This document contains the format of each file that is exported by AHS and prepared for each Health Plan.

Transcription

1 Florida Health Plan Export File Formats This document contains the format of each file that is exported by AHS and prepared for each Health Plan. Contents Health Plan Export File Formats... 1 Revision History... 2 Open Enrollment File... 3 File Name... 3 File Format... 3 Enrollment File... 4 File Name... 4 File Format... 4 Disenrollment File... 5 File Name... 5 File Format... 5 Provider Response File... 6 File Name... 6 File Format... 6 Appendix A... 8 Appendix B... 9 Appendix C Appendix D Appendix E Appendix F Appendix G Appendix H

2 Revision History Date Notes Revised By 03/29/2011 Document Created Greg Holtz 08/01/2011 Added allocation of Characters in the Filler to Medipass Greg Holtz 08/02/2011 Switched certain Error Codes from Errors to Warnings Greg Holtz 01/31/2012 Updated descriptions on Error Codes that were incorrect Greg Holtz 07/01/2012 Changed Error Code 051 from Warning to Error Donna Howe 11/08/2012 Updated Appendix G Specialty Codes Greg Holtz 11/13/2012 Updated Appendix G Specialty Codes Donna Howe 5/07/2013 Updated file name (date) and schedule for when the files are loaded onto the AHS FTP Server for download by the plans (Changes are Red Text Highlighted Yellow) Donna Howe 2

3 Open Enrollment File The Open Enrollment File contains information on each beneficiary who becomes: 1. Locked-In 2. Enters a 90-day change window 3. Enters the annual 60-day open enrollment period The file contains 1 record for each beneficiary who is currently enrolled with the Health Plan and who is subject to Open Enrollment. File Name XXX_OENYYYYMM.dat Notes: XXX = 3 character assigned plan ID The date in the file name will be the effective date of the enrollments within the Enrollment file. File Format The files are in a Fixed Width ASCII flat file format and are loaded onto the AHS FTP Server for download on the following schedule: Tuesday after the monthly processing cycle. 1. Monthly Magic: On the penultimate Saturday of the month. 2. Month End: First day of the next month. 3. MediKids Supplemental: Between the 3 rd and 8 th of the next month. Field Description Length Notes Plan Code Plan Code of the Health Plan 9 Recipient Number Beneficiary s unique Identification number 10 Case Number Beneficiary s Case Number 10 First Name Beneficiary s First name 15 Middle Initial Beneficiary s Middle Initial 1 Last Name Beneficiary s Last Name 25 Address 1 Beneficiary s Address Line 1 30 Address 2 Beneficiary s Address Line 2 30 City Beneficiary s City 30 State Beneficiary s State 2 Zip Code Beneficiary s Zip 10 Phone Number Beneficiary s Phone Number 10 Begin Date The first day of the period outlined by Status Code 8 MMDDYYYY End Date The last day of the period outlined by Status Code 8 MMDDYYYY Status Code Code indicating which period the Beneficiary is currently in. 2 See Appendix A 3

4 Enrollment File The Enrollment File contains the beneficiary s primary care physician selection and any special medical needs information for the beneficiary. The file contains 1 record for each beneficiary who has selected to enroll in the Health Plan starting on the first day of the following month. File Name XXX_RECIYYYYMM.dat Notes: XXX = 3 character assigned plan ID The date in the file name will be the effective date of the enrollments within the file. File Format The files are in a Fixed Width ASCII flat file format and are loaded onto the AHS FTP Server for download on the following schedule: Tuesday after the monthly processing cycle. 1. Monthly Magic: On the penultimate Saturday of the month. 2. Month End: First day of the next month. 3. MediKids Supplemental: Between the 3 rd and 8 th of the next month. Field Description Length Notes Recipient Number Beneficiary s unique Identification number 10 Case Number Beneficiary s Case Number 10 First Name Beneficiary s First name 25 Middle Initial Beneficiary s Middle Initial 1 Last Name Beneficiary s Last Name 15 Address 1 Beneficiary s Address Line 1 30 Address 2 Beneficiary s Address Line 2 30 City Beneficiary s City 30 State Beneficiary s State 2 Zip Code Beneficiary s Zip 10 Phone Number Beneficiary s Phone Number 10 Language Language spoken by the Beneficiary 2 See Appendix B Pregnancy Indicator Indicates if the Beneficiary is pregnant 1 0 = NO, 1 = YES Pregnancy Due Date Expected due date of the Pregnancy 8 MMDDYYYY Special Need Code 1 Indicates if the Beneficiary has a special need 2 See Appendix C Special Need Code 2 Indicates if the Beneficiary has a special need 2 See Appendix C Special Need Code 3 Indicates if the Beneficiary has a special need 2 See Appendix C Special Need Notes Notes about special needs 200 Plan Provider Number Number assigned to the Provider by the Plan 15 Provider Last Name Last Name of the Provider 30 Provider First Name First Name of the Provider 30 Clinic/Hosp/Group Name Name of the Clinic, Hospital, or Group 60 Plan Enrollment Indicator Indicates the Type of Enrollment 1 0 = Mandatory 1 = Voluntary Plan Number Plan Code of the Health Plan 9 4

5 Disenrollment File The Disenrollment File contains the Beneficiaries who will be leaving the Health Plan, effective at the end of the current month. The file contains 1 record for each Beneficiary with the reason they are leaving. File Name XXX_RECI_DE_FLCC_YYYYMM.dat Notes: XXX = 3 character assigned plan ID The date in the file name will be the effective date of the dis-enrollments within the file. File Format The files are in a Fixed Width ASCII flat file format and are loaded onto the AHS FTP Server for download on the following schedule: Tuesday after the monthly processing cycle. 1. Monthly Magic: On the penultimate Saturday of the month. 2. Month End: First day of the next month. 3. MediKids Supplemental: Between the 3 rd and 8 th of the next month. Field Description Length Notes Recipient Number Beneficiary s unique Identification number 10 Case Number Beneficiary s Case Number 10 First Name Beneficiary s First name 25 Middle Initial Beneficiary s Middle Initial 1 Last Name Beneficiary s Last Name 15 Disenroll Date The Last day the Beneficiary will be enrolled 8 MMDDYYYY Disenroll Reason The reason the Beneficiary is leaving the Plan 50 5

6 Provider Response File The Provider Response File is a return of the original Provider Import File with an additional 4 characters added to the end of the file for the error codes (total of 387 characters). File Name XXX_RESP_PROVYYYYDDMM.dat Notes: XXX = 3 character assigned plan ID File Format Field Description Length Notes Plan Code Plan Code of the Health Plan 9 Provider Type Indicates the provider s area of service 1 See Appendix D Plan Provider Number Number assigned to the Provider by the Plan 15 Group Affiliation Number assigned to the Group by the Plan 15 SSN/FEIN SSN or Federal ID Number 9 Provider Last Name Last Name of the Provider or Group Name 30 Provider First Name First Name of the Provider 30 Provider Address 1 Address 1 of the Provider s Location 30 Provider Address 2 Address 2 of the Provider s Location 30 Provider City City of the Provider s Location 30 Provider Zip Code Zip Code of the Provider s Location 9 Provider Area Code Area Code of the Provider Phone Number 3 Provider Phone Number Phone Number of the Provider s Location 7 Provider Phone Ext Phone Extension of the Provider s Location 4 Provider Gender Gender of the Provider 1 M = Male F = Female U = Unknown PCP Indicator Indicates if the Provider is a PCP 1 P = YES, N = NO Provider Limitation Limitation of the Provider 1 See Appendix E Plan Type The Type of Plan 1 See Appendix F Evening Hours Does the Provider have Evening Hours 1 Y = YES, N = NO Saturday Hours Does the Provider have Saturday Hours 1 Y = YES, N = NO Age Restrictions Age Restrictions 20 Primary Specialty Code identifying the provider s specialty 3 See Appendix G Specialty 2 Code identifying the provider s specialty 3 See Appendix G Specialty 3 Code identifying the provider s specialty 3 See Appendix G Language 1 Code identifying the provider s language 2 See Appendix B Language 2 Code identifying the provider s language 2 See Appendix B Language 3 Code identifying the provider s language 2 See Appendix B Hospital Affiliation 1 Hospital with which the Provider is affiliated 9 Hospital Affiliation 2 Hospital with which the Provider is affiliated 9 Hospital Affiliation 3 Hospital with which the Provider is affiliated 9 Hospital Affiliation 4 Hospital with which the Provider is affiliated 9 Hospital Affiliation 5 Hospital with which the Provider is affiliated 9 Wheel Chair Access Does the Provider have wheel chair access 1 Y = YES, N = NO # of Patients The Number of members enrolled with PCP 4 Active Patient Load The Number of allowed member enrollments 4 License Number Professional License Number of the Provider 15 6

7 AHCA Hospital ID Hospital ID 8 CHD Indicator County Health Department Indicator 1 NPI Type I NPI 1 10 NPI Type II NPI 2 10 Medicaid ID Medicaid ID of the Provider 12 Filler *The 1 st Character is being used by MediPass 10 to indicate a CMS Provider. **The 2 nd -5 th Characters are being used by MediPass to indicate maximum monthly Auto Assignment allowed for a Provider. Error Code 4 Digit error code indicating if there is an issue with the record. 4 See Appendix H 7

8 Appendix A List of Status Codes contained in the Open Enrollment File 1 = 90-day change 2 = Locked-In 3 = 60-day Open Enrollment 8

9 Appendix B List of Languages contained in the Enrollment File 01 = English 02 = Spanish 03 = Haitian Creole 04 = Vietnamese 05 = Cambodian 06 = Russian 07 = Laotian 08 = Polish 09 = French 10 = Other 9

10 Appendix C List of Special Need Codes contained in the Enrollment File 1 = Asthma 2 = Diabetes 3 = Heart Disease 4 = High Blood Pressure 5 = Kidney Problems 6 = Birth Defects 7 = Recent Surgery 8 = Cancer 9 = Mental Health Condition 10 = Sickle Cell Disease 11 = Visually Impaired 12 = Hearing Impaired 13 = Speech Impaired 14 = Developmental Delay 15 = Physical Disability 16 = Drug/Alcohol Problem 17 = Mentally Retarded 18 = Substitute Care 19 = Wheelchair Access Req. 20 = Other Chronic Illness 21 = HIV/AIDS 10

11 Appendix D List of Provider Types contained in the Provider Response File P = Primary Care Provider I = Non-PCP Practitioner B = Birthing Center T = Therapy G = Group Practice H = Hospital C = Crisis Stabilization Unit D = Dentist R = Pharmacy A = Ancillary Provider 11

12 Appendix E List of Provider Limitations contained in the Provider Response File X = Accepting New Patients N = No New Patients L = Leaving Network P = Existing Patients Only C = Accepting Children Only A = Accepting Adults Only R = Refer Member To HMO Member Services F = Female Patients Only S = Accepting Children Through CMS Only 12

13 Appendix F List of Plan Types contained in the Provider Response File H = HMO P = PSN M = MediPass 13

14 Appendix G List of Specialty Codes contained in the Provider Response File Highlight Blue Yellow Green Legend Description The code has a new description. The code is new and the description has been moved from one of the codes highlighted in Blue. The old code is listed in parenthesis after the description, ex) (Old code 100) and is not part of the actual description. The code and description are new. 001 = ADOLESCENT MEDICINE 002 = ALLERGY 003 = ANESTHESIOLOGY 004 = CARDIOVASCULAR MEDICINE 005 = DERMATOLOGY 006 = DIABETES 007 = EMERGENCY MEDICINE 008 = ENDOCRINOLOGY 009 = FAMILY PRACTICE 010 = GASTROENTEROLOGY 011 = GENERAL PRACTICE (DEFAULT SPEC FOR PHYS) 012 = PREVENTATIVE MEDICINE 013 = GERIATRICS 014 = GYNECOLOGY 015 = HEMATOLOGY 016 = IMMUNOLOGY 017 = INFECTIOUS DISEASE 018 = INTERNAL MEDICINE 019 = NEONATAL / PERINATAL 020 = NEOPLASTIC DISEASES 021 = NEPHROLOGY 022 = NEUROLOGY 023 = NEUROLOGY / CHILDREN 024 = NEUROPATHOLOGY 025 = NUTRITION 026 = OBSTETRICS 027 = OB-GYN 028 = OCCUPATIONAL MEDICINE 029 = ONCOLOGY 030 = OPHTHALMOLOGY 031 = OTOLARYNGOLOGY 032 = PATHOLOGY 033 = PATHOLOGY, CLINICAL 034 = PATHOLOGY, FORENSIC 035 = PEDIATRICS 036 = PEDIATRIC ALLERGY 14

15 037 = PEDIATRIC CARDIOLOGY 038 = PEDIATRIC ONCOLOGY & HEMATOLOGY 039 = PEDIATRIC NEPHROLOGY 040 = PHARMACOLOGY 041 = PHYSICAL MEDICINE AND REHAB 042 = PSYCHIATRY 043 = PSYCHIATRY, CHILD 044 = PSYCHOANALYSIS 045 = PUBLIC HEALTH 046 = PULMONARY DISEASES 047 = RADIOLOGY 048 = RADIOLOGY, DIAGNOSTIC 049 = RADIOLOGY, PEDIATRIC 050 = RADIOLOGY, THERAPEUTIC 051 = RHEUMATOLOGY 052 = SURGERY, ABDOMINAL 053 = SURGERY, CARDIOVASCULAR 054 = SURGERY, COLON / RECTAL 055 = SURGERY, GENERAL 056 = SURGERY, HAND 057 = SURGERY, NEUROLOGICAL 058 = SURGERY, ORTHOPEDIC 059 = SURGERY, PEDIATRIC 060 = SURGERY, PLASTIC 061 = SURGERY, THORACIC 062 = SURGERY, TRAUMATIC 063 = SURGERY, UROLOGICAL 064=OTHER (NO LONGER EXISTS) 065 = MATERNAL / FETAL 066 = COMPREHENSIVE BEHAVIORAL HEALTH ASSESSMENT 067 = SPECIALIZED THERAPEUTIC FOSTER CARE 068 = CONSUMER DIRECTED CARE 069 = MEDICAL OXYGEN RETAILER 070 = ADULT DENTURES ONLY 071 = GENERAL DENTISTRY 072 = ORAL SURGEON (DENTIST) 073 = PEDODONTIST 074 = OTHER DENTIST 075 = ADULT PRIMARY CARE 076 = CLINICAL NURSE SPECIALIST PSYCH. MENTAL HEALTH 077 = COLLEGE HEALTH NURSE PRACTITIONER 078 = DIABETIC NURSE PRACTITIONER 079 = TRAUMATIC BRAIN INJURY AND SPINAL CORD INJURY 080 = FAMILY NURSE 081 = FAMILY PLANNING 15

16 082 = GERIATRIC 083 = MATERNAL / CHILD HEALTH FAMILY PLANNING 084 = CERTIFIED REGISTERED NURSE ANESTHETIST 085 = CERTIFIED REGISTERED NURSE MIDWIFE 086 = OB/GYN NURSE 087 = PEDIATRIC NURSE 088 = ORTHODONTIST 089 = ASSISTED LIVING FOR THE ELDERLY 090 = OCCUPATIONAL THERAPIST 091 = PHYSICAL THERAPIST 092 = SPEECH THERAPIST 093 = RESPIRATORY THERAPIST 095 = AGED/DISABLED ADULTS 096 = DEVELOPMENTAL DISABILITY 097 = CHANNELING 098 = COMMUNITY SUPPORTED LIVING ARRANGEMENT 099 = PROJECT AIDS CARE 100 = GENETICS 101 = PEDIATRICS, CRITICAL CARE 102 = PEDIATRICS, EMERGENCY CARE 103 = SURGERY, PEDIATRIC - NON-BOARD CERTIFIED 104 = SURGERY, UROLOGIC - NON-BOARD CERTIFIED 110 = FAMILIAL DYSAUTONOMIA 112 = ADULT CYSTIC FIBROSIS 113 = ADULT DAY CARE 114 = PERSONAL CARE 121 = ASSISTED LIVING 122 = EXTENDED CONGREGATE CARE 123 = LIMITED NURSING SPECIALTY LICENSE 124 = LIMITED MENTAL HEALTH SPECIALTY LICENSE 125 = ADULT FAMILY CARE HOME 126 = RESIDENTIAL TREATMENT FACILITY 130 = ANESTHESIOLOGY ASSISTANT 140 = HOSPITALIST (OLD CODE 104) 150 = COMMUNITY PHARMACY 151 = INFUSION PHARMACY 152 = LTC - NON COMMUNITY 153 = INSTITUTIONAL CLASS I PHARMACY (HOSPITAL/NH) 154 = TAX SUPPORTED 155 = 340B PHARMACY 156 = DISPENSING PRACTITIONER 157 = NUCLEAR PHARMACY 158 = SPECIAL PHARMACY (PARENTERAL, ALF, CLSD SYS, ESRD) 160 = RETAIL HEALTH CLINIC 172 = RNFA 16

17 173 = COUNTY HEALTH DEPARTMENT CERTIFIED MATCH RN/LPN 174 = MENTAL HEALTH TCM 800 = MANAGED CARE TREATING PROVIDER - ACUPUNCTURIST 801 = MANAGED CARE TREATING PROVIDER - NUTRITIONIST 802 = MANAGED CARE TREATING PROVIDER - INDPDT DIAGNOST 803 = MANAGED CARE TREATING PROVIDER - OTHER 901 = GENERAL HOSPITAL 905 = COMMUNITY MENTAL HEALTH SERVICES 906 = AMBULATORY SURGERY CENTER 907 = SPECIALIZED MENTAL HEALTH PRACTITIONER 908 = SCHOOL DISTRICT 909 = SKILLED NURSING UNIT HOSPITAL BASED 910 = SKILLED NURSING FACILITY 913 = SWING BED FACILITY 915 = HOSPICE 923 = MEDICAL FOSTER CARE/ PERSONAL CARE PROVIDER 924 = PRESCRIBED PEDIATRIC EXTENDED CARE 927 = PODIATRIST (OLD CODE 102) 928 = CHIROPRACTOR (OLD CODE 100) 929 = PHYSICIAN ASSISTANT 930 = NURSE PRACTITIONER (ARNP) - GROUP 934 = LICENSED MIDWIFE 940 = AMBULANCE 941 = NON-EMERGENCY TRANSPORT 942 = AIR AMBULANCE 943 = TAXICAB COMPANY 944 = GOVERNMENT/MUNICIPAL TRANSPORT 945 = PRIVATE TRANSPORTATION 946 = NON-PROFIT TRANSPORTATION 947 = MULTI-LOAD PRIVATE TRANSPORT 950 = INDEPENDENT LABORATORY 951 = PORTABLE X-RAY COMPANY 960 = AUDIOLOGIST 961 = HEARING AID SPECIALIST 962 = OPTOMETRIST (OLD CODE 101) 963 = OPTICIAN 965 = HOME HEALTH AGENCY 966 = RURAL HEALTH CLINIC 968 = FEDERALLY QUALIFIED HEALTH CENTER 969 = BIRTH CENTER 981 = PROFESSIONAL EARLY INTERVENTION SERVICES 983 = THERAPIST (PT, OT, ST, RT) - GROUP 989 = DIALYSIS CENTER 990 = DURABLE MED EQUIPT/ MEDICAL SUPPLIES 991 = CASE MANAGEMENT AGENCY 17

18 992 = UROLOGIST (OLD CODE 103) BH1 = PSYCHOLOGY, ADULT BH2 = PSYCHOLOGY, CHILD BH3 = MENTAL HEALTH COUNSELOR BH4 = COMMUNITY MENTAL HEALTH CENTER BH5 = CASE MANAGER BH6 = INDIVIDUAL LICENSED PRACTITIONER OF HEALTH ARTS BH7 = PSYCHIATRY (CHILD & ADULT) BH8 = PSYCHOTHERAPY (CHILD & ADULT) D01 = ENDODONTIC D02 = PROSTHODONTISTRY D03 = PERIODONTIST 18

19 Appendix H List of Error Codes contained in the Provider Response File Code Field Description IsWarning 0001 Plan Code Plan Code is a required field Error 0002 Provider Type Provider Type is a required field Error 0003 Plan Provider Number Plan Provider Number is a required field Error 0004 Group Affiliation Group Affiliation is required when Provider Type = 'G' Error 0005 Group Affiliation Group Affiliation must match Plan Provider Number when Provider Type = 'G' 0006 Group Affiliation Group Affiliation must match a previously submitted group or a group on this file Error 0007 SSN or FEIN SSN or FEIN is a required field Error 0008 Provider Last Name Provider Last Name is a required field Error 0009 Address Line 1 Address Line 1 is a required field Error 0010 City City is a required field Error 0011 Zip Code Zip Code is a required field Error 0012 Zip Code Zip Code must be 5 or 9 digits Error 0013 Phone Area Code Area Code must be 3 digits Error 0014 Phone Number Phone Number must be 7 digits Error 0015 PCP Indicator PCP Indicator is a required field when Provider Type = "P" Error PCP Indicator cannot be 'P' when HMO/Medipass 0016 PCP Indicator Indicator = 'H' and Provider Type = 'G' Error Provider Limitation is required when PCP Indicator 0017 Provider Limitation = 'P' Error 0018 HMO/Medipass Indicator HMO/Medipass Indicator is a required field Error 0019 HMO/Medipass Indicator HMO/Medipass Indicator value is not valid Error 0020 Gender Gender value is not valid Warning 0021 Provider Type Provider Type value is not valid Error 0022 PCP Indicator PCP Indicator value is not valid Error 0023 Provider Limitation Provider Limitation value is not valid Error 0024 Evening Hours Evening Hours value is not valid Warning 0025 Saturday Hours Saturday Hours value is not valid Warning Primary Specialty is required when Provider Type is ('P','I','D','T') or Provider Type = 'G' when recipients 0026 Primary Specialty are enrolled to the group Error 0027 Primary Specialty Primary Specialty value is not valid Error 0028 Specialty 2 Specialty 2 value is not valid Warning 0029 Specialty 3 Specialty 3 value is not valid Warning 0030 Language 1 Language 1 value is not valid Warning 0031 Language 2 Language 2 value is not valid Warning 0032 Language 3 Language 3 value is not valid Warning 0033 Hospital Affiliation 1 Hospital Affiliation 1 value is not valid Warning 0034 Hospital Affiliation 2 Hospital Affiliation 2 value is not valid Warning 19 Error

20 0035 Hospital Affiliation 3 Hospital Affiliation 3 value is not valid Warning 0036 # of Member Patients # of Member Patients is required when PCP Indicator = 'P' and (HMO/Medipass Indicator = 'H' or Provider Type = 'G') Warning 0037 # of Member Patients # of Member Patients value is not valid Warning 0038 Hospital Affiliation 4 Hospital Affiliation 4 value is not valid Warning 0039 Hospital Affiliation 5 Hospital Affiliation 5 value is not valid Warning 0040 Active Patient Load Active Patient Load is required when HMO/Medipass Indicator <> 'M' Error 0041 Active Patient Load Active Patient Load value is not valid Error 0042 Wheel Chair Access Wheel Chair Access value is not valid Warning 0043 Professional License Number Professional License Number is required when Provider Type is not ('A','B','C','G','H','R') AHCA Hospital ID is required when HMO/Medipass 0044 AHCA Hospital ID Indicator is ('H','P') AND Provider Type = 'H' Warning 0045 AHCA Hospital ID AHCA Hospital ID value is not valid Warning 0046 County Health Department Indicator County Health Department is required when HMO/Medipass Indicator <> 'M' Warning 0047 County Health Department Indicator County Health Department value is not valid Warning 0048 NPI Type I NPI Type I value is a required field Warning 0049 Medicaid Provider ID Medicaid Provider ID is a required field Warning 0050 Plan Code Plan Code is invalid Error 0051 Age Restrictions Age Restrictions is invalid Error 0052 Not Field Specific Duplicate Record Error Error 20