AHCCCS Technical Interface Guidelines (TIG) - Encounter Interface
Introduction
AHCCCS receives a file from CMS that contains members’ Medicare Part D drug utilization. AHCCCS provides this data to the health plan that the members are enrolled with to help give a fuller picture of the member’s utilization. Contractors should use this information to develop short- and long-term strategies to improve care coordination.
Schedules
The Medicare Part D Drug file runs monthly. It is created around the 26th of each month for the prior month.
Media
The Medicare Part D Drug File will be sent to the AHCCCS FTP server, XXX/PROD/OUT where XXX is the health plan’s folder. The file name is YYYYMM. HPPLANID.MDCPARTD.txt.
Testing
Medicare Part D Drug 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 (File Layout)
Introduction
In accordance with ACOM policy 434 section 2a, the Contractor has two years from the date of service to recover payments for a particular claim, or to identify (tag) claims having a reasonable expectation of recovery using a process to be developed by AHCCCS. The Retroactive TPL Recovery file will facilitate the “tagging” of impacted encounters.
Schedules
Retroactive TPL Recovery is a monthly job that runs on the first Wednesday of the month.
Media
The Retroactive TPL Recovery Input file is placed on the AHCCCS FTP server in the plan’s folder under AZ/hpmnemonic/PROD/IN. The input file is named XXXXXX.RETRORECOVERIES.YYYYMM.txt where XXXXXX is the health plan ID.
The Retroactive TPL Recovery Output file is available on the AHCCCS FTP server in the plan’s folder under AZ/hpmnemonic/PROD/OUT. The output file is named RETROREC.DATA.XXXXXX.YYMM.txt where XXXXXX is the health plan ID.
Testing
Retroactive TPL Recovery 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 (File Layout)
Link to Health Plan Interfaces File Layouts.Retroactive TPL Recovery File Layout
Introduction
AHCCCS will manage exchange of encounter and claims data to Contractors in order to eliminate “blind spots” for services provided to a member shared by multiple programs. Contractors should use this information to develop short- and long-term strategies to improve care coordination.
Schedules
The DEX file runs monthly. It is created around the 2nd of each month for the prior month.
Media
The Dex File will be sent to the AHCCCS FTP server, /XXX/PROD/OUT where XXX is the health plan’s folder. The file name is HPPLANID-DEXMTH-YYMMDD.ZIP.
Testing
Dex 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 (File Layout)
Introduction
The Dex Supplement file is used in conjunction with the Dex file to provide detail line information for Institutional Encounter and Claims. Note: these are only for record type E encounters.
Schedules
The DEX Supplemental file runs monthly. It is created around the 2nd of each month for the prior month.
Media
TThe Dex Supplemental File will be sent to the AHCCCS FTP server, /XXX/PROD/OUT where XXX is the health plan’s folder. The file name is HPPLANID-DEXMTH-SUP-YYMMDD.ZIP.
Testing
Dex Supplemental 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 (File Layout)
Introduction
On a monthly basis, AHCCCS provides each Contractor with an encounter data extract that Contractors must use to compare financial data in the AHCCCS encounter database with the Contractor’s claims financial data. The file is replaced each month and contains the past 30 months of encounter financial data submitted to AHCCCS. If a Contractor misses processing for a month, the following month will include the previous months minus the oldest month, as well as, the new encounters reaching adjudicated status by AHCCCS in the most current month. The file is to be used by the Contractor to verify what has been submitted to AHCCCS.
Schedules
Runs Monthly after the second Encounter cycle completes – Schedules out from INFOMGMT table
Media
The Encounter Monthly Extract will be sent to the AHCCCS FTP server, /XXX/PROD/OUT where XXX is the health plan’s folder. The file name is ENC_PLANID.ZIP.
Please note, the zipped file contains the following encounter file extracts named ENC_type code_PLANID.TXT.
type code = (5 file types):
| ADJ | Adjudicated/approved | status 31 |
| DENIED | Adjudicated/ plan denied | status 43 |
| ACCDNY | Adjudicated/AHCCCS Denied | status 41 |
| PEND | Pended | status 11 |
| VOID | Adjudicated/voided | status 32 |
Testing
Monthly Encounter 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 (File Layout)
Introduction
The status file provides the encounter status (finalized or pended) for all encounters from the most recent encounter processing.
Schedules
Runs as part of both Encounter cycles ENCCYCL1 & ENCYCL2 – FTP Jobs are $AC3E518’s
Media
The 277U file will be sent to the AHCCCS FTP server, /XXX/PROD/EDI-OUT where XXX is the health plan’s folder. The file name is AZU277-PLANID-YYMMDD.TXT.
Testing
277U 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 (File Layout)
Introduction
This file contains additional status information not found on the 277U status file. For example, mainframe denial reasons for encounters and Reinsurance information are in this file.
Schedules
Runs as part of both Encounter Cycles ENCCYCL1 & ENCCYCL2 – FTP Jobs are $AC3E519’s
Media
The 277S Supplemental File will be sent to the AHCCCS FTP server, /XXX/PROD/OUT where XXX is the health plan’s folder. The file name is AZS277-PLANID-YYMMDD.TXT.
Testing
277S Supplemental 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 (File Layout)
Introduction
This file contains pended encounters that passed validation and translation, but failed the adjudication edit or audit process. These encounters will continue to pend and appear on the pend file until the encounters are corrected.
Schedules
Runs as part of both Encounter Cycles ENCCYCL1 & ENCCYCL2 – FTP Under name $AC3E594 – EC91L947
Media
The Pend File will be sent to the AHCCCS FTP server, /XXX/PROD/OUT where XXX is the health plan’s folder. The file name is HPPLANID_CLMMDDYY.ZIP.
Testing
Pend 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 (File Layout)
Introduction
This file contains the number of days encounters have been pended and additional information regarding those pended encounters.
Schedules
Runs as part of both Encounter Cycles ENCCYCL1 & ENCCYCL2 – FTP Under name $AC3E594 – DETLAGIN
Media
The Pended Encounter Detail Aging File will be sent to the AHCCCS FTP server, /XXX/PROD/OUT where XXX is the health plan’s folder. The file name is HPPLANID_DETLAGINMMDDYY.ZIP.
Testing
Pended Encounter Detail Aging 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 (File Layout)
Link to Encounter TIG File Layouts.Pended Encounter Detail Aging File
Introduction
The detailed aging report is a list of pended encounters by transmission submitter number, aging category, form type and error code.
Schedules
Runs as part of both Encounter Cycles ENCCYCL1 & ENCCYCL2 – FTP Under name $AC3E594 – EC9EM187
Media
The Pended Encounter Detailed Aging Report will be sent to the AHCCCS FTP server, /XXX/PROD/OUT where XXX is the health plan’s folder. The file name is HPPLANID_RC_EC9EM187MMDDYY.ZIP.
Testing
Pended Encounter Detailed Aging report 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 (File Layout)
Link to Encounter TIG File Layouts.Pended Encounter Detailed Aging Report File
Introduction
This file contains information regarding duplicate pended encounters and the encounters already in history that are causing the duplicate audit failure.
Schedules
Runs as part of both Encounter Cycles ENCCYCL1 & ENCCYCL2 – FTP Under name $AC3E594 – DUPECRN
Media
The Pended Encounter Duplicate CRN File will be sent to the AHCCCS FTP server, /XXX/PROD/OUT where XXX is the health plan’s folder. The file name is HPPLANID_DUPECRNMMDDYY.ZIP.
Testing
Pended Encounter Duplicate CRN 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 (File Layout)
Link to Encounter TIG File Layouts.Pending Encounter Duplicate CRN File
Introduction
AHCCCS has contracts and agreements with Managed Care Organizations (MCO’s) to deliver medically necessary services to AHCCCS eligible recipients. AHCCCS ACOM Policy 315, AHCCCS Payment Reform Initiative, applies to all AHCCCS MCOs. The purpose of this initiative is to encourage MCO activity in the area of quality improvement, particularly those initiatives that are conducive to improved health outcomes and cost savings, and those related to child and adolescent health, by aligning the incentives of the MCO and provider through shared savings payment arrangements.
Schedules
Runs as part of both Encounter Cycles ENCCYCL1 & ENCCYCL2
Media
The Post Adjudicated Structured Payment File will be placed in to the AHCCCS FTP server, /XXX/PROD/IN where XXX is the health plan’s folder. The file name is AZSP123456.YYYYMMDD.STRUCTRCT.HHMM.999
Testing
Post Adjudicated Structured Payment File 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 (File Layout)
Link to Encounter TIG File Layouts.Post Adjudicated Structured Payment File
Introduction
This file contains comments regarding select pended encounters. The comments are intended to aid in the correction of these pended encounters.
Schedules
Runs as part of both Encounter Cycles ENCCYCL1 & ENCCYCL2 – FTP Under name $AC3E594 – EC91L948
Media
The Comment File will be sent to the AHCCCS FTP server, /XXX/PROD/OUT where XXX is the health plan’s folder. The file name is HPPLANID_CCMMDDYY.ZIP.
Testing
Comment 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 (File Layout)
Introduction
This file contains information regarding action taken on pended encounters during the last cycle.
Schedules
Runs as part of the daily cycle for processing pend corrections – processed in schedule ENCDAILY, Job $AC3E136
Media
The Detail Action Taken File will be sent to the AHCCCS FTP server, /XXX/PROD/OUT where XXX is the health plan’s folder. The file name is HPPLANID.PNMMDDYY.TSN.ZIP.YYMMDD.ACTNTKN.ZIP.
Testing
Detail Action Taken 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 (File Layout)
Link to Encounter TIG File Layouts.Detail Show Action Taken File
Introduction
This report contains information regarding duplicate pended encounters and the encounters that are causing duplicate pended encounters.
Schedules
Runs as part of both Encounter Cycles ENCCYCL1 & ENCCYCL2 – FTP Under name $AC3E594 – EC97R179
Media
The Duplicate CRN by Error Code File will be sent to the AHCCCS FTP server, /XXX/PROD/OUT where XXX is the health plan’s folder. The file name is HPPLANID_RC_EC97R179MMDDYY.ZIP.
Testing
Duplicate CRN by Error Code 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 (File Layout)
Link to Encounter TIG File Layouts.Duplicate CRN by Error Code File
Introduction
This report contains information regarding action taken on pended encounters.
Schedules
Runs as part of the daily cycle for processing pend corrections – processed in schedule ENCDAILY, Job $AC3E136 – Report name is EC91R901
Media
Detail and Summary Show Taken File will be sent to the AHCCCS FTP server, /XXX/PROD/OUT where XXX is the health plan’s folder. The file name is HPPLANID.PHMMDDYY.TSN.ZIP.YYMMDD.RPTS.ZIP.
Testing
Detail and Summary Show Taken 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 (File Layout)
Link to Encounter TIG File Layouts.Detail and Summary Show Taken File