IPA Technical User Guide

Transcription

1 INFORMATION TECHNOLOGY DEPARTMENT Available Files in FTP Server Updated: 09/28/2012 Version MIS

2 Table of Contents Introduction... 2 Eligibility, Or E-List Files... 3 Activity, On-Hold and Healthy Families... 4 Capitation and Claims Files... 5 UM Daily Case Sheets and Census Reports... 6 Health Risk Assessment Files... 7 UM Monthly Bed Day/CCS/Re-Admit/Case Management Reports... 8 Encounter Data... 9 Encounter 837 Test Files...10 Contact Information.11

3 Introduction Available Files in FTP Server Attached herein is an explanation of the types of files that are available in Care1st s FTP server on a routine basis. Additional files may be exchanged periodically, but all files must be encrypted with the correct PGP key. It is very important for all IPA staff to be aware that member/provider PHI information must not be sent via , even if it is zipped or otherwise password-protected. PGP-encrypted files sent via FTP is the only method currently accepted by Care1st as our HIPAA-compliant procedure. If you do not know how to access our FTP server, how to use PGP, if you don t know the contact person at your IPA, or if you have any questions about the following pages, please contact us at Data Exchange: (323) or by dataexchange@care1st.com. 2

4 Eligibility, or E-List Files FTP Location: IPA/elist/out ELIGIBILITY PRODUCTION FILES: FREQUENCY FILE TYPE FILE NAME W, M Transaction Set Files 834_5010_CCYYMMDDHHMMSSRxxxx.LOB.TXT W, M Flat Files (Legacy) ** CCYYMMDDRxxxx.OI.LOBF.TXT.pgp W, M Flat Files (Supplemental) ** CCYYMMDDRxxxx.LOBF2 M Active Member Report ** CCYYMMDDRxxxx_LOB.pdf.pgp M Disenrollment Report ** CCYYMMDDRxxxx_LOB.DIS.pdf.pgp W, M Transaction Set Files** 834_4010_YYYYMMDDRxxxx.LOBF.TXT.pgp W, M Medicare/Commercial Flat Files** CCYYMMRxxxx.txt.pgp M Re-Determination Files Rxxxx_RDYYYYMMDD_30/60/90.txt M On Hold Files Rxxxx_OnHold_IPA_Name_YYMM W Activity Files MMDDRxxxx_100_MOVE M MSP Rxxxx_MSP_CCYYMMDD.csv M CLM Rxxxx_SPD_CLM_CCYYMMDD.csv M TAR Rxxxx_SPD_TAR_ CCYYMMDD.csv W = WEEKLY M = MONTHLY XXXX = REGION LOB = LINE OF BUSINESS ** = LEGACY FILES PHASED OUT IN 2013 Files are placed into the Care1st FTP server by the 5 th of each month. We send a notification to each IPA s designated representative. The notification for monthly e-list states that files should be retrieved by the end of each month. We leave files for one month in the FTP without deleting, to enable IPA s to go back and retrieve older e-lists. We delete files after the month has passed. IPA s do not have permission to delete files. For questions about electronic uploading (FTP) & encryption (PGP) of E-List files, please contact Data Exchange at (323) , or dataexchange@care1st.com For questions about formats, layouts, or data contained in E-List files, please contact Aliza Jimenez at (323) , or ajimenez@care1st.com 3

5 Eligibility, or E-List Files FTP Location: IPA/elist/out FLAT FILES The legacy file contains active membership for Medi-Cal and/or Healthy Families lines of business which contains all 9 byte member numbers. The supplemental file for Medi-cal and Healthy Families will accommodate the expanded 10 byte Care1st member number field located at end of the record. ACTIVE MEMBER REPORT PDF report contains active membership to IPA for Medi-Cal and/or Healthy Families lines of business. DISENROLLMENT REPORT PDF report with members disenrolled from IPA for Medi-Cal and/or Healthy Families lines of business. 834 TRANSACTION SET FILES HIPAA compliant eligibility EDI file with active membership for Medi-Cal, Healthy Families and/or Medicare lines of business. MEDICARE/COMMERCIAL FILES Flat file contains active membership for Medicare/Commercial lines of business. RE-DETERMINATION FILES Current IPA members with anniversary date upcoming in 30, 60 and 90 days from reporting month. ON HOLD FILES IPA members with eligibility Hold status for current month. ACTIVITY FILES Members activity report indicates enrollment or transfer status. ENROLL = Members released from hold, member PCP changes and member transfer in from another IPA. TRANSFER = Members transfer out of IPA. All the files referenced above are placed in the e-list/out directory. MEDICARE SECONDARY PAYER (MSP) MSP provided by CMS. Use this file to determine primary payer vs. secondary payer. SPD CLM AND SPD TAR Both files are available if applicable to the IPA or Medical Group. For questions about electronic uploading (FTP) & encryption (PGP) of Activity, On-Hold or HFP files, For questions about formats, layouts, or data contained in Activity, On-Hold or HFP files, please contact Aliza Jimenez at (323) ext. 6251, or ajimenez@care1st.com 4

6 Capitation and Claims Files FTP Location: IPA/cap/out IPA/md_clms/out To ensure receipt of cap reports, files should be downloaded after the 10 th, and before thefirst of the following month. If a previous month s cap report is requested, it must be regenerated. Reports may vary from the original since it is extracted from current data. Capitation files Mis-directed claims files Filename: Rxxxx_IPAName_MMYY.zip.pgp File name: Rxxxx_CCYYMMDD.zip.pgp Capitation files are placed in FTP by the 10 th of each month. This zipped file includes cap reports, claims report, pharmacy report and capitation analysis reports. Once decrypted, the resulting Winzip file is also password-protected. It is the same from month to month. If having a problem with the Winzip password, you may contact Do Le at <dle@care1st.com> notification sent only if cap files will be uploaded later than the 10 th of the month. Misdirected claims are available daily. For questions about electronic uploading (FTP) & encryption (PGP) of Capitation files, For further questions about Capitation files, including Winzip passwords, please contact Do Le at (323) ext. 6217, or DLe@Care1st.com For further questions about Misdirected claims, please contact Michael Huynh at (323) ext. 6229, or MHuynh@care1st.com 5

7 UM Daily Reports: Case Sheets & Census Reports FTP Location: IPA/reports/out UM Daily Reports are placed in FTP every morning. The files that being with C_ are daily census files by region that are the same census format reports being produced by Health Care Informatics and used by UM daily. The files that begin with U_ are copies of hospital face sheets or medical records received via right fax. The naming convention contains the region number, patient last name, first initial of first name, part of hospital name, Care1st authorization number, authorization type, file sequence for same member, medical record or face sheet, and member admit date. FILE NAMING CONVENTIONS 1 Rxxxx IPA region number 2 LNAME Members last name 3 FINITIAL First initial of members first name 4 HOSPNAME Hospital name 5 AUTH# Authorization number 6 IH or SNF Authorization type Inpatient Hospital or SNF (Secure Nursing Facility) 7 (#) File sequence number 8 MS or FS File content is medical record or face sheet 9 DD-MON-YY Day-Month-Year (18-Mar-10) Case Sheet file Filename U_Rxxxx_LNAME_FINITIAL_HOSPNAME AUTH#_ IH or SNF TYPE(#)_ MR or FS_DD-MON-YY.PDF Census Report file Filename C_Rxxxx_IPANAME_CCYY_MM_DD_AM_CENSUS_AM_MEDICARE.PDF C_Rxxxx_IPANAME_CCYY_MM_DD_CENSUS_AM_MEDICAL.PDF For questions about electronic uploading (FTP) & encryption (PGP) of UM Daily files, For questions about data contained in UM Daily Files, please contact Steve Childs at (323) ext. 6268, or schilds@care1st.com 6

8 UM Reports: HRA files FTP Location: IPA/hra/out Health Risk Assessment (HRA) files will be available upon notification. To summarize you may receive a maximum of 5 separate file types if you have SNP members that completed an HRA. It is possible that you may receive some or no files as it is dependent on the completed HRA s and if any of your SNP members were included during that particular posting period. FILE NAMING CONVENTIONS 1 Rxxxx IPA Region Number 2 HCP Health Care Plans 3 YYYY_MM_DD Year-Month-Day 4 WWW IPA Abbreviation (3 to 4 characters) 5 XXX MSO Abbreviation (3 to 5 characters) 6 IPA IPA Name 7 CarePlans/Risk_Assess/MemberList Description of Specific Information Type in File 8 MAPD/SNP Line of Business PDF s of Individualized Care Plan: SNP members only Rxxxx_HCP_SNP_YYYY_MM_DD_LName_FName_Mem_No.pdf Excel Spreadsheet of Individualized Care Plan: SNP members only Rxxxx_HA_YYYY-MM-DD_WWW_XXX_IPA_CarePlans.xls PDF s of HRA Answers for MAPD members Rxxxx_HRA_MAPD_YYYY_MM_DD_LName_FName_Mem_No.pdf PDF s of HRA Answers for SNP members Rxxxx_HRA_SNP_YYYY_MM_DD_LName_FName_Mem_No.pdf Excel Spreadsheet of all members with a completed HRA and Care Plan both MAPD and SNP with this posting Rxxxx_HA_YYYY-MM-DD_WWW_XXX_IPA_MemberList.xl For questions about electronic uploading (FTP) & encryption (PGP) of HRA files, For questions about data contained in HRA files, please contact Robert Feldman at (323) ext. 6298, or rfeldman@care1st.com 7

9 UM Monthly Reports: FTP Location: IPA/reports/out Bed Day, CCS, ReAdmits and Case Management Report files are uploaded to the reports/out directory by the 10 th of each month. Bed Report file Filename: Rxxxx_O_BED_DAY_RPT.DOC.pgp Bed Report Detailed file Filename : Rxxxx_O_BED_DAY_DTL_RPT.DOC.pgp CCS Report file Filename: Rxxxx_O_MONTHLY_CCS_RPT.XLS.pgp ReAdmits file Filename: Rxxxx_O_READMITS_RPT.XLS.pgp Case Management Report Filename: Rxxxx_O_CASE_MANAGEMENT_RPT.PDF For questions about electronic uploading (FTP) & encryption (PGP) of all Monthly Report files, For questions about Monthly Bed Reports, CCS Reports, Re-Admits and Case Management Reports, please contact Steve Childs at (323) ext. 6268, or schilds@care1st.com 8

10 Encounter Data FTP Location: IPA/encounter/out Encounter Data is transferred to and from the FTP server by the Encounter Department. They keep their own logs and records, and communicate with the various IPA s encounter staff for any information that is needed. Encounter data is due into Care1st by the 10 th of each month (place in directory /encounter/in). Error reports are returned via FTP (/encounter/out). IPA Compliance Report Adequacy Report Lag Report Encounter Error Reports Filename: ipa_yyyymm.pdf.pgp mso_ipa_yyyymm.pdf.pgp Filename: Rxxxx_Adequacy_YYYYMM.pdf.pgp Filename: Rxxxx_LAG_YYYYMM.pdf.pgp Filename: ErrorRxxxxIPANAMEMMDDYY.TXT.pgp For questions about electronic uploading (FTP) & encryption (PGP) of Encounter files, For questions about file formats, file naming or data contained in Encounter files, please contact Sione Ayers at (323) ext. 6299, or sayers@care1st.com 9

11 Encounter 837 Test Data FTP Location: IPA/enc_test/out IPA s who are testing the 837 HIPAA-compliant or NSF formats can find their result files in the FTP server. IPA s who are submitting 837 test files will place their files in IPA/enc_test/in. Claredi Error Reports Filename: velocedi_err_3gbzlh.html.zip.pgp NSF Test Error Reports Filename: ErrorNSF_Rxxxx_IPANAME_TEST#6.TXT.pgp Error reports are due back to the IPA with a 5 day turnaround. Care1st will notify the IPA when the error reports are in the FTP server. For questions about electronic uploading (FTP) & encryption (PGP) of 837 test files, For questions about 837 transaction sets, test format, claredi reports, please contact Aliza Jimenez at (323) ext. 6251, or ajimenez@care1st.com For questions about NSF format or files, please contact Sione Ayers at (323) ext. 6299, or sayers@care1st.com 10

12 Contact Information FTP/PGP For questions about electronic uploading (FTP) & encryption (PGP) of the files listed below, please contact us at Data Exchange: (323) , or E-LIST FILES For questions about formats, layouts, or data contained in E-List files, please contact Aliza Jimenez at (323) ext. 6251, or CAPITATION AND CLAIMS FILES For further questions about Capitation files, including Winzip passwords, please contact Do Le at (323) ext. 6217, or For questions about misdirected claims please contact Michael Huynh at (323) ext. 6229, or UM DAILY REPORTS: Case Sheets and Census Reports For questions about data contained in UM Daily Files, please contact Steve Childs at (323) ext. 6268, or UM MONTHLY REPORTS: Bed Day/CCS/Re-Admit/Case Management Reports For questions about Monthly Bed Reports, CCS Reports, Re-Admits and Case Management Reports, please contact Steve Childs at (323) ext. 6268, or ENCOUNTER DATA For questions about file formats, file naming or data contained in Encounter files, please contact Sione Ayers at (323) ext. 6299, or ENCOUNTER 837 TEST DATA For questions about 837 transaction sets, test format, claredi reports, or files, please contact Aliza Jimenez at (323) ext. 6251, or For questions about NSF format or files, please contact Sione Ayers at (323) ext. 6299, or 11