsible Individual need not be in Medicaid, but all Covered Individuals are in Medicaid with |
|MEC for the designated tax year. A Covered Individual can be a Responsible Individual, and a Covered Individual with no head of household information in Omnicaid will be listed as the |
|Responsible Individual on the form as well as the Covered Individual. |
| |
|Minimal Essential Coverage (MEC) |
|The system checks the client’s COE spans for coverage in the affected tax year. COEs 029, 041, 042, 044, 045, 050, 054 and 085, and any COE spans with Fed Match of 2 are excluded from 1095-B |
|eligibility checking. The client is considered to have MEC for a given month if there is an eligible COE covering any portion of that month. |
| |
|Automated Corrections |
|Automated corrections are only created for the prior tax year. Correction forms are not generated for earlier tax years. |
| |
|Corrections are generated for SSN changes and MEC additions only. Head of household changes and address changes are not considered to be corrections for 1095-B processing, with an exception |
|for the 2015 tax year. The print form for the vendor will be generated in early March, 2016, and the print vendors will immediately start printing and mailing the forms in order to have them |
|mailed out by the IRS print form deadline of 3/31/16. Due to time constraints, the web process that will transmit the IRS file will not be ready at that time. The IRS has extended that |
|deadline to 6/30/16. Since the IRS file is not being produced at the same time as the print file, the system will be generating the IRS file from current data, which could be different from |
|what was generated for the print forms. If there are differences, a correction print form will be produced and mailed to the recipient, so that they have a form that is in sync with the IRS |
|data, including any address changes. |
| |
|MEC coverage that is deleted retroactively is not reported as a correction. If a client gains and loses some months of MEC retroactively, the correction form shows the months of coverage |
|originally reported, plus any months that were added. It does not remove coverage months that were originally reported. For example, if the 1095-B form generated in the annual process shows |
|the client had MEC for January, February, and March, and then the client retroactively loses eligibility for those months, but gains it for December, the correction form will show MEC for |
|January, February, March, and December. |
| |
|Clients who are added with retroactive coverage back to the prior tax year, and who did not have a form generated for that tax year during the annual process, will have an original form |
|generated for that tax year in the correction process. |
| |
|Print Vendors |
|The annual 1095-B form extracts for tax year 2015 are being split between two print vendors – Automated Election Systems, which current prints the Medicaid swipe cards, and Postal Pros, which |
|current prints Managed Care letters. |
| |
|Note that the State decided not to suppress the printing of the social security number on the 1095-B forms. |
| |
|The letter vendor will handle the formatting and mailing of the 1095-B forms from the print vendor extract and will include cover letters in the mailing in both English and Spanish. The cover|
|letters are generic and will not be included in the data extract file sent to the print vendor. See the client 1095-B cover letter exhibit in the client system documentation for details. |
| |
| |
|A Note about the interface grid that follows these remarks: |
| |
|This interface is different from most of the other client interfaces in that the 1095-B related data is pulled from the Omnicaid client database and loaded into an Omnicaid client 1095-B form |
|coverage history table. The data in this table is then used as input by a separate batch process to generate print vendor extracts, and is also used by the web portal process that generates |
|the 1095-B file sent to the IRS. Therefore, we are displaying two interface grids, one that shows the source Omnicaid tables that populate the 1095-B form coverage history table, and another |
|that shows the 1095-B form coverage history table as the source data that populates the print vendor extract record. Finally, see the client 1095-B print vendor exhibit in the client system |
|documentation for a crosswalk that documents how the print vendor is populating the 1095-B tax form fields from the Omnicaid 1095-B print vendor record. |
| |
| |
NEW MEXICO OMNICAID MMIS MANAGED CARE SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
1095-B FORM INTERFACE
Omnicaid client tables used to populate the 1095-B form coverage table: B_CVRG_YR_TB.
|Source |Source |Target |Target |Std | | | |
|Field |Table |Field |Table |Edit |Req |Def |Specificat|
| | | | | | | |ions |
|B_PRNT_TYPE_CD |B_CVRG_YR_TB |WFB51150-FORM-TYPE | |A | | | |
|B_CVRG_YR_NUM |B_CVRG_YR_TB |WFB51150-1095B-YEAR | |A | | | |
|B_CVRG_VOID_IND |B_CVRG_YR_TB |WFB51150-1095B-VOID-CORR-IND | |A |spaces |Not being used currently | |
|B_HH_LAST_NAM |B_CVRG_YR_TB |WFB51150-HH-LAST-NAM | |A | | | |
|B_HH_FST_NAM |B_CVRG_YR_TB |WFB51150-HH-FST-NAM | |A | | | |
|B_HH_MI_NAM |B_CVRG_YR_TB |WFB51150-HH-MI-NAM | |A | | | |
|B_LINE1_AD |B_CVRG_YR_TB |WFB51150-HH-MAIL-LINE1 | |A | | | |
|B_LINE2_AD |B_CVRG_YR_TB |WFB51150-HH-MAIL-LINE2 | |A | | | |
|B_CITY_NAM |B_CVRG_YR_TB |WFB51150-HH-MAIL-CITY | |A | | | |
|B_ST_CD |B_CVRG_YR_TB |WFB51150-HH-MAIL-STATE | |A | | | |
|B_ZIP5_CD |B_CVRG_YR_TB |WFB51150-HH-MAIL-ZIP5 | |A | | | |
|B_ZIP4_CD |B_CVRG_YR_TB |WFB51150-HH-MAIL-ZIP4 | |N | | | |
|B-PLCY-TY-CD |B_IRS_SUMB_TB |WFB51150-PLCY-ORIG-CD | |A | |Set to ‘C’ for government sponsored program | |
|B_ISS_LINE1_NAM |B_IRS_SUMB_TB |WFB51150-ISS-LAST-NAM | |A | | | |
|B_ISS_LINE2_NAM |B_IRS_SUMB_TB |WFB51150-ISS-FST-NAM | |A | | | |
|N/A |N/A |WFB51150-ISS-MI-NAM | |N |spaces | | |
|B_ISS_EIN_NUM |B_IRS_SUMB_TB |WFB51150-ISS-EIN | |A | | | |
|B-ISS-PHON-NUM |B_IRS_SUMB_TB |WFB51150-ISS-CON-PHON-NUM | |A | |This is the State contact number. | |
|B_ISS_LINE1_AD |B_IRS_SUMB_TB |WFB51150-ISS-MAIL-LINE1 | |A | | | |
|B_ISS_LINE2_AD |B_IRS_SUMB_TB |WFB51150-ISS-MAIL-LINE2 | |A | | | |
|B_ISS_CITY_NAM |B_IRS_SUMB_TB |WFB51150-ISS-MAIL-CITY | |A | | | |
|B_ISS_ST_CD |B_IRS_SUMB_TB |WFB51150-ISS-MAIL-STATE | |A | | | |
|B_ISS_ZIP5_CD |B_IRS_SUMB_TB |WFB51150-ISS-MAIL-ZIP5 | |A | | | |
|B_ISS_ZIP4_CD |B_IRS_SUMB_TB |WFB51150-ISS-MAIL-ZIP4 | |A | | | |
|B_LAST_NAM |B_CVRG_YR_TB |WFB51150-COV-LAST-NAM | |A | | | |
|B_FST_NAM |B_CVRG_YR_TB |WFB51150-COV-FST-NAM | |A | | | |
|B_MI_NAM |B_CVRG_YR_TB |WFB51150-COV-MI-NAM | |N | | | |
|B_CURR_ID |B_CVRG_YR_TB |WFB51150-SWIPE-CARD-ID | |A | | | |
|B_SSN_NUM |B_CVRG_YR_TB |WFB51152-COV-SSN-NUM | |A | |May be set to spaces | |
|B_DOB_DT |B_CVRG_YR_TB |WFB51152-COV-DOB-DT | |A | | | |
|B_ALL_MO_CVRG_IND |B_CVRG_YR_TB |WFB51152-COV-YR-IND | |A | | | |
|B_JAN_CVRG_IND |B_CVRG_YR_TB |WFB51152-COV-JAN-IND | |A | | | |
|B_FEB_CVRG_IND |B_CVRG_YR_TB |WFB51152-COV-FEB-IND | |A | | | |
|B_MAR_CVRG_IND |B_CVRG_YR_TB |WFB51152-COV-MAR-IND | |A | | | |
|B_APR_CVRG_IND |B_CVRG_YR_TB |WFB51152-COV-APR-IND | |A | | | |
|B_MAY_CVRG_IND |B_CVRG_YR_TB |WFB51152-COV-MAY-IND | |A | | | |
|B_JUN_CVRG_IND |B_CVRG_YR_TB |WFB51152-COV-JUN-IND | |A | | | |
|B_JUL_CVRG_IND |B_CVRG_YR_TB |WFB51152-COV-JUL-IND | |A | | | |
|B_AUG_CVRG_IND |B_CVRG_YR_TB |WFB51152-COV-AUG-IND | |A | | | |
|B_SEP_CVRG_IND |B_CVRG_YR_TB |WFB51152-COV-SEP-IND | |A | | | |
|B_OCT_CVRG_IND |B_CVRG_YR_TB |WFB51152-COV-OCT-IND | |A | | | |
|B_NOV_CVRG_IND |B_CVRG_YR_TB |WFB51152-COV-NOV-IND | |A | | | |
|B_DEC_CVRG_IND |B_CVRG_YR_TB |WFB51152-COV-DEC-IND | |A | | | |
Notes:
___________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always For Std Edits: D = Date Edit V = Valid Value Edit
C = Conditionally N = Numeric Edits S = System Generated
N = Never
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