Department of Health Care Services California Health Care Options 3130 Kilgore Road, Sacramento CA 95864 July 18th, 2012 Dear Health Plan Participant, The Department of Health Care Services (DHCS), Medi-Cal Managed Care Division (MMCD) has requested MAXIMUS to create a new process to report denied Medical Exemption Requests (MERs) and Emergency Disenrollment Requests (EDERs) to Health Plans for beneficiaries who subsequently enroll into a particular Plan. Denied MER/EDER data files will be accessible on the California Health Care Options Secure Data Exchange Services (SDES) website (http://healthcareoptions.maximus.com/sdes/). Note: plans will only receive MER/EDER denial data if the beneficiary has been enrolled into a Health Plan within 30 days of the date on which the MER/EDER was denied. When a beneficiary is enrolled into a plan, a record will also be present in the Weekly Plan File (WPF). If there is no MER/EDER denial activity for beneficiaries enrolling into a particular plan, an empty MER/EDER file will not be posted to the SDES. The MER/EDER data files will be posted to the SDES on a weekly basis on the same schedule as the WPF. The 2012 file posting schedule is available for download from the SDES website by clicking on the 2012 File Posting Schedule link. The MER/EDER files will be placed in the same location as the WPF. You may obtain an updated copy of the SDES User Guide which contains instructions for accessing the MER/EDER data files from the SDES website by clicking on the User Guide* link. Authorized Plan representatives who have access to the WPF will also have access to the MER/EDER files. New users must complete a SDES Account Request or Access Change Request form to be allowed access to MER/EDER data. A copy of the SDES Account Request or Access
Change Request form can be downloaded from the SDES website by clicking on the Request or Change Access link. The record layout for the MER/EDER data file is provided as an attachment to this letter. MAXIMUS has posted sample MER/EDER data files on the SDES in the individual plan folders. Health Plans are encouraged to download and review the files and submit any technical questions to MAXIMUS via e-mail: cahcohelpdesk@maximus.com; (please use a subject line of MER/EDER data file ). Live files will be available on the SDES starting on Monday July 30 th, 2012. Sincerely, HSGill Harry S. Gill, for DHCS Information Systems Director, MAXIMUS CA HCO
MER/EDER Data File Format Field # Field Name Field Description Attributes (length) 1. BeneficiaryID Beneficiary ID (MAXIMUS assigned) Int (09) 2. ExemptionID Exemption record ID (MAXIMUS assigned) Int (09) 3. CIN Beneficiary CIN Char (09) 4. FirstName Beneficiary First Name Char (15) 5. MiddleInitial Beneficiary Middle Initial Char (01) 6. LastName Beneficiary Last Name Char (20) 7. DOB Date Of Birth (format = MM/DD/YYYY) Char (10) 8. ReasonCode Denial Reason Code Char (01) 9. ReasonDescription Denial Reason Description Char (400) 10. Approval Denial Date (format = MM/DD/YYYY) Char (10) 11. ProviderID Provider ID Vchar (10) 12. ICD9-1 International Classification of Diseases (Ninth Edition) first code 13. ICD9-2 International Classification of Diseases (Ninth Edition) second code Vchar (06) Vchar (06) 14. PlanOfLastTrans Plan Number in which beneficiary is enrolled Vchar (03)
MER/EDER Denial Reason Codes Reason Code Description 1 Condition does not qualify & Began treatment after enrolled 2 Condition Does not qualify & Dr/Dn works with managed care pln 3 Condition Does not qualify & Enrolled for over 90 days 4 Condition Does not qualify & Dr/Dn is in same plan bene is 5 Dr/Dn works with managed care plan & Began trtmnt after enrl 6 Dr/Dn works with managed care plan & Bene has open CCS case 7 Dr/Dn works with managed care plan & Enrolled for ovr 90 days 8 Dr/Dn works with mngd care pln & Dr/Dn is in same plan bene is 9 Beneficiary has open CCS case & Dr/Dn is in same plan bene is A Condition does not qualify for an exemption C Doctor/Dentist told us that treatment is complete D Began treatment for condition after enrolled in a plan E Doctor/Dentist is a member of a Medi-Cal managed care plan F Beneficiary has an open California Children Services CCS case G Enrolled in plan for more than 90 days H Exemption form not completed by doctor I Incomplete/illegible form received a second time J Doctor/Dentist is not approved to provide Medi-Cal services K Not enrolled in Medi-Cal Waiver program L Doctor/Dentist is in the same plan the beneficiary is in Q Beneficiary resides in a voluntary county R Beneficiary has a voluntary status S Old or Invalid Exemption Form X Enrolled over 90 days & Began treatment after enrl Y Beneficiary is not eligible for Medi-Cal managed care plan Z Beneficiary can receive treatment within Medi-Cal GMC program
Sample MER/EDER Data File Record The following is a sample Data File Record for plan 999 (NOTE: All PHI data has been deidentified) "BeneficiaryID","ExemptionID","CIN","FirstName","MiddleInitial","LastName","DOB","Reas oncode","reasondesc","approval","providerid","icd91","icd92","planoflasttrans" "100000000","100000000","00000001M","First1","A","Last1","01/28/1958","G","Enrolled in plan for more than 90 Days","03/01/2012","1992725626","621.2","626.9","999" "200000000","200000000","00000002M","First2","B","Last2","12/26/1966","H","Exemption form not completed by doctor","11/10/2011","xxxxxxxxx","","","305" "300000000","300000000","00000003M","First3","C","Last3","12/12/1961","A","Condition does not qualify for an exemption","03/27/2012","none","271.1","","999" "400000000","400000000","00000004M","First4","D","Last4","03/31/1951","E","Doctor/Dent ist is a member of a Medi-Cal managed care plan","03/29/2012","1548295116","428.32","414.01","999" "500000000","500000000","00000005M","First5","E","Last5","04/18/1957","1","Condition does not qualify & Began treatment after enrolled","03/22/2012","1598761710","","","999"