The Crisis Service 834 Input File allows RBHA’s to receive a Crisis 834 file with the enrollment information for the members enrolled in other AHCCCS health plans in which crisis services were performed.
The Crisis Service 834 Input File is placed by the Health Plan on the AHCCCS communications server in the plan’s folder under AZ/hpmnemonic/PROD/PROD/IN. The file is named CRISIS.XXXXXX.YYYYMMDD.TXT, where XXXXXX is the health plan id.
Crisis Service 834 Input 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.
The Electronic Visit Verification (EVV) MCO PA Extract File provides the Prior Authorization data the providers have entered into the EVV Service Confirmation Portal to be delivered to the health plans through their perspective SFTP Server folders.
For further information see the AHCCCS EVV Service Confirmation Portal Manual.
The EVV MCO PA Extract File is available on the AHCCCS FTP server. File is named WXXXXXX-DYYMMDD-IHHMMSS.sax (where XXXXXX is the health plan id) and is available in the plan's folder under AZ/HP mnemonic/PROD/OUT.
EVV MCO PA 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.
The DUGless Output File provides demographic elements with no identified alternative data source or Social Determinate identifier. This data comes from online portal (DUGless) that is accessed directly by behavioral health providers for the collection of these data elements for members receiving behavioral health services.
For further information see the DUGless Portal Guide.
The DUGless Output File is available on the AHCCCS FTP server. File is named DUGLESS.XXXXXX.YYMMDD.TXT (where XXXXXX is the health plan id) and is available in the plan's folder under AZ/hp mnemonic/PROD/OUT.
DUGless Output 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.
The State Only Input Processor File allows RBHA’s to add, change or terminate State Only eligibility.
The State Only Input Processor file is placed by the Health Plan on the AHCCCS communications server in the plan’s folder under AZ/hpmnemonic/PROD/IN. The file is named DAILYSTO.XXXXXX.YYYYMMDD.TXT, where XXXXXX is the health plan id.
State Only Input Processor 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.
This file contains information regarding members that have open ended Medicaid eligibility on the day the State Only eligibility is added.
The Daily State Only Medicaid file is available on the AHCCCS FTP server in the plan’s folder under AZ/hpmnemonic/PROD/OUT. The file is named DAILYSTO.XXXXXX.MEDICAID.YYMMDD.TXT, where XXXXXX is the health plan id.
Daily State Only Medicaid 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.
This file contains information regarding all members with open State Only eligibility that have open ended Medicaid eligibility.
The Monthly State Only Medicaid file is available on the AHCCCS FTP server in the plan’s folder under AZ/hpmnemonic/PROD/OUT. The file is named MTHLYSTO.XXXXXX.MEDICAID.YYMMDD.TXT, where XXXXXX is the health plan id.
Monthly State Only Medicaid 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.
Active Care Notifications identify new members to a Health Plan who have certain medical conditions that have been reported by the eligibility determination agency.
Active Care Notification Process provides additional information to the Health Plan of members who may require immediate transition of care.
Active Care notifications are produced in data file format. Health Plans, or their services bureaus connect to the Arizona Health Care Cost Containment System (AHCCCS) FTP server and download the data file for batch processing.
Active Care notification 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.
Daily Enrollment Notifications identify:
Daily Enrollment Notifications occur through the HIPAA 834 Transaction Code Set.
Capitation for enrollments will be calculated on a per diem basis. Capitation will be paid through the end of the processing month. Prospective capitation will be paid on a monthly basis (See Monthly Enrollment Notification Process).
Capitation payments and recoupments as a result of Daily Enrollment Notification process are transmitted to the Health Plan on the HIPAA 820 Transaction Code Set.
Enrollment notifications are produced in data file format. Health Plans, or their services bureaus, must dial in to the Arizona Health Care Cost Containment System (AHCCCS) computer system and download the data file for batch processing.
Enrollment Notification and Capitation Notification 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 transmissions takes approximately one week and must be completed prior to implementation of any new processing arrangement.
Enrollment notification and capitation notification data, once delivered to the Health Plan, is considered legal notification of the Health Plan's responsibility for provision of care to AHCCCS members.
Special attention should be given to the daily process immediately preceding the monthly processing, as well as to the daily processing run on the last two days of the month. The daily process which runs prior to the monthly is referred to as the 'last daily' and will contain all rate code changes which are effective for the next month, as well as any new enrollment, and a majority of the dis-enrollments effective at the end of the month. It is important that this last daily be processed by the Health Plans before attempting to run the monthly reconciliation process (See Monthly Enrollment Notification Process.)
The two daily processes that run after the monthly process are different from 'regular' daily process in that they will pay capitation, or recoup capitation into the next month. This is because the monthly, which normally pays prospective capitation, has already run.
The Daily Capitation Notification process (HIPAA 820) also creates the Daily Rate Code Summary. The Rate Code Summary provides a formatted report file for the Health Plan of the total dollar amounts by contract type, rate code, and county. The Daily Rate Code Summary provides a view of the amounts paid for each rate code of the next prospective month's capitation. The Daily Rate Code Summary can also be used to reconcile against the Daily HIPAA 820 TCS.
Daily Rate Code Summary is available on the AHCCCS FTP server.
Daily Rate Code Summary transmissions must be tested in coordination with the AHCCCS ISD operations staff prior to production implementation of a new Health Plan; change in service bureau, or as a result of roster changes. Typical testing of file transmissions takes approximately one week and must be completed prior to implementation of any new processing arrangement.
Daily Rate Code Summary file is created as a formatted report, not a data file.
Arizona Early Intervention File files identify Targeted Support Coordination (TSC) from DES/DDD Recipients under 3 years of age and actively enrolled in Health Plans.
Files track Arizona Early Intervention Program members enrolled in Health Plans in the PMMIS System. A file will be downloaded for each Health Plan.
AzEIP File notifications are produced in data file format. Health Plans, or their services bureaus, must connect to the Arizona Health Care Cost Containment System (AHCCCS) FTP server and download the data file for batch processing.
It is highly recommended that AzEIP File transmissions 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.
The Manual Payment process is used as a tool for manual adjustments to capitation records. Manual payments are utilized to create a payment or recoupment override to manually process records that would not be processed systematically.
From the Health Plan perspective the Manual Payment Process will be incorporated into the Weekly Capitation Notification (HIPAA 820) processes.
The Daily Manual Payment Roster and Weekly Capitation Notification file (HIPAA 820) are available on the AHCCCS communications server.
Daily Manual Payment Roster and Weekly Capitation Notification transmissions must be tested in coordination with 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 transmissions takes approximately one week and must be completed prior to implementation of any new processing arrangement.
The Mass Adjustment process is used as a tool for administrative adjustment of contracted rates. Previously paid amounts are recouped, and then repaid at the new rate. From the Health Plans' perspective, the mass adjustment resembles the Daily Enrollment Notification process in that it is transaction driven. The mass adjustment transmission file (HIPAA 820) is identical to that produced using the Daily Enrollment Notification process.
The Weekly Capitation Notification file (HIPAA 820) is available on the AHCCCS communications server.
Weekly Capitation Notification transmissions must be tested in coordination with 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 transmissions takes approximately one week and must be completed prior to implementation of any new processing arrangement.
The Members with Choice file identifies for the health plan all enrolled members that will have an annual open enrollment choice sixty days prior to the annual enrollment date. Please note, if a member does not make a selection in the first month, they will again appear on the next month’s file.
The Members with Choice file is available on the AHCCCS SFTP server in the plan’s folder under AZ/hpmnemonic/PROD/OUT. File is named ccyymm.MWC.
The Members with Choice file must be tested in coordination with the AHCCCS ISD operations staff prior to production implementation of a new Health Plan, change in service bureau, or as a result of roster changes. Typical testing of file transmissions takes approximately one week and must be completed prior to implementation of any new processing arrangement.
Monthly Enrollment Notification files identify the total active population for each Health Plan as of the first of the next month. The Monthly Enrollment Notification file is used to reconcile the Health Plan's member file against that of AHCCCS. In order for this reconciliation to be successful, it is important that all daily transmission files, including the last daily, be processed prior to the monthly reconciliation.
There are no Monthly Capitation Notification files. Capitation is transmitted to Health Plans weekly in HIPAA 820 TCS.
Monthly Enrollment Notification file is available on the AHCCCS communications server.
Monthly Enrollment Notification is produced in 834 data file format only.
Monthly Enrollment Notification and Monthly Capitation Notification file transmissions must be tested in coordination with the AHCCCS ISD operations staff prior to production implementation of a new Health Plan, change in service bureau, or as a result of roster changes. Typical testing of file transmissions takes approximately one week and must be completed prior to implementation of any new processing arrangement.
Monthly Enrollment Notification data, once delivered to the Health Plan, is considered legal notification of the Health Plan's responsibility for provision of care to AHCCCS members.
Monthly Enrollment Notification files are retained on the AHCCCS computer server for one month.
The Monthly Rate Code Summary provides a report for the Health Plan of the total dollar amounts by contract type, rate code, and county. The Monthly Rate Code Summary provides a view of the capitation paid for each rate code for the prospective month's capitation. The Monthly Rate Code Summary can also be used to reconcile against the Weekly HIPAA 820 TCS.
Monthly Rate Code Summary is available on the AHCCCS FTP server.
Monthly Rate Code Summary transmissions must be tested in coordination with the AHCCCS ISD operations staff prior to production implementation of a new Health Plan, change in service bureau, or as a result of roster changes. Typical testing of file transmissions takes approximately one week and must be completed prior to implementation of any new processing arrangement.
Monthly Rate Code Summary files are retained on the AHCCCS computer server for one month.
The Open Enrollment Potential Transition Listing files provide the Health Plan with the basic demographic information of all members who may be joining or leaving the plan.
Important Note: Listing should not be confused with Enrollment Notification data. Whereas Enrollment Notification data, once delivered to the Health Plan, is considered legal notification, this is only preliminary information based on the member's choice during the Open Enrollment Period.
The Health Plan can use this information to begin preparing for the new members joining their plan and the transition of the members leaving their plan.
The Open Enrollment Potential Transition file is available on the AHCCCS SFTP server in the plan’s folder under AZ/hpmnemonic/PROD/OUT. File is named ccyymm.PTL.
The Open Enrollment Potential Transition Listing 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.
Prior Plan Listing identifies members who have been enrolled into a new Health Plan that were previously disenrolled from another Health Plan up to 90 days in the past. Prior Plan Listing process provides information to the previous Health Plan of members who have now enrolled into a different Health Plan for transition of care.
Prior Plan Listing notifications are produced in data file format. Health Plans, or their services bureaus, must login to the Arizona Health Care Cost Containment System (AHCCCS) FTP server and download the data file for batch processing.
Prior Plan Listing notification 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.
Health Plans (HPs) are required by AHCCCS contract to submit new additions and updates to existing Commercial Third Party insurance coverage information associated with their enrolled Medicaid Members. This TPL information is processed, verified and stored in the AHCCCS PMMIS database. It is used to cost avoid medical, dental and pharmacy expense where AHCCCS members have other insurance coverage that must be exhausted prior to using Medicaid funds.
This process is intended to garner information about Commercial coverage and is not to be used for reporting Medicare traditional Fee-for-Service or Medicare Advantage coverage.
NOTE: Subscriptions to Medicare Supplemental coverage policies are considered commercial coverage because the premiums are paid by the member in addition regular Medicare coverage. Supplemental Medicare policies are to be reported in this process.
AHCCCS edits HP encounters for required TPL coverage and denies encounters for members with existing TPL insurance records for the covered dates of service. Plans are required to recoup primary payment and/ or provide corrected TPL coverage information in order to re- submit the encounter.
TPL coverage addition, change and termination information is provided through either of two coverage notification processes. Both have the same data requirements for an acceptable transaction.
Health Plans may use:
The AHCCCS TPL Contractor provides Health Plans access to an on-line database- REF DB. Plan staffs register and manually enter new TPL leads and updates to existing TPL lead records directly into this database. The Contractor then verifies the TPL coverage information provided and submits verified records back to AHCCCS to be added directly into the PMMIS Database- RP155 Table. AHCCCS Web Link = https://www.azahcccs.gov/PlansProviders/HealthPlans/tpl.html
The Third Party Leads File submission process is accomplished by Health Plans depositing a prescribed TLP Lead File on the AHCCCS communications server- SFTP. (See file layout below) The file records will be edited and records with invalid syntax or missing required fields will be rejected.
Filename protocol - yymmdd.tpl
File Location - placed in the Health Plan's folder under AZ/*** /PROD/IN
(Where *** = HP mnemonic)
The files may be placed on the server at any time and are picked up in a nightly sweep for incoming “.tpl” files with that days processing date. Plans may deposit multiple files with the same date. Advance dated files will be picked up on that processing date. However, prior dated files will never be picked up. If the sweep fails to pick up the file, it must be renamed for the next full days processing.
The Third Party Leads Submission File is placed by the Health Plan on the AHCCCS communications server.
Health Plans receive a Lead Outcome Report indicating the status of the detail records submitted on their TPL Lead files. The report ‘Messages’ field for each record will indicate the outcome; either record added or not added and the reason. The report is placed in the Plans folder on the AHCCCS Communication Server.
Filename: yymmdd.RP94D576.TPL.report.txt
File Location: AZ/***/PROD/OUT
Third Party Leads Submission file transmissions must be tested in coordination with AHCCCS ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of other changes. Typical testing of transmissions takes approximately one week and must be completed prior to implementation of any new processing arrangement.
The Third Party Liability (TPL)/Coordination of Benefits (COB) process provides Health Plans (HP) with several files important to the accurate and timely updating of AHCCCS TPL/COB coverage information. The files are placed on HP’s SFTP sites according routine schedules. HPs are required to pick up and use this information to update their own TPL/COB subsystems to maintain up-to-date coverage information and maximize cost avoidance where other insurance carriers are required to pay primary to AHCCCS Medicaid.
Commercial TPL coverage data is received in the form of a coverage referral record from many different sources including HPs, eligibility sources (DES, SSA, etc.) and our TPL Contractor. The referrals are edited and acceptable records are written to PMMIS Table 155 in a ‘P’ Pend status. AHCCCS runs a nightly sweep of the table and copies Pend status commercial records to our TPL Contractor, at which point the status is changed to “R’ Referred. Those referrals are researched through our Contractor’s validation process. Records are returned to AHCCCS and updates are posted that either verify TPL coverage and update the RP155 record and ‘R’ status to Verified (status = ‘V’) or invalidate the coverage to “Invalid” (Status= ‘I’). Invalid status records are moved to the AHCCCS PMMIS table RP155H (History).
Validated TPL records are used for encounter editing. Where an active TPL coverage record exists for Date of Service on a paid encounter, evidence of TPL/COB must be present in the encounter; if not, the encounter will be denied and returned for recoupment of payment and/or resubmission.
In addition to the commercial TPL verifications, Medicare data is also provided on the Daily and Monthly Verified files.
NOTE: (XXX= Plan’s pneumonic)
The TPL File is available on the AHCCCS communications server.
TPL file transmissions must be tested in coordination with AHCCCS ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of roster changes. Typical testing of transmissions takes approximately one week and must be completed prior to implementation of any new processing arrangement.
The Unique Population file contains additional information regarding members that is not included on the 834 file. This information includes the following indicators:
The Unique Population File is produced on the first of the month.
The Unique Population file is available on the AHCCCS FTP server in the plan’s folder under AZ/hpmnemonic/PROD/OUT. The file is named YYYYMM_HPXXXXXX_Mthly_Unique_Elg_Pop.txt where XXXXXX is the health plan ID.
Unique Population 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.
The SMI Determination Outcome Eligible file is a daily summary of all records submitted by Solari to AHCCCS to indicate the final SMI status of AHCCCS eligible members.
Weekdays by 10.00pm
The SMI Determination Outcome Non-Eligible Report will be sent to the AHCCCS SFTP server, /XXX/PROD/OUT where XXX is the Health Plan folder. The file name is SMI-Determination-Outcome-Elig-Report_yyyymmdd_XXXXXX.DAT (where XXXXXX is the Health Plan ID).
SMI Open Not Submitted 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.
The SMI Determination Outcome Non-Eligible Report is a daily summary of all records submitted by Solari to AHCCCS to indicate the final SMI status of non-AHCCCS eligible members. The report is used for RBHA affiliated health plans to create State Only records and/or correct members’ AHCCCS ID’s as needed.
Weekdays by 10.00pm
The SMI Determination Outcome Non-Eligible Report will be sent to the AHCCCS SFTP server, /XXX/PROD/OUT where XXX is the Health Plan folder. The file name is SMI-Determination-Outcome-NonElig-Report_yyyymmdd_XXXXXX.DAT (where XXXXXX is the Health Plan ID).
SMI Open Not Submitted 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.
The Open SMI Pended Eligible Report is a daily summary of all submitted records where the SMI status of AHCCCS eligible members is under evaluation by Solari.
Weekdays by 10.00pm
The Open SMI Pended Eligible Report will be sent to the AHCCCS SFTP server, /XXX/PROD/OUT where XXX is the Health Plan folder. The file name is Open-SMI-Pended-Elig-Report_yyyymmdd_XXXXXX.DAT (where XXXXXX is the Health Plan ID).
SMI Submitted 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.
The Open SMI Pended Non-Eligible Report is a daily summary of all submitted records where the SMI status of non-AHCCCS eligible members is under evaluation by Solari. The report is used for RBHA affiliated health plans to create State Only records and/or correct members’ AHCCCS ID’s as needed.
Weekdays by 10.00pm
The SMI Submitted will be sent to the AHCCCS SFTP server, /XXX/PROD/OUT where XXX is the Health Plan folder. The file name is Open-SMI-Pended_NonElig-Report_yyyymmdd_XXXXXX.DAT (where XXXXXX is the Health Plan ID).
SMI Submitted 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.
