Reconciliation Process

Transcription

1 Reconciliation Process 08/08/2013 A service of Maryland Health Benefit Exchange

2 Agenda Enrollment Process Enrollment Reconciliation Financial Process Financial Reconciliation Reconciliation Data Elements Error Report 834 Reconciliation Error Codes 820 Reconciliation Error Codes 2

3 Enrollment Process Action 1: Maryland Health Connection will send a daily 834 file to carrier s inbox. Action 2: Carriers sends 999 as an implementation acknowledgement for EDI format errors to carrier s outbox. Action 3: Carrier sends daily error report if there are any data errors to carrier s outbox. 3

4 Enrollment Process Action 4: Carrier sends daily effectuation file to carrier s outbox. Action 5: Maryland Health connection Validates daily effectuation file and pass to CMS. Action 6: CMS sends 820 and corresponding APTC Payments to the Carrier(Frequency TBD) Standard file naming convention for the reconciliation file that is sent to the carrier: MHBE_<Carrier_ID>_RECON_YYYYMMDDHHM MSS.X12_834.txt.pgp 4

5 Enrollment Reconciliation Action 1: Maryland Health Connection will send a monthly 834 full file(all enrollees for the month) to carrier s inbox on 21 st of every month. Action 2: Carriers sends 999 as an implementation acknowledgement for EDI format errors to carrier s outbox. Action 3: Carrier sends error report if there are any data errors to carrier s outbox. 5

6 Enrollment Reconciliation Action 4: Maryland Health Connection representative and Carrier s representative will have a manual interaction on the data errors occurred. Action 5: Maryland Health Connection corrects and resends the 834 file to the carriers for the errors reported on 999 and the error report for Carrier updates. 6

7 Financial Process Action 1: Maryland Health Connection will send a weekly 820 to carrier s inbox. Action 2: Carriers sends 999 as an implementation acknowledgement for EDI format errors to carrier s outbox. Action 3: Carrier sends error report if there are any data errors to carrier s outbox. 7

8 Financial Process Action 4: Maryland Health Connection corrects and resends the 820 file to the carriers for the errors reported on 999 and the error report for Carrier updates. Action 5: Maryland Health Connection will send the payment check to the carrier. MHC will send 820 every Monday, Carriers will receive the money by Thursday each week. If Thursday happens to be a State holiday, Carriers will get the money on next business day. Standard file naming convention for the reconciliation file that is sent to the carrier: MHBE_<Carrier_ID>_RECON_YYYYMMDDHHM MSS.X12_820.txt.pgp 8

9 Financial Reconciliation Action 1: Maryland Health Connection will send a weekly 820 file to carrier s inbox. Action 2: Carriers sends 999 as an implementation acknowledgement for EDI format errors to carrier s outbox. 9

10 Financial Reconciliation Action 3: Carrier sends error report if there are any data errors to carrier s outbox. Action 4: Maryland Health Connection representative and Carrier s representative will have a manual interaction on the data errors occurred. Action 5: Maryland Health Connection corrects and resends the 820 file to the carriers for the errors reported on 999 and the error report for Carrier updates. Action 6: Maryland Health Connection will send the payment to the carrier. Action 7: CMS sends the 820 to the carrier. Action 8: CMS sends the APTC payments to the carrier. Note : These 820 from MHBE and APTC payments from CMS when summed up should be equal to total premium amounts due to carrier for subscribers that elected to pay the Exchange, if there are any discrepancies in premium,carrier need to contact Exchange. If there is an issue with APTC amounts, Carrier need to contact CMS. It is the carrier who is responsible for financial reconciliation. 10

11 Reconciliation Data Elements Error Report Reconciliation Data Elements Error Report 11

12 834 Reconciliation Error Codes Error Code Error Message RECENR001 Sponsor Name discrepancy, doesn't match 834 RECENR002 Sponsor FI discrepancy, doesn't match 834 RECENR003 Payer Name discrepancy, doesn't match 834 RECENR004 Payer FI discrepancy, doesn't match 834 RECENR005 Broker Name discrepancy, doesn't match 834 RECENR006 Broker NPN discrepancy, doesn't match 834 RECENR007 HIX ID discrepancy, doesn't match 834 RECENR008 Subscriber Indicator mismatch RECENR009 Individual Relationship code mismatch RECENR010 Exchange Assigned Subscriber ID RECENR011 Exchange Assigned Member ID RECENR012 Issuer Assigned Subscriber ID RECENR013 Issuer Assigned Member ID RECENR014 Last Name mismatch RECENR015 First Name Name mismatch RECENR016 SSN mismatch RECENR017 Address mismatch RECENR018 DOB mismatch RECENR019 State Code mismatch RECENR020 Postal Code mismatch RECENR021 Gender Code mismatch RECENR022 Marital Status Code mismatch RECENR023 Tobacco Use code mismatch RECENR024 Custodial parent Info mismatch 12

13 834 Reconciliation Error Codes Error Code RECENR025 RECENR026 RECENR027 RECENR028 RECENR029 RECENR030 RECENR031 RECENR032 RECENR033 RECENR034 RECENR035 RECENR036 RECENR037 RECENR038 Error Message Responsible Person Info mismatch Insurance Line Code mismatch Coverage Level Code mismatch Benefit Begin Date mismatch Benefit End Date mismatch Premium Paid to Date End mismatch Last Premium Paid Date mismatch Plan ID mismatch Maintenance Efective Date mismatch Benefit Begin Date mismatch Medical Premium mismatch Dental Premium mismatch APTC amount mismatch Carrier Description of Error 13

14 820 Reconciliation Error Codes Error Code Error Message RECPAY001 Payment do not match with the 834 RECPAY002 Exchange Assigned ID mismatch RECPAY003 Carrier Assigned ID mismatch RECPAY004 Policy ID mismatch RECPAY005 APTC amount mismatch RECPAY006 Premium Amount mismatch RECPAY007 Premium Payment Adjustment Amount mismatch RECPAY008 Invoice Amount mismatch RECPAY009 Adjustment Amount mismatch RECPAY010 Refund Amount mismatch RECPAY011 Total Returned Amount mismatch RECPAY012 HIX ID mismatch RECPAY013 Payer Name mismatch RECPAY014 Payer Federal Taxpayer s Identification Number mismatch RECPAY015 Payee Name mismatch RECPAY016 Payee Federal Taxpayer s Identification Number mismatch RECPAY017 QHP ID mismatch RECPAY018 Policy Number mismatch RECPAY019 Payment cannot be zero RECPAY020 Invalid Payment Code RECPAY021 Payment cannot be positive for the given payment code RECPAY022 Payment cannot be negative for the given payment code RECPAY023 Invalid member RECPAY024 Member Last Name mismatch RECPAY025 First Name mismatch RECPAY026 Coverage dates mismatch RECPAY027 Carrier description of error 14

15 QUESTIONS? 15