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MMCD - Senior and Persons with a Disability Health Plan FAQ

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enrollment process

Health Risk Assessment

Revised Facility site review

Outreach and Education

Plan Readiness

Contract 

Data    

Other   

 

 

  

How will we get the file for new SPDs? Will the file be a different FAME file or will they be added to the same FAME file we get now?

Plans will get the file the same way they do today.

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Can we have SPD info by date of birth so we can see how many to expect per month?

This data was sent by DHCS to health plan contacts on, or shortly after 11/3/2010.

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Can the health plans have a list of the SPD aid-codes?

SPDs have been defined as Medi-Cal only FFS (non-duals) beneficiaries in the following aid codes:
20, 24, 26, 2E, 2H, 36, 60, 64, 66, 6A, 6C, 6E, 6G, 6H, 6J, 6N, 6P, 6V, 10,14, 16, 1E, 1H.

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Will the SPD population have any lock in period?

No, the State of California does not allow for a lock-in period.

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If a beneficiary wants to choose a plan before their date of birth, how will that be processed and what happens to the element of choice? 

As a voluntary member before they become mandatory, these SPDs have the right to choose as always.

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How often can a member change plans? 

A member can change plans at anytime. 

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Does the current default algorithm apply to SPDs? If so, what happens with the default assignment process if the provider the member has been seeing is in multiple plans? 

The current default algorithm will be applied to SPDs only if they do not make a plan choice and DHCS is not able to link the individual to a plan based on the most utilized fee-for-service (FFS) provider. However, if a member's most utilized FFS provider is available in the networks of all plans in the county, then the member will be defaulted using the auto assignment algorithm.

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How will the provider being used by the member be communicated to the plan? 

Managed care health plans will receive member-specific utilization data files that will include national provider identifier numbers.

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Will SPD members who are already in plans receive the material from the state and be put in the default process?

No. Members in plans will only receive notice of the change that is occurring in their respective county.

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What methodology will be used for default assignment of Members?

An effort will be made to link beneficiaries to a health plan by matching them with their highest utilized physician or physician group, and/or highest cost physician or physician group. If a match cannot be made, they will follow the current DHCS default algorithm.

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Will health plans receive outstanding TAR data for those members to be enrolled in their plans?  

Yes. This is detailed in Policy Letter 11-003 (PDF).     

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Do certain conditions have to be present for continuity of care to exist with established out-of-network providers?   

As required in Welfare and Institutions Code 14182 (b) (13), a member must have an ongoing relationship with the out-of-network provider, and the provider must agree to the health plan's rate for the service offered, or the applicable Medi-Cal fee-for-service rate, whichever is higher.  Also the health plan must determine that the provider meets applicable professional standards and has no disqualifying quality of care issues.

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What types of specialties can constitute a PCP?

Per Welfare and Institutions Code 14182 (b) (11), any specialist or clinic may serve as a primary care provider if the specialist or clinic agrees to serve in a primary care provider role and is qualified to treat the required range of conditions of the enrollee.

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Will plans be able to send a separate, SPD specific Provider Directory to members?

Health plans will be required to have one, all-inclusive provider directory. A Policy Letter will be released with details regarding specific required content in February. If a plan wishes to created an additional Provider Directory in addition to the one required, it must be reviewed and approved by DHCS.

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Will plans receive samples of member notices, county inserts, and the enrollment packet?

Enrollment Packets are available at the Health Care Options Website.  Member Notices and County Inserts are available on the Seniors and Persons With Disabilities Notification and Enrollment Information webpage.

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Will the plans have the opportunity to request the data elements needed to stratify the members?

Yes. MMCD will provide test files to plans in early 2011 to allow plans time to get familiar with the data files before they have to begin using it for risk assessment and stratification. This will also allow time for DHCS to address issues identified by plans.

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Will claims data from the state include pharmacy data (e.g. the medications the Member is/has received)?

Yes. All Medi-Cal paid pharmacy data will be included.

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When will the plans receive the claims data and will the data be part of the eligibility file or separate?

Starting in May 2011, the data files will be available to plans shortly after the 1st working day of each month. These files will be separate files, not part of the eligibility files, and will be available to plans via a secure FTP site.  Complete details about these files, including when they will become available each month, how plans will access them, and the testing process, will be provided in an All Plan Letter well in advance of when the testing process begins.

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Will the state be mandating/developing a standard health risk assessment for the plans to use? When will plans receive it, and in what format?

No. The State is reviewing risk assessment tools that were submitted by the health plans prior to 3/1/2011. Policy Letter 11-001 (PDF), issued on 1/5/2011, describes the minimum criteria for approval of the tools.

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Will the Member Evaluation Tool be sent to the health plans electronically?

Yes. The Member Evaluation Tool (MET) will be sent electronically.

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Will plans receive a sample of the Health Information Form (a.k.a. the MET)?   

Yes. DHCS sent the Health Information Form (HIF) to plans on 12/7/2010. A sample HIF is posted on our website.    

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Which types of providers (PCP, Specialists, etc) will the revised FSR tool be used for?

The FSR tool will be used with Primary Care sites. The tool is detailed in Policy Letter 10-016 (PDF), released 12/31/2010.

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How much more extensive is the new FSR tool compared to the enhanced tool already in use by multiple plans?

The new section of the tool is more in-depth and looks to build upon the old tool in its specificity of physical accessibility. Please see Policy Letter 10-016 (PDF), released 12/31/2010.

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Will DHCS share the revised Facility Site Review tool?

Yes. The revised FSR tool was released in Policy Letter 10-016 on 1/3/2011, and a conference call with health plans was held on 1/5/2011. A webinar training took place on 1/13/2011, and in-person trainings will take place as follows: 2/14/2011 in Pomona, and 2/23/2011 in Sacramento. 

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What will be specifically required from health plans in terms of sensitivity training both for providers and plan staff? 

Master trainers will be required to attend sensitivity training, and will ultimately be responsible for conducting sensitivity training for plan staff and providers. 

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Can you tell us what formats the member materials will be available in, for example: large print, Braille, audio, etc? 

Materials will be available in all threshold languages, Braille and audio. 

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Does DHCS have plans to coordinate with health plans for specific outreach and education activities?   

DHCS has consulted with an advisory group (that includes plan representation) on beneficiary informing materials and SPD sensitivity training, and will work with plans on developing plan-specific outreach and education activities. DHCS also encourages health plans to conduct plan-specific outreach and education activities independently, those of which need to be reviewed and approved by DHCS.

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During the community presentations, will health plans be invited to present information about the health plan?   

Health Plans will not be presenting. However, plans will be invited to the presentations and will be allowed to set up booths or tables and will be allowed to answer any questions that attendees may have. Plans must adhere to the marketing guidelines previously set forth in their managed care contracts.

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Will DHCS continue to provide implementation materials to plans for review through conference calls?

Yes. DHCS has provided, and will continue to provide, all necessary materials available to plans for review and input through emails and conference calls. Many of the same materials can be found here throughout the website.  

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As part of SPD sensitivity training, are plans required to train their entire network of providers (specialists, ancillary, hospital, etc.), or PCPs only?

Currently, health plans are responsible for the training of their entire network of providers.

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Will the plan readiness review only look at new requirements from the waiver or existing contract requirements? Will the plan readiness review be an internal process, or actual site visits to plans by DHCS staff? 

No. It will be based both on new requirements and on existing contract requirements in relation to plans' ability to serve SPDs, and done internally by DHCS in collaboration with the health plans. 

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What is the timeline for the deliverable process? 

Deliverables will most likely be sent to health plans in February or March. There will be ample time given to submit deliverables to DHCS.

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Will any services be carved out of health plan contracts with the mandatory enrollment of SPDs?

There will be no additional services carved out coinciding with the mandatory enrollment of SPDs.

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Can we provide the codes associated with the Service Indicator Description on the TAR data set?

The Service Indicator Description is self-explanatory, so codes are not needed. Sample descriptions include: Hospital, Pharmacy, Outpatient, Surgical, MRI, etc. Codes are not included with the descriptions.

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Can we tell if a file was downloaded and by whom in case it appears to be missing from the SFTP site?

The data files are not removed from the SFTP site when downloaded by plans. The files will only be removed by DHCS after they have been available on the SFTP site for 14 calendar days after plans are notified by e-mail that the files are available for downloading. MMCD will not be able to tell if a file was downloaded by a plan, but could research this if necessary.

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Will plans receive information about the provider used to default a member to a plan?

The weekly plan file provided by HCO currently indicates whether a plan assignment is a default or the member’s choice. When a member is defaulted to a plan based on provider linkage, the file will include an NPI number or other number for that provider. When a member chooses a plan and selects a PCP, the PCP information is reflected in the file.

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If a beneficiary is in one plan and moved to a second plan, will the second plan receive the member’s FFS and TAR data?

The FFS claims and TARs data will be provided for all Medi-Cal only SPD beneficiaries identified as new enrollees in a plan, regardless of whether were new to managed care or were moving from another plan.

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Can plans receive provider names and addresses for the NPIs provided in the TAR data?

The TAR data includes not only the NPI, but also the provider name. The database from which TARs data is pulled does not support sharing provider addresses. We assume that plans will use their own resources for locating addresses since the TAR data includes the provider name.

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In the FFS claims data, there is a column named Claim Control Number CCN and it is said to uniquely identify any record. How can we identify a claim line within a claim group?   

The term "record" in this case is synonymous with "claim." The CCN uniquely identifies the claim. All detail lines for a claim will have the same CCN.

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How can duplicate claims be detected?

Duplicate claims should not appear in the extracted data files as they would be denied payment due to the duplication. Only paid claims will be extracted.

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If there are lag claims for a new enrollee that came after the month they joined the plan, will the plan get the lag claims in subsequent months for this enrollee?

No. The claims data will be extracted when the beneficiary is identified as a new enrollee and provided to the plan at that time only. We anticipate that TARs data will be helpful in identifying approved services for which claims may not yet have been received.

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If an enrollee joined the plan, then left the plan for several months, and then returned to the previous plan, will we get another 12 months of historical data for this enrollee?

Yes. In this situation, the beneficiary will be identified as a new enrollee if they were in a pending status for the previous month and changed to active status for the current month. The FFS claims and TARs data will be provided for all Medi-Cal only SPD beneficiaries identified as new enrollees, regardless of whether they had been enrolled in the plan in some prior period. However, only FFS data will be provided. The plan will not receive any encounter data for that member from their period of enrollment in another managed care plan.

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When downloading the TAR Test File from DHCS, the following discrepancies were noted.  Please clarify. 
• There is a field called enc_cin which was not described in PL-11-003.  Is this the Recipient ID, please validate.
• TAR Control Number field missing
• Submitting Provider Name field is missing
• Submitting Provider Number field is missing
• Rendering Provider Name field is missing
• Rendering Provider Number field is missing

The TAR Test File that was made available on February 25, was a de-identified sample file created to test our processes and the plans’ ability to retrieve the files from the SFTP site.  Instead of providing actual Recipient IDs, the system used the Encrypted CIN field containing the same encrypted CINs in the corresponding claims data file.  The fields identified above as missing were deleted to further de-identify and generalize the file.  These missing fields will be included in the actual member-specific files, including the second test file to be distributed in April 2011.

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Can you tell us what the average file size and the estimated maximum file size for these monthly files will be?

The data will be extracted monthly after the new Medi-Cal only SPD enrollees have been identified for each plan code.  As we do not know exactly how many, or which, enrollees may be assigned to each plan code each month, we cannot anticipate the volume of the associated claims and TARs.  Therefore, we are not able to estimate the sizes of the files. 

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Would it be possible to receive the TAR data file in a comma delimited format going forward?

We are looking into the possibility of changing in the future, but for now it will remain in Excel.  If we are able to make the format change, we will notify all plans at least a month in advance.

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Can TARs data be provided as a text file instead of Excel?  Comma delimited?

We do intend to eventually change the TARs data from an Excel file to a text file, but that change will not be made by the time plans begin receiving the monthly data files in May 2011.  At this time we do not know when this change will be made, but will inform plans when the change is imminent.

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Will there be a standardized naming convention for the files?

Yes

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Can the attachments to the Policy Letter be provided in electronic format?   

Yes.  The electronic document will be sent to plans no later than the week of March 28, 2011.

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Will typos in the tables be fixed?

No.  The descriptions in the tables were taken exactly as they appear in the database.  Data is provided to the plans as it exists in the database.

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In the claim file, are the data beginning in columns 52 and 109 the primary diagnosis code description and secondary diagnosis code description? 

The primary diagnosis code is in columns 45 through 51, with the associated description for the code in the field immediately following.  The secondary diagnosis code is in columns 102 through 108, with the associated description immediately following.

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Some fields specify a certain length, but the data may actually be fewer characters than the field length.  (The example given was the Original Place of Service Code in Table 5 where there are both one and two character values.)  Is the field left aligned with trailing zeroes or right aligned with leading zeroes?

We are researching this question and will respond as soon as possible.

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The CINs provided in the files don’t look like real CINs.  What are they?

The data in the first test file was de-identified using encrypted CINs to ensure no breach of PHI.  Future files will have real CINs and real data.

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In the TARs data file, what does “units” mean?

"Units" in a TAR generally refers to the number of visits approved. However, in the case of a TAR for transportation services, the units will refer to miles approved.

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ICD9 Codes are being formatted as text, without preceding zeroes and decimals.  How can we figure out the code?

This is one area where the quality of the fee-for-service data poses challenges.  We can only provide the data the way it was received and put into the data warehouse.  As FFS claims are paid based on procedure code, the diagnosis code is not always reliable.  Decimals are not included in this field in the database, but are inferred.  Plans are encouraged to take advantage of their own knowledge and experience with ICD9 Codes when making use of this data.

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If no data is provided for some members in the monthly file, how will plans know whether there wasn't any data available or there is something wrong with the file?

All the CINs for the current month's newly effective SPD members will be included in the data files.  If no data was available for a specific member, the CIN will appear in the file with all other data elements blank except the last field, Claim History Indicator, which will contain an N.

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Will data be provided for people enrolled mid-month, such as someone released from hold status?

No. We are identifying newly enrolled beneficiaries at MEDS renewal that were previously pending and will now be actively enrolled. 

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What is the timing for receipt of the next file?

We’re not certain when in April 2011 we will be distributing the next data file.  The designated points of contact for each plan will be notified when the files are available.

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How will the MET data be provided?

The MET has been renamed as the Health Information Form (HIF).  Health Care Options (the enrollment contractor, Maximus) will extract the data from completed HIF forms and provide to plans in a data file.

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There appear to be code errors in the CPT/HCPCS field, seeing zero digits to eleven, twelve or thirteen.  Can you explain?

This may be another FFS data quality issue.  The plan that raised this question was invited to send examples to the designated mailbox (mmcddata@dhcs.ca.gov) for DHCS to research.  Note:  If a plan sends in a data file for DHCS review, the file must be sent secured.  If the file is not sent secured, it will be deleted by DHCS.

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Would it be possible to get the claims file with delimiters?   

The claims file has been established in a fixed width format adhering to the file layout in Attachment 1 of MMCD Policy Letter 11-003 and does not accommodate delimiters.

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Regarding multiple Claims files by county, is it possible to get one merged claims file?      

The data files are based on beneficiaries enrolled in specific plan codes (counties). For tracking and monitoring purposes, as well as an added layer of security to ensure that health plans are provided only the data for the members enrolled in their contracted plan codes, claim files are provided by individual plan code. Therefore, we cannot provide merged files.   

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Can the TARs files be provided in one file, instead of by county, and in CSV format?       

For the same reasons noted in the answer to the above question relating to the claims files, TARs files are provided by individual plan code. We are working toward providing the TARs data formatted as text files in the future and hope that plans will find the data easier to process once that is implemented. However, for now the TARs files will continue to be provided in Excel.     

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Some fields specify a certain length, but the data may actually be fewer characters than the field length. (For example, the Original Place of Service Code in Table 5 where there are both one and two character values.) Is the field left aligned with trailing zeroes or right aligned with leading zeroes?       

The Original Place of Service Code is left justified with trailing spaces.

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In the TARs data files, please confirm the format for the "Service From Date" and "Service Through Date". The format has appeared three different ways:  
• In the TAR layout included in the PL11-003 Rev 2 document, the format appears as 01DEC2010 or DDMMMYYYY 
• The test file available on February 25th used the format mm/dd/yyyy    
• The April test file used the format mm/dd/yy    

Some formatting issues arose when the TARs data was transferred from the database to the Excel files. We are taking steps to ensure that future files will have the "Service From Date" and "Service Through Date" fields formatted as 2 DDMMMYYYY as appears in the policy letter.

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In the first test file, 34,256 of the 74,987 records had an all numeric 11 digit code in this field indicative of a true national drug code, but that there were a large number of records with what looks to be junk values. For example: ZD10, YSICALTHERP, XRAYXRAYEXA, WHEMAT0L0GY, W10. Is the NDC, HCPC or local code not available in these instances?     

You may not be looking at claim types to see which of the records are pharmacy records. The NDCs with the weird values occur because that‟s the way the data was sent to the department. However, if you look at the data in terms of the claim type, the weird values do not matter since they would not be necessary for the claim. For instance, an outpatient or inpatient claims never report NDC; only pharmacy claims do. You will see some NDCs on claim type 4 (medical) since these are probably the Physician-Administered Drug (PAD) claims which have one segment a drug claim and the other segment the physician code.

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Which form of claims adjustment is used in your system? Is an adjustment claim a full replacement of the original claim provided with an annotation pointing back to the original? Or does an adjustment claim come through that only contains the pieces of data which have been adjusted/changed?     

The data can contain two types of adjustments. The most common type is an adjustment claim that is a full replacement of the original claim and is considered a void or a void and replacement. An adjustment code of „3‟ is just a void, and a „5‟ would be considered the void side of the replacement. Adjustment code „4‟ is considered the replacement or the positive side of the void. The less common type of adjustment contains only the data elements that have been adjusted/changed. The type of adjustment is used to correct claims (e.g., price adjustments) and uses adjustment codes "1‟ and "2‟.

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We noticed that the first line on the latest TAR file was blank. Could this be taken out on future submissions so that we do not have to customize our system to handle it?     

We recognize the blank row in the TAR file as an issue and are taking steps to remove it from future submissions.

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We are requesting clarification regarding the exact naming convention of the files that we will be receiving for Claims and TAR files. The first claims test file was named MBR_SPEC_CLMS_D201012_TEST_PLN999. Although the Plan anticipates receiving a file with a similar naming convention, the specific naming convention will assist the Plan is preparing for receipt of the live files. Will the county be identified in the naming or is it indicated by Plan code? Also, we are assuming D201012 is the date but need to validate.      

The naming conventions for the claims and TARs files will conform to the following standards:

  • Standard for FFS claims files - MBR.SPEC.CLMS.PLN###.DYYYYMM
  • Standard for TARs files - SPD_TAR_EXTRACT_###.xls
  • Plan codes (represented here by ###) will be used rather than county names.
  • DYYYYMM is the date. It identifies the year and month of beneficiary enrollment for which the data is provided.

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    Should ICD9 Diagnosis Codes of zeroes (usually „00‟ or „00000‟ be interpreted as NULL or blank? In the future, will diagnosis codes include a decimal point? Will Procedure Modifier of „00‟ be interpreted as NULL or blank?    

  • Zero („0‟or „0000‟ values for Diagnosis Codes should be interpreted as NULL, not blanks.
  • No, diagnosis codes in future files will not have decimal points.
  • Zero („0‟or „0000‟ values for Procedure Modifiers should be interpreted as NULL, not blanks.

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    In the claims file, is the Drug_Quantity_Dispensed field formatted correctly? We are seeing quantities like 60,000 for some medications where we believe the quantity likely should be 60.

    This field does allow for an implied decimal to the 1000th. Therefore, you are correct that an item reported as 60,000 most likely should be 60. The field should be read as containing an implied decimal with three digits to the right.

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    Our plan is spending a lot of time converting the Excel version of the TARs data file into a text file. In March 2011, DHCS indicated the Excel file would be converted to a text file. When will that change take place? If that will not happen soon, could the lines breaks be removed from the fields to improve processing time?

    The project to convert the TAR data file from an Excel file to a text file has been put on hold until April 2012 due to a major vendor transition currently underway.  MMCD made a special appeal for this project to proceed sooner but were not successful.  We are sorry about the time it is taking your programmer to convert the Excel file to a text file, but there is nothing we can do at this time to help improve the processing time.

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    In the TAR files received, for services that were not for pharmaceutical agents the Plan is not receiving any information on “Rendering Provider”. Will the missing information be available on future files? The lack of information is a barrier for the Plan in identifying a provider in which to coordinate care.

    DHCS’s Utilization Management Division, which oversees the review and approval of TARs, provided this response:  “If a provider has submitted a claim for payment and the claim has been paid, the Rendering Provider information will show in the TAR data.  Keep in mind sometimes the Rendering Provider is the same as the Submitting Provider, and it will not be shown in both fields. Also, even though a TAR is issued for services by a provider, it's possible that a beneficiary will not use the services.”

    Therefore, the Rendering Provider field is not populated until the claim has been paid for the TAR service and only when the Rendering Provider is a provider other than the Submitting Provider.  If the Submitting Provider renders the service, the Rendering Provider field is not populated.  We suggest that plans use the Submitting Provider as the contact if the Rendering Provider information is not available in a TAR record.

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    We downloaded the TAR files for the SPD members and found that in over 5,000 rows of data, 4277 rows of data had “Service Through Dates” ending prior to June 2011, and about 1500 after June 2011.  Should we expect that DHCS will continue to send TARs with “Service Through Dates” that have already passed?  Can we interpret requests with “Service Through Dates” that end prior to June 2011 as authorizations that are no longer valid or have expired?

    DHCS will continue to send monthly FFS utilization and TAR files that reflect the most recent 12 months of available data as described in the Policy Letter 11-003 dated February 10, 2011.  The “Service through Dates” is interpreted as the ending date that the TAR is valid for the services, equipment or drugs being requested.  You are correct that TARs with an end date prior to June 2011 are no longer in effect, but this data still may be of use to your plan in understanding members’ recent care needs.

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    We noticed that the TAR files for different months have the exact same filename (SPD_TAR_EXTRACT_307.xls).  Could the files be submitted with a unique identifier appended to the end of the filename such as the creation date (YYYYMMDD)?

    We will explore the possibility of including a date in the filename.  If this change in the naming convention is implemented, we will notify all plans.

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    Our team ran across the following discrepancies between the TAR file layout and the test file and would appreciate clarification from DHCS:

    Field on Test File but not Layout
    enc_cin (This looks to be the Recipient ID on Layout?)

    Fields on Layout but not on Test file
    TAR Control Number
    Recipient ID (could be enc_cin field on Test file)
    Submitting Provider Number
    Submitting Provider Name
    Rendering Provider Name
    Rendering Provider Numbers       

    The TAR test file you appear to be referencing is the test file made available to plans on February 25, 2011.  That was a de-identified sample file created to test our processes and the plans’ ability to retrieve the files from the SFTP site.  Instead of providing actual Recipient IDs, the system used the Encrypted CIN field containing the same encrypted CINs in the corresponding claims data file.  The fields you identified as not being on the test file were deleted to further de-identify and generalize the file.  These missing fields were included in the actual member-specific files, both the second test file distributed in April 2011 and the ongoing monthly files.

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    Is the file we received on May 2, 2011, a production file or a test file? The file name is: MBR.SPEC.CLMS.PLN000.D201105.

    As indicated in MMCD Policy Letter 11-003, DHCS provided test files to plans in February and April 2011.  In February 2011, the same files containing de-identified claims and TARs data were provided to all plans.  In April 2011, each plan received live data files for new SPD enrollees in their plan code(s).  The ongoing production of the live claims and TARs data files began in May 2011.  As expected, the size of the files increased when mandatory enrollment of seniors and persons with disabilities began in June 2011.  The monthly production and timelines for these files continues as indicated in Policy Letter 11-003 (PDF)

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    We noticed that the DHCS altered the directory structure of the files. We updated our FTP script to conform with the change you made; however, with this new change, we no longer have the rights to delete files from your side after we retrieve them. Previously we had this right. Can you see if there is anything on your end that can be modified to allow us to delete files from your end after we retrieve the files?

    Your previous ability to delete files after retrieval was the result of incorrect set up.  DHCS did not intend for health plans to have delete rights for the Member Specific data, and this has been corrected.  As indicated in MMCD Policy Letter 11-003 (PDF), the files are available to plans for 14 calendar days.  DHCS will delete the files after that time.

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    The TAR files sent to us by the State have three columns of data with what appears to be populated by a pre-defined set of values. Please provide the possible values for these three tables:
    • Service Indicator Description
    • Sub-Service Indicator Code
    • Sub-Service Indicator Description

    Table 1 Service Indicator Code and Description (PDF)     

    Table 2 Sub-Service Code and Description (PDF)    

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    Of SB 208 and the 1115 Waiver STCs, which is the operative document that plans should adhere to? 

    Both. SB 208 is state law, and the STCs must be followed in order to satisfy federal waiver requirements.

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