AHCCCS Technical Interface Guidelines (TIG) - Health Plan Interface

Introduction

The Crisis Service 834 Input File allows RBHA’s to receive a Crisis 834 file with the enrollment information for the members enrolled in other AHCCCS health plans in which crisis services were performed.

 

Schedules

• The Crisis Service 834 Input file may be placed on the server at any time and is picked up in a nightly sweep.

 

Media

The Crisis Service 834 Input File is placed by the Health Plan on the AHCCCS communications server in the plan’s folder under AZ/hpmnemonic/PROD/PROD/IN. The file is named CRISIS.XXXXXX.YYYYMMDD.TXT, where XXXXXX is the health plan id.

 

Testing

Crisis Service 834 Input file transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.

 

Reference Documents

• Crisis Service 834 Input File

Introduction

The Electronic Visit Verification (EVV) MCO PA Extract File provides the Prior Authorization data the providers have entered into the EVV Service Confirmation Portal to be delivered to the health plans through their perspective SFTP Server folders.

For further information see the AHCCCS EVV Service Confirmation Portal Manual.

 

Schedules

• Electronic Visit Verification (EVV) MCO PA Extract is produced daily, including Holidays.

 

Media

The EVV MCO PA Extract File is available on the AHCCCS FTP server. File is named WXXXXXX-DYYMMDD-IHHMMSS.sax (where XXXXXX is the health plan id) and is available in the plan's folder under AZ/HP mnemonic/PROD/OUT.

 

Testing

EVV MCO PA Extract File transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.

 

Reference Documents

• EVV MCO PA Extract File Layout

Introduction

The DUGless Output File provides demographic elements with no identified alternative data source or Social Determinate identifier. This data comes from online portal (DUGless) that is accessed directly by behavioral health providers for the collection of these data elements for members receiving behavioral health services.

For further information see the DUGless Portal Guide.

 

Schedules

• The DUGless Output File is produced semi-monthly on the 2nd and 4th Fridays.

 

Media

The DUGless Output File is available on the AHCCCS FTP server. File is named DUGLESS.XXXXXX.YYMMDD.TXT (where XXXXXX is the health plan id) and is available in the plan's folder under AZ/hp mnemonic/PROD/OUT.

 

Testing

DUGless Output file transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.

 

Reference Documents

• DUGless File Layout

Introduction

The State Only Input Processor File allows RBHA’s to add, change or terminate State Only eligibility.

 

Schedules

• The State Only Input Processor file may be placed on the server at any time and is picked up in a nightly sweep.

 

Media

The State Only Input Processor file is placed by the Health Plan on the AHCCCS communications server in the plan’s folder under AZ/hpmnemonic/PROD/IN. The file is named DAILYSTO.XXXXXX.YYYYMMDD.TXT, where XXXXXX is the health plan id.

 

Testing

State Only Input Processor file transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.

 

Reference Documents

• State Only Input Processor Layout

Introduction

This file contains information regarding members that have open ended Medicaid eligibility on the day the State Only eligibility is added.

 

Schedules

• Daily State Only Medicaid is produced nightly.

 

Media

The Daily State Only Medicaid file is available on the AHCCCS FTP server in the plan’s folder under AZ/hpmnemonic/PROD/OUT. The file is named DAILYSTO.XXXXXX.MEDICAID.YYMMDD.TXT, where XXXXXX is the health plan id.

 

Testing

Daily State Only Medicaid file transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.

 

Reference Documents

• Daily State Only Medicaid File Layout

Introduction

This file contains information regarding all members with open State Only eligibility that have open ended Medicaid eligibility.

 

Schedules

• Monthly State Only Medicaid is produced monthly, three days prior to the end of the month.

 

Media

The Monthly State Only Medicaid file is available on the AHCCCS FTP server in the plan’s folder under AZ/hpmnemonic/PROD/OUT. The file is named MTHLYSTO.XXXXXX.MEDICAID.YYMMDD.TXT, where XXXXXX is the health plan id.

 

Testing

Monthly State Only Medicaid file transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.

 

Reference Documents

• Monthly State Only Medicaid File Layout

Introduction

Active Care Notifications identify new members to a Health Plan who have certain medical conditions that have been reported by the eligibility determination agency.

Active Care Notification Process provides additional information to the Health Plan of members who may require immediate transition of care.

 

Schedules

• The Active Care File normally completes between 8:00 p.m. and 11:59 p.m. each night for the day's activity. File is named yymmdd.ACR and is available in the plan's folder under /AZ/hp mnemonic/PROD/OUT.

 

Media

Active Care notifications are produced in data file format. Health Plans, or their services bureaus connect to the Arizona Health Care Cost Containment System (AHCCCS) FTP server and download the data file for batch processing.

 

Testing

Active Care notification file transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.

 

Reference Documents

• Active Care File Layout

Introduction

Daily Enrollment Notifications identify:

• new additions (members) to a Health Plan for which the Health Plan is responsible
• persons disenrolled or deceased for whom the Health Plan is no longer responsible
• changes to member's demographic data such as name, address or date of birth
• other changes, such as rate code changes.

Daily Enrollment Notifications occur through the HIPAA 834 Transaction Code Set.

Capitation for enrollments will be calculated on a per diem basis. Capitation will be paid through the end of the processing month. Prospective capitation will be paid on a monthly basis (See Monthly Enrollment Notification Process).

Capitation payments and recoupments as a result of Daily Enrollment Notification process are transmitted to the Health Plan on the HIPAA 820 Transaction Code Set.

 

Schedules

• Enrollment processing normally completes between 8:00 p.m. and 11:59 p.m. each night for the day's activity.
• HIPAA 834 and 820 TCS files are downloaded to the AHCCCS Communications Server and available for extraction by the Health Plan by 11:59 p.m.

 

Media

Enrollment notifications are produced in data file format. Health Plans, or their services bureaus, must dial in to the Arizona Health Care Cost Containment System (AHCCCS) computer system and download the data file for batch processing.

 

Testing

Enrollment Notification and Capitation Notification file transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmissions takes approximately one week and must be completed prior to implementation of any new processing arrangement.

 

Reference Documents

• HIPAA 834 Companion Document for Daily Enrollment Notification
• HIPAA 820 Companion Document for Weekly Capitation Notification.

 

Notes

Enrollment notification and capitation notification data, once delivered to the Health Plan, is considered legal notification of the Health Plan's responsibility for provision of care to AHCCCS members.

Special attention should be given to the daily process immediately preceding the monthly processing, as well as to the daily processing run on the last two days of the month. The daily process which runs prior to the monthly is referred to as the 'last daily' and will contain all rate code changes which are effective for the next month, as well as any new enrollment, and a majority of the dis-enrollments effective at the end of the month. It is important that this last daily be processed by the Health Plans before attempting to run the monthly reconciliation process (See Monthly Enrollment Notification Process.)

The two daily processes that run after the monthly process are different from 'regular' daily process in that they will pay capitation, or recoup capitation into the next month. This is because the monthly, which normally pays prospective capitation, has already run.

Introduction

The Daily Capitation Notification process (HIPAA 820) also creates the Daily Rate Code Summary. The Rate Code Summary provides a formatted report file for the Health Plan of the total dollar amounts by contract type, rate code, and county. The Daily Rate Code Summary provides a view of the amounts paid for each rate code of the next prospective month's capitation. The Daily Rate Code Summary can also be used to reconcile against the Daily HIPAA 820 TCS.

 

Schedules

• Daily Rate Code Summary files are created and available on the AHCCCS Communications server at approximately the same time as the Daily Capitation Notification file (HIPAA 820). File is named yymmdd.DRC and is available in the plan’s folder under AZ/hp mnemonic/PROD/OUT

 

Media

Daily Rate Code Summary is available on the AHCCCS FTP server.

 

Testing

Daily Rate Code Summary transmissions must be tested in coordination with the AHCCCS ISD operations staff prior to production implementation of a new Health Plan; change in service bureau, or as a result of roster changes. Typical testing of file transmissions takes approximately one week and must be completed prior to implementation of any new processing arrangement.

 

Reference Documents

• Daily Rate Code Summary File Layout

 

Notes

Daily Rate Code Summary file is created as a formatted report, not a data file.

Introduction

Arizona Early Intervention File files identify Targeted Support Coordination (TSC) from DES/DDD Recipients under 3 years of age and actively enrolled in Health Plans.

Files track Arizona Early Intervention Program members enrolled in Health Plans in the PMMIS System. A file will be downloaded for each Health Plan.

 

Schedules

• EIP file runs on the first day of each month. File is named ccyymm.EIP and is available in the plan’s folder under AZ/hpmnemonic/PROD/OUT

 

Media

AzEIP File notifications are produced in data file format. Health Plans, or their services bureaus, must connect to the Arizona Health Care Cost Containment System (AHCCCS) FTP server and download the data file for batch processing.

 

Testing

It is highly recommended that AzEIP File transmissions be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week.

 

Reference Documents

• AzEIP File Layout

Introduction

The Manual Payment process is used as a tool for manual adjustments to capitation records. Manual payments are utilized to create a payment or recoupment override to manually process records that would not be processed systematically.

From the Health Plan perspective the Manual Payment Process will be incorporated into the Weekly Capitation Notification (HIPAA 820) processes.

 

Schedules

• Manual Payment Update on-line entry during the day.
• Manual Payment Roster are downloaded to the AHCCCS Communications Server and available for extraction by the Health Plan by 11:59 p.m.
• 820 TCS files

 

Media

The Daily Manual Payment Roster and Weekly Capitation Notification file (HIPAA 820) are available on the AHCCCS communications server.

 

Testing

Daily Manual Payment Roster and Weekly Capitation Notification transmissions must be tested in coordination with AHCCCS ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmissions takes approximately one week and must be completed prior to implementation of any new processing arrangement.

 

Reference Documents

• Manual Payment Roster File Layout
• HIPAA 820 Companion Document

Introduction

The Mass Adjustment process is used as a tool for administrative adjustment of contracted rates. Previously paid amounts are recouped, and then repaid at the new rate. From the Health Plans' perspective, the mass adjustment resembles the Daily Enrollment Notification process in that it is transaction driven. The mass adjustment transmission file (HIPAA 820) is identical to that produced using the Daily Enrollment Notification process.

 

Schedules

• Mass Adjustment Processing is normally scheduled after the completion of the daily roster process as needed. Health Plans are notified of the adjustment in writing prior to processing.
• HIPAA 820 TCS files are downloaded to the AHCCCS Communications Server and available for extraction by the Health Plan by 11:59 p.m. on a weekly basis.

 

Media

The Weekly Capitation Notification file (HIPAA 820) is available on the AHCCCS communications server.

 

Testing

Weekly Capitation Notification transmissions must be tested in coordination with AHCCCS ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmissions takes approximately one week and must be completed prior to implementation of any new processing arrangement.

 

Reference Documents

• HIPAA 820 Companion Document

Introduction

The Members with Choice file identifies for the health plan all enrolled members that will have an annual open enrollment choice sixty days prior to the annual enrollment date. Please note, if a member does not make a selection in the first month, they will again appear on the next month’s file.

 

Schedules

• Members with Choice file is a monthly file that is produced around the 5th of the month.

 

Media

The Members with Choice file is available on the AHCCCS SFTP server in the plan’s folder under AZ/hpmnemonic/PROD/OUT. File is named ccyymm.MWC.

 

Testing

The Members with Choice file must be tested in coordination with the AHCCCS ISD operations staff prior to production implementation of a new Health Plan, change in service bureau, or as a result of roster changes. Typical testing of file transmissions takes approximately one week and must be completed prior to implementation of any new processing arrangement.

 

Reference Documents

• Member with Choice File Layout

Introduction

Monthly Enrollment Notification files identify the total active population for each Health Plan as of the first of the next month. The Monthly Enrollment Notification file is used to reconcile the Health Plan's member file against that of AHCCCS. In order for this reconciliation to be successful, it is important that all daily transmission files, including the last daily, be processed prior to the monthly reconciliation.

There are no Monthly Capitation Notification files. Capitation is transmitted to Health Plans weekly in HIPAA 820 TCS.

 

Schedules

• Monthly Enrollment Notification occurs three days before the first of the next month for each Health Plan under contract with AHCCCS. For a thirty-one day month, the Monthly Notification file is run after the 'Last Daily' Enrollment Notification file on the twenty-ninth day of the month. The ‘Last Daily' and Monthly Enrollment Notification processing schedules are published in advance of each monthly cycle and is available from AHCCCS web site.
• Month End File Availability Notice

 

Media

Monthly Enrollment Notification file is available on the AHCCCS communications server.

Monthly Enrollment Notification is produced in 834 data file format only.

 

Testing

Monthly Enrollment Notification and Monthly Capitation Notification file transmissions must be tested in coordination with the AHCCCS ISD operations staff prior to production implementation of a new Health Plan, change in service bureau, or as a result of roster changes. Typical testing of file transmissions takes approximately one week and must be completed prior to implementation of any new processing arrangement.

 

Reference Documents

• HIPAA 834 Companion Document

 

Notes

Monthly Enrollment Notification data, once delivered to the Health Plan, is considered legal notification of the Health Plan's responsibility for provision of care to AHCCCS members.

Monthly Enrollment Notification files are retained on the AHCCCS computer server for one month.

Introduction

The Monthly Rate Code Summary provides a report for the Health Plan of the total dollar amounts by contract type, rate code, and county. The Monthly Rate Code Summary provides a view of the capitation paid for each rate code for the prospective month's capitation. The Monthly Rate Code Summary can also be used to reconcile against the Weekly HIPAA 820 TCS.

 

Schedules

• Monthly Rate Code Summary files are created and available on the AHCCCS Communications server at approximately the same time as the Monthly Enrollment Notification file File is named ccyymm.SUM and is available in the plan’s folder under AZ/hpmnemonic/PROD/OUT

 

Media

Monthly Rate Code Summary is available on the AHCCCS FTP server.

 

Testing

Monthly Rate Code Summary transmissions must be tested in coordination with the AHCCCS ISD operations staff prior to production implementation of a new Health Plan, change in service bureau, or as a result of roster changes. Typical testing of file transmissions takes approximately one week and must be completed prior to implementation of any new processing arrangement.

 

Reference Documents

• Monthly Rate Code Summary File Layout

 

Notes

Monthly Rate Code Summary files are retained on the AHCCCS computer server for one month.

Introduction

The Open Enrollment Potential Transition Listing files provide the Health Plan with the basic demographic information of all members who may be joining or leaving the plan.

Important Note: Listing should not be confused with Enrollment Notification data. Whereas Enrollment Notification data, once delivered to the Health Plan, is considered legal notification, this is only preliminary information based on the member's choice during the Open Enrollment Period.

The Health Plan can use this information to begin preparing for the new members joining their plan and the transition of the members leaving their plan.

 

Schedules

• The Open Enrollment Potential Transition Listing file is produced on the third of the month.

 

Media

The Open Enrollment Potential Transition file is available on the AHCCCS SFTP server in the plan’s folder under AZ/hpmnemonic/PROD/OUT. File is named ccyymm.PTL.

 

Testing

The Open Enrollment Potential Transition Listing file transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.

 

Reference Documents

• Open Enrollment Potential Transition Listing File Layout

Introduction

Prior Plan Listing identifies members who have been enrolled into a new Health Plan that were previously disenrolled from another Health Plan up to 90 days in the past. Prior Plan Listing process provides information to the previous Health Plan of members who have now enrolled into a different Health Plan for transition of care.

 

Schedules

• Prior Plan Listing normally completes between 8:00 p.m. and 11:59 p.m. each night for the day's activity. File is named ccyymm.PPL and is available in the plan’s folder under AZ/hpmnemonic/PROD/OUT

 

Media

Prior Plan Listing notifications are produced in data file format. Health Plans, or their services bureaus, must login to the Arizona Health Care Cost Containment System (AHCCCS) FTP server and download the data file for batch processing.

 

Testing

Prior Plan Listing notification file transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.

 

Reference Documents

• Prior Plan Listing File Layout

Introduction

Health Plans (HPs) are required by AHCCCS contract to submit new additions and updates to existing Commercial Third Party insurance coverage information associated with their enrolled Medicaid Members. This TPL information is processed, verified and stored in the AHCCCS PMMIS database. It is used to cost avoid medical, dental and pharmacy expense where AHCCCS members have other insurance coverage that must be exhausted prior to using Medicaid funds.

This process is intended to garner information about Commercial coverage and is not to be used for reporting Medicare traditional Fee-for-Service or Medicare Advantage coverage.

NOTE: Subscriptions to Medicare Supplemental coverage policies are considered commercial coverage because the premiums are paid by the member in addition regular Medicare coverage. Supplemental Medicare policies are to be reported in this process.

AHCCCS edits HP encounters for required TPL coverage and denies encounters for members with existing TPL insurance records for the covered dates of service. Plans are required to recoup primary payment and/ or provide corrected TPL coverage information in order to re- submit the encounter.

Schedules

TPL coverage addition, change and termination information is provided through either of two coverage notification processes. Both have the same data requirements for an acceptable transaction.

Health Plans may use:

• The website provided by the AHCCCS TPL contractor

  The AHCCCS TPL Contractor provides Health Plans access to an on-line database- REF DB. Plan staffs register and manually enter new TPL leads and updates to existing TPL lead records directly into this database. The Contractor then verifies the TPL coverage information provided and submits verified records back to AHCCCS to be added directly into the PMMIS Database- RP155 Table. AHCCCS Web Link = https://www.azahcccs.gov/PlansProviders/HealthPlans/tpl.html

• The Third Party Leads file submission file process

  The Third Party Leads File submission process is accomplished by Health Plans depositing a prescribed TLP Lead File on the AHCCCS communications server- SFTP. (See file layout below) The file records will be edited and records with invalid syntax or missing required fields will be rejected.

  Filename protocol - yymmdd.tpl

  File Location - placed in the Health Plan's folder under AZ/*** /PROD/IN

  (Where *** = HP mnemonic)

  The files may be placed on the server at any time and are picked up in a nightly sweep for incoming “.tpl” files with that days processing date. Plans may deposit multiple files with the same date. Advance dated files will be picked up on that processing date. However, prior dated files will never be picked up. If the sweep fails to pick up the file, it must be renamed for the next full days processing.

Media

The Third Party Leads Submission File is placed by the Health Plan on the AHCCCS communications server.

Reporting

Health Plans receive a Lead Outcome Report indicating the status of the detail records submitted on their TPL Lead files. The report ‘Messages’ field for each record will indicate the outcome; either record added or not added and the reason. The report is placed in the Plans folder on the AHCCCS Communication Server.

Filename: yymmdd.RP94D576.TPL.report.txt

File Location: AZ/***/PROD/OUT

Testing

Third Party Leads Submission file transmissions must be tested in coordination with AHCCCS ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of other changes. Typical testing of transmissions takes approximately one week and must be completed prior to implementation of any new processing arrangement.

Reference Documents

Third Party Leads Submissions File Layout

Introduction

The Third Party Liability (TPL)/Coordination of Benefits (COB) process provides Health Plans (HP) with several files important to the accurate and timely updating of AHCCCS TPL/COB coverage information. The files are placed on HP’s SFTP sites according routine schedules. HPs are required to pick up and use this information to update their own TPL/COB subsystems to maintain up-to-date coverage information and maximize cost avoidance where other insurance carriers are required to pay primary to AHCCCS Medicaid.

Commercial TPL coverage data is received in the form of a coverage referral record from many different sources including HPs, eligibility sources (DES, SSA, etc.) and our TPL Contractor. The referrals are edited and acceptable records are written to PMMIS Table 155 in a ‘P’ Pend status. AHCCCS runs a nightly sweep of the table and copies Pend status commercial records to our TPL Contractor, at which point the status is changed to “R’ Referred. Those referrals are researched through our Contractor’s validation process. Records are returned to AHCCCS and updates are posted that either verify TPL coverage and update the RP155 record and ‘R’ status to Verified (status = ‘V’) or invalidate the coverage to “Invalid” (Status= ‘I’). Invalid status records are moved to the AHCCCS PMMIS table RP155H (History).

Validated TPL records are used for encounter editing. Where an active TPL coverage record exists for Date of Service on a paid encounter, evidence of TPL/COB must be present in the encounter; if not, the encounter will be denied and returned for recoupment of payment and/or resubmission.

In addition to the commercial TPL verifications, Medicare data is also provided on the Daily and Monthly Verified files.

Schedules

NOTE: (XXX= Plan’s pneumonic)

• The Outgoing and Incoming TPL referral file processing is performed seven days a week with the TPL Contractor.
• The Medicare data update process is performed on several different schedules including daily, semi-monthly, and monthly. NOTE: HPs will see this same Medicare information in the TPL section of the daily and Monthly 834 transmissions.
• TPL Daily File (Verified Data) is downloaded to the AHCCCS Communications Server (SFTP) and available for extraction by the HPs by 7:00 a.m. the next day. File is named yymmdd.TPL. It is available in the HP’s SFTP folder under /AZ/XXX /PROD/OUT and will contain both TPL and Medicare data for AHCCCS members enrolled with the HP. This data reflects only validated coverage information that will be used for encounter editing at AHCCCS. NOTE: HPs will see this same Commercial and Medicare information in the TPL section of the daily 834 transmissions but with less detail.
• TPL Daily Invalid Notification File contains that days invalid Commercial TPL referrals and is downloaded to the AHCCCS SFTP and is available for extraction by the HPs by 7:00 a.m. the next day. File is named yymmdd.NOT. It is available in the HP’s SFTP folder under /AZ/XXX/PROD/OUT and will contain Commercial TPL data for AHCCCS members enrolled with the HP. Invalid TPL records are not used for encounter editing. These records are returned to the plans for correction and potential resubmission. NOTE: This file does not contain Medicare information.
• TPL Monthly File (Verified Data) contains both TPL and Medicare data based upon the membership as of the first of the month and is downloaded to the AHCCCS SFTP and is available for extraction by the HP. File is named yyyymm.TPL. It is available in the HP’s folder under /AZ/XXX/PROD/OUT. NOTE: Contractors will see this same Commercial and Medicare information in the TPL section of the Monthly 834 transmissions but with less detail.
• Master Carrier ID File is downloaded to the SFTP each Friday and is available for extraction by the HPs by 7:00 a.m. the next day. File is named RFCARIDmmddyy.TXT and is available in the ShareINFO folder under /AZ/ShareINFO/Reference/PROD/OUT. This is a full file replacement copy of the PMMIS RF563 Master Carrier ID Table and contains AHCCCS Commercial carrier IDs to be used for HP TPL referrals submitted through the Third Party Leads Submission Process.

Media

The TPL File is available on the AHCCCS communications server.

Testing

TPL file transmissions must be tested in coordination with AHCCCS ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of roster changes. Typical testing of transmissions takes approximately one week and must be completed prior to implementation of any new processing arrangement.

Introduction

The Unique Population file contains additional information regarding members that is not included on the 834 file. This information includes the following indicators:

• PREVIOUS CHILD REHABILITATIVE SVC (PCR)
• SEVERELY EMOTIONALLY DISTURBED (SED)
• NEONATAL ABSTINENCE SYNDROME (NAS)
• SEVERE COMBINED IMMUNODEFICIENCY (SCI)
• AUTISM OR AT RISK (AUT)
• OFFICE OF HUMAN RIGHTS SPC ASSIST (OHR)
• ADOPTION IVE
• STATE ADOPTION SUBSIDY
• CHILDREN'S REHABILITATION SERVICES
• SMI OPT OUT

Schedules

The Unique Population File is produced on the first of the month.

Media

The Unique Population file is available on the AHCCCS FTP server in the plan’s folder under AZ/hpmnemonic/PROD/OUT. The file is named YYYYMM_HPXXXXXX_Mthly_Unique_Elg_Pop.txt where XXXXXX is the health plan ID.

Testing

Unique Population file transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.

Reference Documents

Unique Population File Layout

Introduction

The SMI_SED Determination Outcome Eligible file is a daily summary of all records submitted by Solari to AHCCCS to indicate the final SMI or SED status of AHCCCS eligible members.

Schedules

Weekdays by 10.00pm

Media

The SMI_SED Determination Outcome Eligible Report will be sent to the AHCCCS SFTP server, /XXX/PROD/OUT where XXX is the Health Plan folder. The file name is SMI_SED-Determination-Outcome-Elig-Report_yyyymmdd_XXXXXX.DAT (where XXXXXX is the Health Plan ID).

Testing

SMI_SED Open Not Submitted file transmissions must be tested in coordination with the AHCCCS ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.

Reference Documents

SMI_SED Determination Outcome Eligible Report Layout

Introduction

The SMI_SED Determination Outcome Non-Eligible Report is a daily summary of all records submitted by Solari to AHCCCS to indicate the final SMI or SED status of non-AHCCCS eligible members. The report is used for RBHA affiliated health plans to create State Only records and/or correct members’ AHCCCS ID’s as needed.

Schedules

Weekdays by 10.00pm

Media

The SMI_SED Determination Outcome Non-Eligible Report will be sent to the AHCCCS SFTP server, /XXX/PROD/OUT where XXX is the Health Plan folder. The file name is SMI_SED-Determination-Outcome-NonElig-Report_yyyymmdd_XXXXXX.DAT (where XXXXXX is the Health Plan ID).

Testing

SMI_SED Open Not Submitted file transmissions must be tested in coordination with the AHCCCS ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.

Reference Documents

SMI_SED Determination Outcome Non-Eligible Report Layout

Introduction

The Open SMI_SED Pended Eligible Report is a daily summary of all submitted records where the SMI and SED status of AHCCCS eligible members is under evaluation by Solari.

Schedules

Weekdays by 10.00pm

Media

The Open SMI_SED Pended Eligible Report will be sent to the AHCCCS SFTP server, /XXX/PROD/OUT where XXX is the Health Plan folder. The file name is Open-SMI_SED-Pended-Elig-Report_yyyymmdd_XXXXXX.DAT (where XXXXXX is the Health Plan ID).

Testing

SMI_SED Submitted file transmissions must be tested in coordination with the AHCCCS ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.

Reference Documents

Open SMI_SED Pended Eligible Report Layout

Introduction

The Open SMI_SED Pended Non-Eligible Report is a daily summary of all submitted records where the SMI or SED status of non-AHCCCS eligible members is under evaluation by Solari. The report is used for RBHA affiliated health plans to create State Only records and/or correct members’ AHCCCS ID’s as needed.

Schedules

Weekdays by 10.00pm

Media

The SMI_SED Submitted will be sent to the AHCCCS SFTP server, /XXX/PROD/OUT where XXX is the Health Plan folder. The file name is Open-SMI_SED-Pended_NonElig-Report_yyyymmdd_XXXXXX.DAT (where XXXXXX is the Health Plan ID).

Testing

SMI_SED Submitted file transmissions must be tested in coordination with the AHCCCS ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.

Reference Documents

Open SMI_SED Pended Non-Eligible Report Layout