Carrier Implementation Planning
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1 Implementation Planning Overview of Key Activities April 18, 2013 A service of Maryland Health Benefit Exchange
2 Documentation Status 2
3 Documentation Update Document Original Delivery Comments Due To be Finalized Integration Package 834 Companion Guide 820 Companion Guide Interfaces Test Plan TPA Technical Integration Package 2/20/13 3/11/13 4/23/2013 2/20/13 3/11/13 4/23/2013 3/7/13 4/12/13 4/23/2013 4/4/13 4/18/13 5/2/13 1/31/13 3/11/13 4/23/13 3
4 Document Control We continue to receive valuable questions and feedback on the documentation we have provided. To support development of the interfaces, documentation will be locked down on 4/23. The documentation will continue to be updated monthly. All new questions and comments will be assessed as they have been in the past, and included in the monthly update. Any significant changes will be brought back to EIAC for discussion. Subsequent releases of the interface software will incorporate both updates made to the documentation as well any bug fixes found during testing. 4
5 Feedback Summary Error Report v. Effectuation File Allowing for legacy TPA to interactions Standardizing error report format 5
6 TPA Process Flows End to End Flow Enrollment Flow Reconciliation Flow 6
7 SHOP/TPA Program 3 7
8 SHOP/TPA Program 3 Enrollment (Inbound) dfd TPA Program 3 Maryland Health Connection Shop/TPA Program Shop/TPA Program 3 1. Once confirmation of participation occurs and the participation rate is met, the Maryland Health Connection sends the group file to the. 2. The sends a group acknowledgement file to the Maryland Health connection. 3. The Maryland Health Connection sends an 834 change file for all groups to the s on a daily basis. 4. The sends the 999 acknowledgement file to the Maryland Health Connection. 5. If there are any discrepancies, the will send an error report file to the Maryland Health Connection. 5 8
9 SHOP/TPA Program 3 Reconciliation dfd Shop/Reconciliation (Program 3) Shop/Reconciliation (Program 3) Maryland Health Connection 1b 3 CMS 1a 2 4 Shop/Reconciliation (Program 3) 1. The Maryland Health Connection sends the 834 full file to: a. b. CMS 2. The sends the 999 acknowledgement file to the Maryland Health Connection 3. If there are any discrepancies in the 834 full file, the generates an error report and contacts the Maryland Health Connection. 4. The Maryland Health Exchange will send resolution of discrepancies reported to the. 9
10 TPA Program 2 10
11 TPA Program 2 Enrollment (Inbound) dfd TPA Program 2 TPA Program 2 TPA Program TPA 8 10 Maryland Health Connection Once the confirmation of participation and the enrollment rate is met, the Maryland Health Connection sends the group file to the TPA 2. The TPA sends an acknowledgement of the group file to the Maryland Health Connection. 3. TPA sends group file to carrier. 4. The Maryland Health Connection sends an 834 change file to the TPA on a daily basis. 5. The TPA sends the 999 acknowledgement file to the Maryland Health Connection 6. The TPA sends the enrollment file to the. 7. The TPA sends an acknowledgement file to the 8. The TPA sends the 834 effectuation file to the Maryland Health Connection. 9. The Maryland Health Connection sends the 999 acknowledgement file to the TPA. 10. If there are any discrepancies, the TPA generates and sends an error report to the Maryland Health Connection 11. The TPA contacts the to resolve discrepancies 11
12 TPA Program 2 Reconciliation dfd Reconciliation (Program 2) Reconciliation (Program 2) 1b CMS Maryland Health Connection Reconciliation (Program 2) 1. The Maryland Health Connection sends the 834 full file to the TPA and CMS 2. The TPA sends the 999 acknowledgement file to the Maryland Health Connection 3. If there are any discrepancies, the Maryland health Connection generates an error report file and sends to the TPA 4. After discrepancies have been resolved, TPA sends the full file to the 5. The sends an acknowledgement file to the TPA 6. If there are any discrepancies in the full file, the generates an error report and sends this to the TPA. TPA and resolve these discrepancies. 1a 3 TPA 12
13 TPA Program 1 13
14 TPA Program 1 Enrollment (Inbound) dfd TPA Program 1 TPA Program a 4b 2 TPA Maryland Health Connection 5 3b 4a 1 Employer TPA Program 1 1. Employer creates an account in the Maryland Health Connection. 2. The Maryland Health Connection will send this employer data to TPA. 3. Once open enrollment ends and the participation rate is met, the TPA sends the group file to the / Maryland Health Connection. 4. / Maryland Health Connection sends acknowledgement of group file to the TPA 5. The /TPA enroll users and resolve discrepancies. 6. The TPA sends the 834 effectuation file to the Maryland Health Connection 7. The Maryland Health Connection sends the 999 acknowledgement file to the TPA 14
15 TPA Program 1 Reconciliation dfd Reconciliation (Program 1) Reconciliation (Program 1) Maryland Health Connection TPA CMS Reconciliation (Program 1) 1. The TPA sends the full file to 2. The sends an acknowledgement file to the TPA 3. If there are any discrepancies in the full file, the generates an error file and sends it to the TPA. 4. The TPA resolves discrepancies with. 5. TPA sends the 834 full file to Maryland Health Connection. 6. The Maryland Health Connection sends a 999 acknowledgement to TPA 7. The Maryland Health Connection generates an error report and sends it to the TPA if there are discrepancies. 8. The TPA/Maryland Health Connection resolves discrepancies 9. The Maryland Health Connection sends the 834 full file CMS
16 Process Flows Enrollment Flow Termination Flow Reconciliation Flow 16
17 Individual 17
18 Individual Enrollment (Inbound) dfd 834 Inbound- Daily 834 Inbound- Daily Enrollee 1 2 Maryland Health Connection Inbound - Daily 1. An enrollee approaches the Maryland Health Connection for enrollment, disenrollment, Termination, Re-instatement and life events. 2. The Maryland Health Connection sends the 834 Change file to the on a daily basis. 3. The sends a 999 acknowledgement file to the Maryland Health Connection. 4. If there are any discrepancies, the sends an error report to the Maryland Health Connection. 5. Error report is reconciled between the Maryland Health Connection and the. 18
19 Individual Termination (Outbound) dfd 834 Outbound- Daily 834 Outbound- Daily (Non- Payment Scenario) Maryland Health Connection Outbound- Daily (Individual) 1. An enrollee has been flagged for non-payment by the or individual elected to pay to. 2. sends the 834 change file to the Maryland Health Connection. 3. The Maryland Health Connection sends the 999 acknowledgement file to the. 4. If there are any discrepancies, the Maryland Health connection sends an error report file to the. 1 Enrolle 19
20 Individual Reconciliation (Monthly) dfd Reconciliation (Monthly) Reconciliation (Monthly) 1b Maryland Health Connection CMS 1a 2 3 Monthly Inbound (Reconciliation) 1a. On the 15th of every month, the Maryland Health Connection sends a 834 full file to the. 1b. The Maryland Health Connection sends a 834 full file to CMS 2. The sends the 999 acknowledgement file to the Maryland Health Connection. 3. In the event that the 834 file contains issues that need to be reconciled, the generates an error report and sends it to the Maryland Health Connection. 20
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