PCP/PCD Patient Status: N = New C = Current 80 1132 1132 PCP/PCD Status 1 A/N If the Fund is Health then populate Primary Care Provider. If the Fund is Dental then populate Dental Provider. PCP/PCD Provider First Name PCP/PCD First If the Fund is Health then 81 1133 1182 50 A/N Name populate Primary Care Provider. If the Fund is Dental then populate Dental Provider. PCP/PCD Provider Last Name PCP/PCD Last If the Fund is Health then 82 1183 1232 50 A/N Name populate Primary Care Provider. If the Fund is Dental then populate Dental Provider. Other Group Insurance 83 1233 1258 RX OGI 26 A/N Plan Name Other Group Insurance 84 1259 1278 RX ID# For OGI 20 A/N Member ID# RX For Other Group Insurance 85 1279 1293 15 A/N OGI Group # A=Active EBC Debit Card 86 1294 1303 EBC Debit Card 9 A/N N I=Inactive Indicator and Start/Stop (Ex. A20100401) Blank Date 87 1304 1500 Filler 198 For Future Additions Note 1: To identify the record type is 2 or 3 All member and dependent records need to be identified as record type 2 (add record) or record type 3 (change record). A member or dependent that is enrolled in a given plan for the time is an ADD first record and should be indicated as a record type 2. For example, a member/dependent is active in Health Healthchoice from 1/1/2015 to 12/31/2016. On 1/1/2017 they move to HealthCare X then the member record should be identified as record type 2. To identify the record type 4. For record type 4 only the following fields will be populated Carrier Member SSN From Member SSN Effective Date Person Code
80 1132 1132 PCP/PCD Status 1 A/N PCP/PCD Patient Status: N = New C = Current If the Fund is Health then populate Primary Care Provider. If the Fund is Dental then populate Dental Provider. 81 1133 1182 PCP/PCD First Name 50 A/N PCP/PCD Provider First Name If the Fund is Health then populate Primary Care Provider. If the Fund is Dental then populate Dental Provider. 82 1183 1232 PCP/PCD Last Name 50 A/N PCP/PCD Provider Last Name If the Fund is Health then populate Primary Care Provider. If the Fund is Dental then populate Dental Provider. 83 1233 1258 RX OGI 26 A/N Other Group Insurance Plan Name 84 1259 1278 RX ID# For OGI 20 A/N Other Group Insurance Member ID# 85 1279 1293 RX For OGI 15 A/N Other Group Insurance Group # 86 1294 1303 EBC Debit Card 9 A/N N (Ex. A20100401) A=Active I=Inactive Blank EBC Debit Card Indicator and Start/Stop Date 87 1304 1500 Filler 198 For Future Additions Note 1: To identify the record type is 2 or 3 All member and dependent records need to be identified as record type 2 (add record) or record type 3 (change record). A member or dependent that is enrolled in a given plan for the first time is an ADD record and should be indicated as a record type 2. For example, a member/dependent is active in Health Healthchoice from 1/1/2015 to 12/31/2016. On 1/1/2017 they move to HealthCare X then the member record should be identified as record type 2. To identify the record type 4. For record type 4 only the following fields will be populated Carrier Member SSN From Member SSN Effective Date Person Code
Solicitation0900000303Attachment4.docx