AHCCCS Technical Interface Guidelines (TIG)

 

Health Plan Interface - Daily Enrollment Notification Process


Introduction

Daily Enrollment Notifications identify:

  • new additions (members) to a Health Plan for which the Health Plan is responsible
  • persons disenrolled or deceased for whom the Health Plan is no longer responsible
  • changes to member's demographic data such as name, address or date of birth
  • other changes, such as rate code changes.

Daily Enrollment Notifications occur through the HIPAA 834 Transaction Code Set.

Capitation for enrollments will be calculated on a per diem basis. Capitation will be paid through the end of the processing month. Prospective capitation will be paid on a monthly basis (See Monthly Enrollment Notification Process).

Capitation payments and recoupments as a result of Daily Enrollment Notification process are transmitted to the Health Plan on the HIPAA 820 Transaction Code Set.

 

Schedules

  • Enrollment processing normally completes between 8:00 p.m. and 11:59 p.m. each night for the day's activity.
  • HIPAA 834 and 820 TCS files are downloaded to the AHCCCS Communications Server and available for extraction by the Health Plan by 11:59 p.m.

 

Media

Enrollment notifications are produced in data file format. Health Plans, or their services bureaus, must dial in to the Arizona Health Care Cost Containment System (AHCCCS) computer system and download the data file for batch processing.

 

Testing

Enrollment Notification and Capitation Notification file transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmissions takes approximately one week and must be completed prior to implementation of any new processing arrangement.

 

Reference Documents

 

Notes

Enrollment notification and capitation notification data, once delivered to the Health Plan, is considered legal notification of the Health Plan's responsibility for provision of care to AHCCCS members.

Special attention should be given to the daily process immediately preceding the monthly processing, as well as to the daily processing run on the last two days of the month. The daily process which runs prior to the monthly is referred to as the 'last daily' and will contain all rate code changes which are effective for the next month, as well as any new enrollment, and a majority of the dis-enrollments effective at the end of the month. It is important that this last daily be processed by the Health Plans before attempting to run the monthly reconciliation process (See Monthly Enrollment Notification Process.)

The two daily processes that run after the monthly process are different from 'regular' daily process in that they will pay capitation, or recoup capitation into the next month. This is because the monthly, which normally pays prospective capitation, has already run.