Specification Question Clarification Rationale What is the frequency of Monthly, but representing CHIA requires monthly submission? persons over a rolling 24 Eligibility files to capture month period with open the attributes necessary for andor closed segments of matching to the various eligibility. Claims Files coming in on the same schedule. What is the format of the Each submission must start The Header and Trailer file? with a Header Record and Records help to determine end with a Trailer Record to period-specific editing and define the contents of the create an intake control for data within the submission. quality. The asterisk is an Each Detail Record must inherited symbol from contain elements in an previous filings that asterisk delimited format. submitters had already coded their systems to compile for previous version of the MA APCD. What does each row in a Each row, or Detail Record, CHIA recognizes that file represent? contains the information of information at this detailed a unique Eligibility + level is necessary for Product that a carrier or aggregation and reporting maintains to utilization and aids with process Member claims. maintaining Master Member IDs to nsure privacy of data. There appear to be similar Many of the elements in the CHIA is required to fields on eligibility that are files use similar semantics standardize and analyze also collected on the claims and a few are exact information on Members file. Can you clarify? duplicates. CHIA is and the variations of concerned with the details Eligibility. The like presented in the ME File elements on the regardless of the Records mirror what is information presented on typically billed by providers the Claims Files. and aids with QA work when analyzing covered services, in- vs. and/or Third Party Administrator attributes.
Specification Question Clarification Rationale What is the frequency of submission? Monthly, but representing persons over a rolling 24 month period with open andor closed segments of eligibility. CHIA requires monthly Eligibility files to capture the attributes necessary for matching to the various Claims Files coming in on the same schedule. What is the format of the file? Each submission must start with a Header Record and end with a Trailer Record to define the contents of the data within the submission. Each Detail Record must contain elements in an asterisk delimited format. The Header and Trailer Records help to determine period-specific editing and create an intake control for quality. The asterisk is an inherited symbol from previous filings that submitters had already coded their systems to compile for previous version of the MA APCD. What does each row in a file represent? Each row, or Detail Record, contains the information of a unique Eligibility + Product that a carrier or maintains to process Member claims. CHIA recognizes that information at this detailed level is necessary for aggregation and reporting utilization and aids with maintaining Master Member IDs to nsure privacy of data. There appear to be similar fields on eligibility that are also collected on the claims file. Can you clarify? Many of the elements in the files use similar semantics and a few are exact duplicates. CHIA is concerned with the details presented in the ME File regardless of the information presented on the Claims Files. CHIA is required to standardize and analyze information on Members and the variations of Eligibility. The like elements on the Records mirror what is typically billed by providers and aids with QA work when analyzing covered services, in- vs. and/or Third Party Administrator attributes.
v6-apcd-member-eligibility-file-submission-guide-Redline-.docx