ELIGIBILITY PROCESSING

ELIGIBILITY PROCESSING PROCEDURES (IEHP EDI Partner Connection)

Eligibility processing procedures are a key concern of all Providers in the IEHP network. IEHP receives Medi-Cal eligibility information from DHCS via an 834 file on a monthly basis. DHCS provides daily electronic eligibility files to update the Member files during the course of each month. For IEHP’s DualChoice CalMediConnect Plan (Medicare – Medicaid Plan) program, IEHP receives confirmed enrollment data from CMS on a daily basis via the Daily Transaction Reply Report (DTRR). Once confirmation is received from CMS on the DTRR, the information is uploaded.

Data files offer the most comprehensive Member information available to Providers. The files include both eligibility and demographic data provided from the monthly and daily 834 and daily IEHP Enrollment Unit files.

IEHP processes the information received and assigns a PCP (that is linked to an IPA) and Hospital to each Member based on Member choice or prior affiliation with a PCP. In the event that neither Member choice nor prior affiliation is definable, an auto assignment process is conducted to assign a PCP and a Hospital to the Member, taking into account Member demographic information, such as address, age, gender, and language preference. IEHP then creates an eligibility file for each Provider that contains only those Members assigned to that entity.

Data files are placed on the SFTP server for each Provider. A full monthly file is provided by the 1st of each month. Weekly files, that contain updated information, are provided three times a month. Providers are required to pick up their eligibility information from the SFTP server within three days of transmission by IEHP. IPAs are required to submit eligibility lists to their contracted PCPs by the 5th and 15th of each month for the current months’enrollment.

Capitated Providers also receive a monthly electronic file with their capitation checks that identifies retroactive eligible Members (adds) and Members who are no longer assigned to that Provider (deletes).

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