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KY MMIS Interoperability Plan Kentucky MMIS Project
Cabinet for Health and Family Services
Kentucky Medicaid Office
March 7, 2008
Cabinet for Health and Family Services Kentucky Medicaid Office
Role: Name:
Author Bill Ponder
Reviewer Patti George
EDS Management Glenn Jennings, Account Manager
Client Commissioner Elizabeth A. Johnson Claims Division Director Rhonda Poston Executive Director/CIO Lorna S. Jones Chief Technical Officer Sandeep Kapoor
DELIVERABLE TITLE: New KY MMIS Interoperability Plan DATE SUBMITTED: March 7, 2008
LOCATION and FILE NAME: KY_MMIS_InterOperability_Plan_v4.1(03-07-2008).doc AUTHORING TOOL: MSWord2002
Document Change Log Version Changed Date Changed By Reason
1.0 3/6/2006 Bill Ponder Creation of document – 1st Draft.
2.0 3/27/2006 Bill Ponder Added record layouts for items not yet designed when 1st Draft was created.
3.0 3/31/2006 Bill Ponder Implemented changes from 3/27 review
4.0 9/10/2007 Bill Ponder Updated for DSD Refresh
4.1 01/31/2008 02/04/2008
Cathy Hill Made revisions for Commonwealth per Patti George
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Table of Contents
1 Introduction ......................................................................................................................................... 1 1.1 Purpose......................................................................................................................................... 1 1.2 Scope............................................................................................................................................ 1
2 Interfaces by Functional Area............................................................................................................ 2 2.1 Buy-in Data Functional Area Interfaces........................................................................................ 3
2.1.1 Buy-in Data Interface Diagram ........................................................................................ 3 2.1.2 Buy-in Data Entities ......................................................................................................... 3
2.2 Claims Functional Area............................................................................................................... 13 2.2.1 Claims Interface Diagram .............................................................................................. 13 2.2.2 Claims Entities ............................................................................................................... 14
2.3 Data Warehouse Functional Area Interfaces.............................................................................. 40 2.3.1 Data Warehouse Interface Diagram .............................................................................. 40 2.3.2 Data Warehouse Entities ............................................................................................... 40
2.4 EPSDT Functional Area Interfaces............................................................................................. 56 2.4.1 EPSDT Interface Diagram ............................................................................................. 56 2.4.2 EPSDT Entities .............................................................................................................. 56
2.5 External Data Sharing Functional Area Interfaces ..................................................................... 59 2.5.1 External Data Sharing Interface Diagram...................................................................... 59 2.5.2 External Data Sharing Entities....................................................................................... 59
2.6 Financial Functional Area Interfaces .......................................................................................... 83 2.6.1 Financial Interface Diagram........................................................................................... 83
2.7 MAR Functional Area Interfaces................................................................................................. 97 2.7.1 MAR Interface Diagram ................................................................................................. 97 2.7.2 MAR Entities .................................................................................................................. 97
2.8 Managed Care Functional Area Interfaces............................................................................... 103 2.8.1 Managed Care Interface Diagram ............................................................................... 103 2.8.2 Managed Care Entities ................................................................................................ 103
2.9 Member Data Functional Area Interfaces................................................................................. 112 2.9.1 Member Data Interface Diagram ................................................................................. 112 2.9.2 Member Entities........................................................................................................... 113
2.10 Prior Authorization Functional Area Interfaces ......................................................................... 143 2.10.1 Prior Authorization Interface Diagram ......................................................................... 143 2.10.2 Prior Authorization Entities .......................................................................................... 143
2.11 Provider Functional Area Interfaces ......................................................................................... 148 2.11.1 Provider Interface Diagram.......................................................................................... 148 2.11.2 Provider Interface Entities............................................................................................ 148
2.12 Reference Functional Area Interfaces ...................................................................................... 162 2.12.1 Reference Interface Diagram....................................................................................... 162 2.12.2 Reference Interface Entities ........................................................................................ 162
2.13 Third Party Liability Functional Area Interfaces ........................................................................ 169 2.13.1 Third Party Liability Interface Diagram ........................................................................ 169 2.13.2 Third Party Liability Entities ......................................................................................... 169
3 Entity Interface Cross-Reference List........................................................................................... 196 3.1 CMS Interfaces ......................................................................................................................... 196 3.2 COBC Interfaces....................................................................................................................... 197 3.3 Custom Data Processing Interfaces ......................................................................................... 197 3.4 DMS Interfaces ......................................................................................................................... 198 3.5 eKASPER Interfaces ................................................................................................................ 199 3.6 eMARS Interfaces..................................................................................................................... 200 3.7 First Data Bank Interfaces ........................................................................................................ 201 3.8 First Health KMAA Interfaces ................................................................................................... 202
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3.9 First Health PBA Interfaces ...................................................................................................... 203 3.10 Impact Plus Interfaces .............................................................................................................. 204 3.11 IPRO Interfaces ........................................................................................................................ 204 3.12 KAMES Interfaces..................................................................................................................... 205 3.13 KASES Interfaces ..................................................................................................................... 206 3.14 McKesson Interfaces ................................................................................................................ 206 3.15 Myers & Stauffer Interfaces ...................................................................................................... 207 3.16 Navigant Interfaces................................................................................................................... 207 3.17 PA-62 Interfaces ....................................................................................................................... 207 3.18 PA-62/SDX Combined Interfaces ............................................................................................. 207 3.19 Passport Health Plan (AmeriHealth Mercy) Interfaces............................................................. 208 3.20 HMS Interfaces ......................................................................................................................... 210 3.21 Price Waterhouse Coopers Interfaces...................................................................................... 211 3.22 Provider Interfaces.................................................................................................................... 212 3.23 SHPS Interfaces ....................................................................................................................... 213 3.24 SDX Interfaces.......................................................................................................................... 213 3.25 Transportation Cabinet Interfaces ............................................................................................ 213 3.26 VAN (Transaction Service Providers) Interfaces ...................................................................... 214 3.27 Vital Stats Interfaces................................................................................................................. 215
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1 Introduction
This document is the Kentucky MMIS Interoperability Plan.
1.1 Purpose The Interoperability Plan complements the Project Workbook (PWB), technical design by providing details on external interfaces, within each interChange functional area.
1.2 Scope The Interoperability Plan is intended to reflect every external interface to be incorporated into interChange and the design of that interface.
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2 Interfaces by Functional Area
This section explains the interfaces within each interChange functional area. The following hierarchy is utilized for each functional area:
• 2.X - Functional Area
• 2.X.1 - Functional Area Interface Diagram
• 2.X.2 - Functional Area Entity List
• 2.X.2.X - Entity Interface List
• 2.X.2.X.1 - Interface
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2.1 Buy-in Data Functional Area Interfaces
2.1.1 Buy-in Data Interface Diagram A context diagram for entities within the functional area is shown below.
2.1.2 Buy-in Data Entities Name Description
CMS Centers for Medicare and Medicaid Services
KMAA First Health Kentucky Medicaid Administrative Agent
HMS Health Management Systems
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2.1.2.1 CMS Input File ID Name Interface
Type Description Subsystems
Impacted System Entry Point
Data Owner
784, 788 Buy-in Billing File The Buy-in Billing Files come from CMS. They are sent to the Commonwealth Data Center where they are forwarded to HMS. HMS scrubs the file and sends it to interChange.
Buy-in interChange CMS
328 Buy-in Part D File The Buy-in Part D file from CMS is routed to interChange from the Commonwealth Data Center. It is actually a response file to the part D extract that interChange sends to CMS.
Buy-in interChange CMS
Name Source System Source Contact Name
Source Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Buy-in Billing CMS through Commonwealth Data Center
Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com During the day contact Cliff Robey at (502) 564-5183. After hours call (502) 564-7946
Buy-in Part D CMS through Commonwealth Data Center
Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com During the day contact Cliff Robey at (502) 564-5183. After hours call (502) 564-7946
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Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Buy-in Billing CMS through Commonwealth Data Center
Flat file FTP Monthly Fixed width 160 Batch BUYJM605 buy_a_bill_pcg_ccyymmdd_hhmmss.dat
buy_b_bill_pcg_ccyymmdd_hhmmss.dat
Buy-in Part D CMS through Commonwealth Data Center
Flat file FTP Monthly Fixed width 180 Batch ELGJM650elm600r_ccyymmdd_hhmmss.dat
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2.1.2.1.1 Buy-in Billing The Buy-in Billing files for Part A and Part B come from CMS. They are delivered to the Commonwealth Data Center and then re-transmitted to HMS. HMS will cleanse this data and then send it to interChange.
Buy-in Part A Billing Record Layout can be found on the PWB Tech Design Buy-in Data Maintenance Input/Output Files Buy-In New CMS Layouts
Buy-in Part B Billing Record Layout can be found on the PWB Tech Design Buy-in Data Maintenance Input/Output Files Buy-In New CMS Layouts
2.1.2.1.2 Buy-in Part D CMS sends the Buy-in Part D file to interChange through the Commonwealth Data Center using the interChange (ODC) EDI environment and Commonwealth Data Center EDI environment.
Buy-in Part D Header, Detail and Trailer Record Layout can be found on the PWB Tech Design Buy-in Data Maintenance Input/Output Files Part D MMA Enrollment Response File
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2.1.2.2 CMS Output File ID Name Interface
Type Description Subsystems
Impacted System Entry Point
Data Owner
555 Buy-in Input Data
File The Buy-in Input file is sent to CMS through the Commonwealth Data Center. The original input file is created by HMS and sent to interChange through Commonwealth Data Center. The file is used to update interChange Buy-in Data, then forwarded to CMS.
Buy-in CMS HMS
381 EDB Finder File The Eligibility Database finder file is created and sent to CMS through the Commonwealth Data Center
Buy-in CMS interChange
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Buy-in Input Data
CMS through Commonwealth Data Center
Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com During the day contact Cliff Robey at (502) 564-5183. After hours call (502) 564-7946
EDB Finder CMS through Commonwealth Data Center
Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com During the day contact Cliff Robey at (502) 564-5183. After hours call (502) 564-7946
Name Destination System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Buy-in Input Data CMS through Commonwealth Data Center
Flat file FTP Monthly Fixed width
120 Batch BUYJM603 buy_a_send_pcg_ccyymmdd_hhmmss.dat
EDB Finder CMS through Commonwealth Data Center
Flat file FTP Monthly Fixed width
80 Batch ELGJM153 buym_edbfinder_ccyymmdd_hhmmss.dat
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2.1.2.2.1 Buy-in Input Data The Buy-in Input Part A and Input Part B files are created by HMS and sent to the interChange through Commonwealth Data Center including the Commonwealth Data Center EDI Environment. The interChange (ODC) EDI Environment is the point of entry into interChange. In interChange the buy-in tables are updated and reports are produced. Then the file is sent to CMS through the Commonwealth Data Center.
Buy-in Input Record Layout can be found on the PWB Tech Design Buyin Data Maintenance Input/Output Files PCG Modified CMS Layouts
2.1.2.2.2 EDB Finder InterChange sends the EDB (Eligibility Data Base) Finder file to CMS through the Commonwealth Data Center using the interChange (ODC) EDI environment and Commonwealth Data Center EDI environment.
EDB Record Layout can be found on the PWB Tech Design Buyin Data Maintenance Input/Output Files EDS EDB file layout
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2.1.2.3 First Health KMAA Output File ID Name Interface
Type Description Subsystems
Impacted System Entry Point
Data Owner
598 Buy-in Updates
File Buy-in Updates are sent to First Health KMAA to reflect any Buy-in Data changes in interChange.
Buy-in FIQM InterChange
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Buy-in Updates FIQM Bob Gaston (804) 527-5745 BGaston@fhsc.comBill Ponder (502) 209-3145 Bill.Ponder@eds.com
Contact Bob Gaston, if unreachable, call 800-453-8780, option 3, category – applications, type – FIQM, item – Data Loads/Extracts
Name Destination System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Buy-in Updates FIQM Flat file FTP Daily Fixed width 120 Batch BUYJD603 buyd_actions_ccyymmdd_hhmmss.dat
2.1.2.3.1 Buy-in Updates Buy-in Data adds and changes are sent to KMAA.
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Buy-in Update Header Detail and Trailer Record Layout can be found on the PWB Tech Design Buyin Data Maintenance Input/Output Files KMAA extract file
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2.1.2.4 HMS Input File Id Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
568 Medicare Entitlement
File Medicare Entitlement Data is sent to interChange from HMS in an EDB layout. It is used to update interChange Buy-in Data. Two update reports are created and sent directly to HMS.
Buy-in interChange HMS
Name Source System
Source Contact Name
Source Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Medicare Entitlement
HMS Chris Sallee (704) 372-9384 ext 8117
CSallee@Hmsy.com Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Chris Sallee. After hours, dial the HMS Help Desk, (866) 857-0089
Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Medicare Entitlement
HMS Flat file FTP Request Fixed width 351 Batch ELGJM150 buym_edbreturn_ccyymmdd_hhmmss.dat
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2.1.2.4.1 Medicare Entitlement The Medicare Entitlement file is sent by HMS to interChange for processing. The Entitlement Update process creates 2 reports that are sent to HMS using FTP.
Medicare Entitlement Record Layout can be found on the PWB Tech Design Buyin Data Maintenance Input/Output Files CMS EDB file layout
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2.2 Claims Functional Area
2.2.1 Claims Interface Diagram A context diagram for entities within the functional area is shown below.
Providers
HMSPBA
Passport
COBC
interChange
Transportation Cabinet
Passport Advantage
McKesson
DMS
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2.2.2 Claims Entities Name Description
COBC CMS Medicare Coordination of Benefits Contractor, Group Health Incorporated (GHI)
DMS Kentucky CHFS Department for Medicaid Services
McKesson McKesson ClaimCheck
Passport Passport Health Plan – Medicaid Managed Care
Passport Advantage Passport Advantage – Medicare Advantage HMO Plan
PBA First Health Pharmacy Benefits Administrator
HMS Health Management Systems
Providers Medicaid Healthcare Providers
Transportation Kentucky Transportation Cabinet
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2.2.2.1 COBC Input File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
450 Crossover Claims File Medicare Claims that “cross over” to Medicaid are transmitted to interChange via the CMS Coordination of Benefits Contractor.
Claims interChange COBC
Name Source System
Source Contact Name
Source Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Crossover Claims
COBC Becky Able (803) 772-0911 beckyable1@aol.com Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact COBC Help Desk Technical Support at (212) 615-4357
Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Crossover Claims COBC Flat file FTP Daily X12 N/A Batch X12 837I PCOB.BA.N0944.PARTA.sssssss
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2.2.2.1.1 Crossover Claims The COBC sends 837 Crossover batches to interChange where they are translated by BizTalk and then processed.
File Structures
The COBC will send ANSI X12N 837 standard transactions to interChange. Consult the following HIPAA implementation guides for more information.
• Health Care Claim: Institutional ASC X12N 837 (004010X096A1) National EDI Transaction Set Implementation Guide
• Health Care Claim: Professional ASC X12N 837 (004010X098A1) National EDI Transaction Set Implementation Guide
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2.2.2.2 DMS Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
504 ICF/MR Claims File Claim statistics for Provider type 11 – text file for spreadsheet import Provider, Claims interChange
503 Nursing Facilities Claims
File Claim statistics for Provider type 12 – text file for spreadsheet import Provider, Claims interChange
636 Ineligible Crossover Claims
File Medicare Part A Pharmacy Crossover Claims for members who have Nursing Facility claims in the same dates of service span (two files are created for spreadsheet import: a preliminary file and a follow-up file). These files are used to create letters.
Provider, Claims interChange
659 Preventive Service Claims
File Claim statistics for Preventive Services Providers (units and amounts paid by provider and procedure code) – text file for spreadsheet import
Provider, Claims interChange
Name Destination
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
ICF/MR Claims DMS Frances Wise (502) 564-5707 Frances.Wise@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Frances Wise
Nursing Facilities Claims
DMS Frances Wise (502) 564-5707 Frances.Wise@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Frances Wise
Ineligible Crossover Claims
DMS Evette Patton (502) 564-1012 Evette.Patton@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Evette Patton
Preventive Service Claims
DMS Patty Sewell (502) 564-6511 PJSewell@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Patty Sewell
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Name Destination Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
ICF/MR Claims DMS Flat file CD Monthly Fixed width 200 Batch DSSJMDM4 DSS-9938-M
Nursing Facilities Claims
DMS Flat file CD Monthly Fixed width 200 Batch DSSJMDM3 DSS-9936-M
Ineligible Crossover Claims
DMS Flat file CD Quarterly Fixed width 427 Batch DSSJMDQ3 DSS-9939-Q
Preventive Service Claims
DMS Flat file CD Quarterly Fixed width 185 Batch DSSJMDM5 DSS-9935-M
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2.2.2.2.1 ICF/MR Claims Monthly claim data is extracted and summarized by ICF/MR provider, formatted as a delimited field import file and imported to ONBASE where an ONBASE client user can view or download.
Detail and Summary Record Layout can be found on the PWB Tech Design Data Warehouse Input/Output Files ICFMR Claims Interface Layout
2.2.2.2.2 Nursing Facilities Claims Monthly claim data is extracted and summarized by Nursing Facilities provider, formatted as a delimited field import file and imported to ONBASE where an ONBASE client user can view or download.
Detail and Summary Record Layout can be found on the PWB Tech Design Data Warehouse Input/Output Files Nursing Facilities Claims Interface Layout
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2.2.2.2.3 Ineligible Crossover Claims Medicare Part A Pharmacy Crossover Claims are extracted quarterly for members who have Nursing Facility claims in the same dates of service. The data is extracted into two files, a preliminary file and a follow-up file. They are formatted as delimited field import files and imported to ONBASE where an ONBASE client user can view or download.
Header and Detail Record (both files) can be found on the PWB Tech Design Data Warehouse Input/Output Files Ineligible Part A Crossover Claims Layout
2.2.2.2.4 Preventive Services Claims Monthly claim data is extracted and summarized by Preventive Services Providers and procedure code, formatted as a delimited field import file and imported into ONBASE where an ONBASE client user can view or download the data.
Header and Detail Records can be found on the PWB Tech Design Data Warehouse Input/Output Files Preventive Service Layout
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2.2.2.3 First Health PBA Input File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
421 Pharmacy Claims File Pharmacy Claims from First Health Pharmacy Benefits Administrator
Claims interChange PBA
Name Source System
Source Contact Name
Source Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Pharmacy Claims
PBA Bruce Slough (804) 934-4247 Bruce.Slough@firsthealth.com
Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Bruce Slough or Steve Elkins (ElkinsSt@fhsc.com) (804) 317-1991, if unreachable, call 800-453-8780, option 3, category – applications, type – First RX, item – Extract-claims
Name Source System Transaction Type
Transmission Type
Frequency Record Format Record length
Batch or Real-time
Job Name File Name
Pharmacy Claims PBA Flat file FTP Every two weeks
NCPDP Batch 1.1 N/A Batch NCPDP kym_batch11_ccyymmdd_hhmmss.dat
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2.2.2.3.1 Pharmacy Claims Adjudicated pharmacy claims are sent using NCPDP Batch version 1.1 via FTP from the PBA to the MMIS every other Friday.
Pharmacy claims will be formatted as a pharmacy encounter batch using the NCPDP batch version 1.1 standard. Consult the NCPDP Version 1 Release 1 Batch Standard Batch Implementation Guide (January 2000) and the NCPDP Version 1 Release 1 Batch Transaction Standard (January 2000) for more information.
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2.2.2.4 First Health PBA Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point Data Owner
627 Non-pharmacy claims
File Monthly Claims extracts excluding pharmacy Claims PBA Claims
425 J-code Claims File Quarterly Claims extract for J-code procedures used for Drug Rebate
Claims PBA Claims
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Non-pharmacy Claims
PBA Bruce Slough (804) 934-4247 Bruce.Slough@firsthealth.com
Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Bruce Slough or Steve Elkins (ElkinsSt@fhsc.com) (804) 317-1991, if unreachable, call 800-453-8780, option 3, category – applications, type – First RX, item – Extract-claims
J-code Claims PBA Bruce Slough (804) 934-4247 Bruce.Slough@firsthealth.com
Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Bruce Slough or Steve Elkins (ElkinsSt@fhsc.com) (804) 317-1991, if unreachable, call 800-453-8780, option 3, category – applications, type – First RX, item – Extract-claims
Name Destination System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Non-pharmacy Claims
PBA Flat file Tape Monthly Fixed width 626 Batch DSSJMFH3 first_health_pba_ub92_claims_detail_ccyymmdd_hhmmss.dat
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Name Destination System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
J-code Claims PBA Flat file Tape Quarterly Fixed width 283 Batch DSSJQ160 first_health_pba_jcode_ccyymmdd_hhmmss.dat
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2.2.2.4.1 Non-pharmacy Claims Monthly claim data is extracted from interChange, excluding pharmacy claims. The file is sent to the PBA through the interChange (ODC) EDI environment. The file will contain three different layouts, one for professional, one for institutional and one for dental.
Professional Claim, Institutional Claim and Dental Claim Record Layouts can be found on the PWB Tech Design Data Warehouse Input/Output Files First Health Paid Claims Layout
2.2.2.4.2 J-code Claims Claim data is extracted quarterly for claims with J-code procedures. This data will be sent via FTP to the PBA.
J-code claim Record Layout can be found on the PWB Tech Design Data Warehouse Input/Output Files First Health J Code Claims Layout
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2.2.2.5 McKesson Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
643 Dental Claims File Dental Claims extracted for input into McKesson ClaimCheck. The Dental Claim Check module is not available in a non-mainframe version so dental claims are sent daily to the McKesson mainframe for processing and reporting.
Claims ClaimCheck interChange
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Dental Claims ClaimCheck Sarah Hawkins
(303) 346-7787 Sarah.Hawkins@McKesson.com
Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Sarah Hawkins
Name Destination System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Dental Claims ClaimCheck Flat file FTP Weekly Fixed width 2530 Batch CLMJDI20 CGMPRD.CCDEK.FTP.TRANSIN
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2.2.2.5.1 Dental Claims Claims data for dental claims will be extracted and transmitted to McKesson using the interChange (ODC) EDI Environment to facilitate the file transfer.
McKesson claim extract layout can be found on the PWB Tech Design Claims Input/Output Files output – McKesson ClaimCheck Dental File
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2.2.2.6 Passport Input File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
542 Professional Encounters
File Region 3 Managed Care Encounter batch file from the Passport Health Plan
Claims interChange Passport
540 Institutional Encounters
File Region 3 Managed Care Encounter batch file from the Passport Health Plan
Claims interChange Passport
541 Dental Encounters File Region 3 Managed Care Encounter batch file from the Passport Health Plan
Claims interChange Passport
528 Pharmacy Encounters
File Region 3 Managed Care Encounter batch file from the Passport Health Plan
Claims interChange Passport
Name Source System
Source Contact Name
Source Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Professional Encounters
Passport Gail Gatto (215) 937-8474 Gail.Gatto@kmhp.comBill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Gail or after hours contact EDI Help Desk at (215) 937-8473
Institutional Encounters
Passport Gail Gatto (215) 937-8474 Gail.Gatto@kmhp.comBill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Gail or after hours contact EDI Help Desk at (215) 937-8473
Dental Encounters
Passport Gail Gatto (215) 937-8474 Gail.Gatto@kmhp.comBill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Gail or after hours contact EDI Help Desk at (215) 937-8473
Pharmacy Encounters
Passport Gail Gatto (215) 937-8474 Gail.Gatto@kmhp.comBill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Gail or after hours contact EDI Help Desk at (215) 937-8473
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Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Professional Encounters
Passport Flat file FTP Request 837P N/A Batch X12 837P KYW837PR_0_ccyymmdd.hhmmss.X12
Institutional Encounters
Passport Flat file FTP Request 837I N/A Batch X12 837I KYW837IN_0_ccyymmdd.hhmmss.X12
Dental Encounters Passport Flat file FTP Request 837D N/A Batch X12 837D KYW837DE_0_ccyymmdd.hhmmss.X12 r
Pharmacy Encounters
Passport Flat file FTP Request NCPDP Batch 1.1
N/A Batch NCPDP KYWNCPDP_0_ccyymmdd.hhmmss.X12
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2.2.2.6.1 Professional Claims Passport sends 837P batch files to the MMIS via FTP. The files are checked for HIPAA compliance. If compliant a 997 file is sent back to Passport. If compliant, the 837 file is translated by BizTalk into XML and processed. If there are any transaction errors, they will be sent by interChange in an XML format to BizTalk to be translated into an unsolicited 277 transaction batch and sent back to Passport.
Passport will send ANSI X12N 837 standard transactions to interChange. Consult the following HIPAA implementation guide for more information.
• Health Care Claim: Professional ASC X12N 837 (004010X098A1) National EDI Transaction Set Implementation Guide
o Appendix B EDI Control Directory - B.2 Functional Acknowledgment Transaction Set, 997
• Health Care Payer Unsolicited Claims Status ANSI ASC X12.317 277 (003070X070) National EDI Transaction Set Implementation Guide
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2.2.2.6.2 Institutional Claims Passport sends 837I batch files to the MMIS via FTP. The files are checked for HIPAA compliance. If compliant a 997 file is sent back to Passport. If compliant, the 837 file is translated by BizTalk into XML and processed. If there are any transaction errors, they will be sent by interChange in an XML format to BizTalk to be translated into an unsolicited 277 transaction batch and sent back to Passport.
Passport will send ANSI X12N 837 standard transactions to interChange. Consult the following HIPAA implementation guides for more information.
• Health Care Claim: Institutional ASC X12N 837 (004010X096A1) National EDI Transaction Set Implementation Guide
o Appendix B EDI Control Directory - B.2 Functional Acknowledgment Transaction Set, 997
• Health Care Payer Unsolicited Claims Status ANSI ASC X12.317 277 (003070X070) National EDI Transaction Set Implementation Guide
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2.2.2.6.3 Dental Claims Passport sends 837D batch files to the MMIS via FTP. The files are checked for HIPAA compliance. If compliant a 997 file is sent back to Passport. If compliant, the 837 file is translated by BizTalk into XML and processed. If there are any transaction errors, they will be sent by interChange in an XML format to BizTalk to be translated into an unsolicited 277 transaction batch and sent back to Passport.
Passport will send ANSI X12N 837 standard transactions to interChange. Consult the following HIPAA implementation guides for more information.
• Health Care Claim: Dental ASC X12N 837 (004010X097A1) National EDI Transaction Set Implementation Guide
o Appendix B EDI Control Directory - B.2 Functional Acknowledgment Transaction Set, 997
• Health Care Payer Unsolicited Claims Status ANSI ASC X12.317 277 (003070X070) National EDI Transaction Set Implementation Guide
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2.2.2.6.4 Pharmacy Claims Passport sends NCPDP batch files to the MMIS via FTP. The files are checked for compliance. If compliant an NCPDP acknowledgement file is sent back to Passport. If compliant, the NCPDP file is translated by interChange (ODC) EDI into XML and processed. If there are any transaction errors, they will be sent by interChange in an XML format to BizTalk to be translated into an unsolicited 277 transaction batch and sent back to Passport.
Pharmacy claims will be formatted as a pharmacy encounter batch using the NCPDP batch version 1.1 standard. Consult the NCPDP Version 1 Release 1 Batch Standard Batch Implementation Guide (January 2000) and the NCPDP Version 1 Release 1 Batch Transaction Standard (January 2000) for more information.
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2.2.2.7 Passport Advantage Input File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
543 Crossover Claims File Passport Advantage is a Medicare Advantage HMO Plan (Part C). Certain claim types that Passport Advantage will process are not part of the COBC as a crossover. Passport Advantage will send those crossover claims to interChange
Claims interChange Passport Advantage
Name Source System
Source Contact Name
Source Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Crossover Claims Passport Advantage
Donna Everwine (215) 937-8695 Donna.Everwine@kmhp.com
Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Donna or after hours contact EDI Help Desk at (215) 937-8473
Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Crossover Claims Passport Advantage Flat file FTP Request 837 N/A Batch FTS PASSMTPLmmyy.txt
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2.2.2.7.1 Crossover Claims Passport Advantage will send 837 Crossover batches to interChange where they are translated by BizTalk and then processed. A 997 file is sent back when the 837 file passes HIPAA compliance.
Passport will send ANSI X12N 837 standard transactions to interChange. Consult the following HIPAA implementation guides for more information.
• Health Care Claim: Institutional ASC X12N 837 (004010X096A1) National EDI Transaction Set Implementation Guide
o Appendix B EDI Control Directory - B.2 Functional Acknowledgment Transaction Set, 997
• Health Care Claim: Professional ASC X12N 837 (004010X098A1) National EDI Transaction Set Implementation Guide
o Appendix B EDI Control Directory - B.2 Functional Acknowledgment Transaction Set, 997
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2.2.2.8 HMS Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point Data Owner
555 Paid Claims File Paid claims file extract for HMS Claims HMS interChange
Name Destination System
Destination Contact Name
Source Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Paid Claims HMS Chris Sallee (704) 372-9384 ext 8117
CSallee@Hmsy.com Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Chris Sallee. After hours, dial the HMS Help Desk, (866) 857-0089
Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Paid Claims HMS Flat file FTP Monthly Fixed width 436 Batch BUYJM603 buy_a_send_pcg_ccyymmdd_hhmmss.dat
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2.2.2.8.1 Paid Claims Monthly paid claim data is extracted and sent to HMS using the interChange (ODC) EDI Environment to facilitate the file transfer.
Professional Claim, Institutional Claim and Dental Claim Record Layouts can be found on the PWB Tech Design Data Warehouse Input/Output Files HMS Layout
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2.2.2.9 Transportation Cabinet Input File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
362 Encounters File Non-emergency transportation encounters are sent to interChange from the Transportation Cabinet
Claims interChange Transportation Cabinet
Name Source System
Source Contact Name
Source Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Encounters Transportation Cabinet
Jeremy Thompson
(502) 564-7433 Jeremy.Thompson@ky.gov
Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Larry Pilcher (502) 564-8900
Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Encounters Transportation Cabinet Flat file FTP Request NSF 320 Batch NSF DT.AIS.P300.A1845.ENC
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2.2.2.9.1 Encounters The Transportation Cabinet sends a batch file of non-emergency transportation encounters to interchange in NSF format. A proprietary response file is sent back. The file is translated into claims xml and sent to InterChange for processing.
NSF Claim File Record Layout can be found on the PWB Tech Design EDI and Claim Capture Input/Output Files NET Encounter Spec and the Response File Record Layout can be found on the PWB Tech Design EDI and Claim Capture Input/Output Files Transportation Encounter Response
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2.3 Data Warehouse Functional Area Interfaces
2.3.1 Data Warehouse Interface Diagram A context diagram for entities within the functional area is shown below.
2.3.2 Data Warehouse Entities Name Description
eKASPER Kentucky All Schedule Prescription Electronic Reporting
KASES Kentucky Automated Support and Enforcement System
KAMES Kentucky Automated Management and Eligibility System
IPRO Health Care Quality Review and Improvement Organization
Navigant Navigant Consulting, Inc
PwC PricewaterhouseCoopers
Vital Statistics Kentucky CHFS Office of Vital Statistics
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2.3.2.1 eKASPER Input File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
725 Member Eligibility File Member Eligibility Information DSS eKASPER interChange
Name Source System
Source Contact Name
Source Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Member Eligibility eKASPER Michael Smithson
(502) 564-7985 ext 3829
Michael.Smithson@ky.gov
Marilynn Hartman
(502) 209-3128 Marilynn.Hartman@eds.com
Contact Michael Smithson, then Ashish Virmani 502-564-6479 x4547
Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Member Eligibility eKASPER Flat file FTP Monthly Fixed width 347 Batch DSSJWIKM ekasper_member_rx_ccyymmdd_hhmmss.dat
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2.3.2.1.1 Member Eligibility eKASPER will extract the data and send it to interChange Data Warehouse via secure FTP.
Member Eligibility Record Layout can be found on the PWB Tech Design Data Warehouse Input/Output Files eKASPER Layout
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2.3.2.2 eKASPER Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point Data Owner
807 Member Eligibility File Member Eligibility Information DSS eKASPER interChange
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Member Eligibility eKASPER Michael Smithson
(502) 564-7985 ext 3829
Michael.Smithson@ky.gov
Marilynn Hartman
(502) 209-3128 Marilynn.Hartman@eds.com
Contact Michael Smithson
Name Destination
System Transaction Type Transmis
sion TypeFrequency Record Format Record length Batch or Real-
time Job Name File Name
Weekly, Member Eligibility
eKASPER Flat file FTPS
Friday
Fixed width 181 Batch DSSJWOKM ekasper_member_req_ccyymmdd_hhmmss
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2.3.2.2.1 Member Eligibility The interChange Data Warehouse will extract the data and send it to eKASPER via secure FTP.
Member Eligibility Record Layout can be found on the PWB Tech Design Data Warehouse Input/Output Files eKASPER Layout
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2.3.2.3 IPRO Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
397 Managed Care Eligibility File Managed Care Eligibility Data DSS IPRO interChange
673 Encounter Files File Encounter Files by claim type DSS IPRO interChange
674 Provider File Provider Extract DSS IPRO interChange
675 Drug Codes File Pharmacy Extract DSS IPRO interChange
741 Procedure Codes File Procedure Codes Extract DSS IPRO interChange
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address Escalation Procedure
Managed Care Eligibility
IPRO Chuck Merlino (516) 326-7767 ext 334
cmerlino@ipro.org Marilynn Hartman
(502) 209-3128 Marilynn.Hartman@eds.com Contact Chuck Merlino
Encounter Files IPRO Chuck Merlino (516) 326-7767 ext 334
cmerlino@ipro.org Marilynn Hartman
(502) 209-3128 Marilynn.Hartman@eds.com Contact Chuck Merlino
Provider IPRO Chuck Merlino (516) 326-7767 ext 334
cmerlino@ipro.org Marilynn Hartman
(502) 209-3128 Marilynn.Hartman@eds.com Contact Chuck Merlino
Drug Codes IPRO Chuck Merlino (516) 326-7767 ext 334
cmerlino@ipro.org Marilynn Hartman
(502) 209-3128 Marilynn.Hartman@eds.com Contact Chuck Merlino
Procedure Codes IPRO Chuck Merlino (516) 326-7767 ext 334
cmerlino@ipro.org Marilynn Hartman
(502) 209-3128 Marilynn.Hartman@eds.com Contact Chuck Merlino
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Name Destination System
Transaction Type
Transmission Type
Frequency Record Format
Record length Batch or Real-time
Job Name File Name
Monthly, Managed Care Eligibility
IPRO Flat file FTPS
Last Friday
Fixed width 120 Batch DSSJOIP2 ipro_elig_ccyymmdd_hhmmss.dat
Monthly, Encounter Files IPRO Flat file FTPS
Last Friday
Fixed width 831 Batch DSSJOIP4 ipro_enc_ccyymmdd_hhmmss.dat
Monthly, Provider IPRO Flat file FTPS
Last Friday
Fixed width 407 Batch DSSJOIP5 ipro_prov_ccyymmdd_hhmmss.dat
Monthly, Drug Codes IPRO Flat file FTPS
Last Friday
Fixed width 61 Batch DSSJOIP3 ipro_phar_ccyymmdd_hhmmss.dat
Monthly, Procedure Codes
IPRO Flat file FTPS
Last Friday
Fixed width 70 Batch DSSJOIP1 ipro_dent_ccyymmdd_hhmmss.dat
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2.3.2.3.1 Managed Care Eligibility The interChange Data Warehouse will extract the data and send it to IPRO via FTP.
Managed Care Eligibility Record Layout can be found on the PWB Tech Design Data Warehouse Input/Output Files IPRO Extract Layout
2.3.2.3.2 Encounter Files The interChange Data Warehouse will extract the data and send it to IPRO via FTP.
Professional Encounter Record Layout can be found on the PWB Tech Design Data Warehouse Input/Output Files IPRO Extract Layout
Inpatient Encounter Record Layout can be found on the PWB Tech Design Data Warehouse Input/Output Files IPRO Extract Layout
Outpatient Encounter Record Layout can be found on the PWB Tech Design Data Warehouse Input/Output Files IPRO Extract Layout
Dental Encounter Record Layout can be found on the PWB Tech Design Data Warehouse Input/Output Files IPRO Extract Layout
Pharmacy Encounter Record Layout can be found on the PWB Tech Design Data Warehouse Input/Output Files IPRO Extract Layout
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2.3.2.3.3 Provider The interChange Data Warehouse will extract the data and send it to IPRO via FTP.
Provider Record Layout can be found on the PWB Tech Design Data Warehouse Input/Output Files IPRO Extract Layout
2.3.2.3.4 Drug Code The interChange Data Warehouse will extract the data and send it to IPRO via FTP.
Drug Code Record Layout can be found on the PWB Tech Design Data Warehouse Input/Output Files IPRO Extract Layout
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2.3.2.3.5 Procedure Code The interChange Data Warehouse will extract the data and send it to IPRO via FTP.
Procedure Code Record Layout can be found on the PWB Tech Design Data Warehouse Input/Output Files IPRO Extract Layout
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2.3.2.4 Navigant Output File ID Name Interface Type Description Subsystems Impacted System Entry Point Data Owner
732 Inpatient Claims File This is an Inpatient Claims extract used by Navigant for DRG Rate Setting
DSS Navigant interChange
396 Outpatient Claims File This is an Outpatient Claims extract used by Navigant for DRG Rate Setting
DSS Navigant interChange
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Inpatient Claims DSS James Petterson (206) 292-2385 Marilynn Hartman
(502) 209-3128 Marilynn.Hartman@eds.com
Contact James Petterson
Outpatient Claims DSS James Petterson (206) 292-2385 Marilynn Hartman
(502) 209-3128 Marilynn.Hartman@eds.com
Contact James Petterson
Name Destination System
Transaction Type
Transmission Type
Frequency Record Format Record length Batch or Real-time
Job Name File Name
Inpatient Claims
DSS Flat file FTP Monthly, last Friday
Variable 684 Batch DSSJONAV navigant.ah_in_li_ccyymmdd_hhmmss.dat
Outpatient Claims
DSS Flat file FTP Monthly, last Friday
Variable 601 Batch DSSJONAV navigant.ah_out_li_ccyymmdd_hhmmss.dat
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2.3.2.4.1 Inpatient Claims The interChange Data Warehouse will extract the data and send it to Navigant via FTP.
Navigant Inpatient Extract Layout can be found on the PWB Tech Design Data Warehouse Input/Output Files Navigant Layout
2.3.2.4.2 Outpatient Claims The interChange Data Warehouse will extract the data and send it to Navigant via FTP.
Navigant Outpatient Extract Layout can be found on the PWB Tech Design Data Warehouse Input/Output Files Navigant Layout
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2.3.2.5 PricewaterhouseCoopers Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
394 Budget Forecast Data
File This is an extract of financial data used by PwC for budget forecasting DSS PwC interChange
795 Managed Care Rate Setting
File This is an extract of financial data used by PwC for setting rates for the Passport Health Plan
DSS PwC interChange
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address Escalation Procedure
Budget Forecast Data
DSS Vanessa Sam (415) 498-5616 Vannessa.O.Sam@us.pwc.com
Marilynn Hartman
(502) 209-3128 Marilynn.Hartman@eds.com Contact Vanessa Sam
Managed Care Rate Setting
DSS Vanessa Sam (415) 498-5616 Vannessa.O.Sam@us.pwc.com
Marilynn Hartman
(502) 209-3128 Marilynn.Hartman@eds.com Contact Vanessa Sam
Name Destination System
Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Budget Forecast Data
DSS Flat file FTP Request Fixed width 108 Batch DSSJOPW1 pwc_clms_ccyymmdd_hhmmss.dat
Managed Care Rate Setting
DSS Flat file FTP Request Fixed width 56 Batch DSSJOPW1 pwc_pp_hh_ccyymmdd_hhmmss.dat
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2.3.2.5.1 Budget Forecast Data The interChange Data Warehouse will extract the data and send it to PricewaterhouseCoopers through the interChange (ODC) EDI Environment.
PwC Data Record Layout can be found on the PWB Tech Design Data Warehouse Input/Output Files PwC Budget Forecasting Layout
2.3.2.5.2 Managed Care Data The interChange Data Warehouse will extract the data and send it to PricewaterhouseCoopers through the interChange (ODC) EDI Environment.
Managed Care Data Record Layout can be found on the PWB Tech Design Data Warehouse Input/Output Files PwC Passport Rating Layout
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2.3.2.6 Vital Statistics Input File ID Name Interface Type Description Subsystems
Impacted System Entry Point Data Owner
680 Date of Death File File Date of Death File DSS DSS interChange
679 Date of Birth File File Date of Birth File DSS DSS interChange
Name Source System
Source Contact Name
Source Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Date of Death File
Vital Stats Rebekah Collins (502) 564-0105 ext 10506
Rebekah.Collins@ky.gov
Marilynn Hartman (502) 209-3128 Marilynn.Hartman@eds.com
Call Rebekah Collins
Date of Birth File Vital Stats Rebekah Collins (502) 564-0105 ext 10506
Rebekah.Collins@ky.gov
Marilynn Hartman (502) 209-3128 Marilynn.Hartman@eds.com
Call Rebekah Collins
Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Date of Death File Vital Stats Flat file FTP Request Fixed width 230 Batch DSSJMVSD death_record_ccyymmdd_hhmmss.txt
Date of Birth File Vital Stats Flat file FTP Request Fixed width 448 Batch DSSJMVSB birth_record_ccyymmdd_hhmmss.dat
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2.3.2.6.1 Date of Death File Vital Stats will extract the data and send it to interChange Data Warehouse via FTP.
Date of Death Record Layout can be found on the PWB Tech Design Data Warehouse Input/Output Files Vital Statistics Death_Birth File Layout
2.3.2.6.2 Date of Birth File Vital Stats will extract the data and send it to interChange Data Warehouse via secure FTP.
Date of Birth Record Layout can be found on the PWB Tech Design Data Warehouse Input/Output Files Vital Statistics Death_Birth File Layout
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2.4 EPSDT Functional Area Interfaces
2.4.1 EPSDT Interface Diagram A context diagram for entities within the functional area is shown below.
2.4.2 EPSDT Entities Name Description
CDP Custom Data Processing, Inc
2.4.2.1 CDP Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
628 EPSDT Cases File This is an EPSDT case load extract of claims for members under 21
DSS CDP interChange
415 EPSDT Eligibility File This is an extract of EPSDT members under 21 DSS CDP interChange
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
EPSDT Cases CDP Mike Combs (866) 237-4814 MikeCombs@cdp-ky.com
Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Call Mike Combs
EPSDT Eligibility CDP Mike Combs (866) 237-4814 MikeCombs@cdp-ky.com
Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Call Mike Combs
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Name Destination System
Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
EPSDT Cases CDP Flat file CD Every other month, first work day
Fixed width
324 Batch EPSJMCDP epspcdps_ext_ccyymmdd_hhmmss.dat
EPSDT Eligibility
CDP Flat file CD Monthly, first work day
Fixed width
517 Batch EPSJMCDP epspcdpm_ext_ccyymmdd_hhmmss.dat
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2.4.2.1.1 EPSDT Cases InterChange will extract EPSDT Cases to a file, then send the file to CDP through the interChange (ODC) EDI Environment using FTP.
EPSDT Cases Record Layout can be found on the PWB Tech Design EPSDT Input/Output Files Output – Total EPSDT Member Case Load
2.4.2.1.2 EPSDT Eligibility InterChange will extract EPSDT Members to a file, then send the file to CDP through the interChange (ODC) EDI Environment using FTP.
EPSDT Eligibility Record Layout can be found on the PWB Tech Design EPSDT Input/Output Files Output – New Eligible EPSDT Member File
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2.5 External Data Sharing Functional Area Interfaces
2.5.1 External Data Sharing Interface Diagram A context diagram for entities within the functional area is shown below.
2.5.2 External Data Sharing Entities Name Description
BBS Users Bulletin Board System submitters
Billing Agents Agents who bill health care claims on behalf of a provider
Providers Health care providers providing service to Medicaid members
Software Vendors Software vendors who provide software used in billing health care claims
VAN’s Transaction Service Providers who establish a Value-added Network (VAN) in order to send transactions on the behalf of submitters
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2.5.2.1 Dial-up Input File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
663, 661, Claims File Claims are submitted using the BBS. 997’s are returned in batch mode. The Dial-up User can be a provider, a Billing Agent or Software Vendor.
BBS, RAS, Claims
BBS interChange
Name Source System Source Contact Information EDS Contact Name EDS Contact Phone Number
EDS Contact Email Address Escalation Procedure
Claims Dial-up User Trading Partner Database (Submitter ID Lookup)
EDI Help Desk 800-205-4696 KY_EDI_HelpDesk@eds.com Call EDI Help Desk
Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Claims Dial-up User 837 Dial-up Request 837 X12 n/a Batch X12 837I
X12 837P
837i\tpid_sak.dat
837p\tpid_sak.dat
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2.5.2.1.1 Claims Users dial up the BBS and deliver 837 claim transactions. The 837’s are sent to BizTalk where they are translated and sent to the MMIS for processing. Prior to sending the transactions on to the MMIS, BizTalk sends a 997 acknowledgement back to the user to download. The MMIS will process the claim batch and send back a claim response to BizTalk.
BBS Users will send ANSI X12N 837 standard transactions to interChange. Consult the following HIPAA Implementation Guides for more information.
• Health Care Claim: Dental ASC X12N 837 (004010X097A1) National EDI Transaction Set Implementation Guide
o Appendix B EDI Control Directory - B.2 Functional Acknowledgment Transaction Set, 997
• Health Care Claim: Institutional ASC X12N 837 (004010X096A1) National EDI Transaction Set Implementation Guide
o Appendix B EDI Control Directory - B.2 Functional Acknowledgment Transaction Set, 997
• Health Care Claim: Professional ASC X12N 837 (004010X098A1) National EDI Transaction Set Implementation Guide
o Appendix B EDI Control Directory - B.2 Functional Acknowledgment Transaction Set, 997
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2.5.2.2 Dial-up Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
667 Remittance Advice File Electronic Remittance Advice in the form of a HIPAA 835 transaction is sent from interChange to the BBS for BBS Users to download
BBS, Financial BBS interChange
723 Claims Status File Along with the 835 transactions will come a file of unsolicited 277 transactions showing each claim for a provider that is suspended.
BBS, Financial BBS interChange
Name Source System
Source Contact Information EDS Contact Name EDS Contact Phone Number
EDS Contact Email Address Escalation Procedure
Remittance Advice
BBS Trading Partner Database (BBS Submitter ID Lookup)
EDI Help Desk 800-205-4696 KY_EDI_HelpDesk@eds.com Call EDI Help Desk
Claim Status BBS Trading Partner Database (BBS Submitter ID Lookup)
EDI Help Desk 800-205-4696 KY_EDI_HelpDesk@eds.com Call EDI Help Desk
Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Remittance Advice
BBS 835 Dial-up Weekly 835 X12 n/a Batch X12 835 835\tpid.nnn
Claim Status BBS 277U Dial-up Weekly 277U X12 n/a Batch X12 277U 277\tpid.nnn
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2.5.2.2.1 Remittance Advice InterChange will send remittance advices weekly to the BBS as designated. Within the interChange (ODC) EDI Environment, BizTalk will translate the remittance advice into an 835 and forward it to the BBS where it is available for download by the BBS User.
InterChange will create ANSI X12N 835 standard transactions. Consult the Health Care Claim Payment/Advice ASC X12N 835 (004010X091A1) National EDI Transaction Set Implementation Guide for more information.
2.5.2.2.2 Claim Status InterChange will send claim status for suspended claims weekly to the BBS in conjunction with 835. Within the interChange (ODC) EDI Environment, BizTalk will translate the claim status records into an unsolicited 277 file and forward it to the BBS where it is available for download by the BBS User.
InterChange will create ANSI X12N 277 standard transactions. Consult the Health Care Payer Unsolicited Claims Status ANSI ASC X12.317 277 (003070X070) National EDI Transaction Set Implementation Guide for more information.
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.5.2.3 Provider Internet Input File ID Name Interface Type Description Subsystems Impacted System Entry
Point Data Owner
774 Interactive Claims
File Claims are submitted interactively using the Provider Internet Direct Data Entry. A RAS Server will be in place for dial-up to the same Provider Internet application available through the Internet.
Provider Internet, Claims
Internet interChange
711 Batch Claims File Claims batches (837 batch files) are submitted using the Provider Internet Batch Interface. These can be submitted by a provider, a billing agent or software vendor application. A RAS Server will be in place for dial-up to the same Provider Internet application available through the Internet.
Provider Internet, Claims
Internet interChange
697 Interactive Eligibility Inquiry
File Various eligibility inquiry requests are submitted interactively by providers using Provider Internet, examples are a member id lookup, presumptive eligibility inquiry, service limitations. A RAS Server will be in place for dial-up to the same Provider Internet application available through the Internet.
Provider Internet, Claims
Internet interChange
747 Batch Eligibility Inquiry
File Eligibility inquiry batches (270 batch files) are submitted using the Provider Internet Batch Interface. These can be submitted by a provider, a billing agent or software vendor application. A RAS Server will be in place for dial-up to the same Provider Internet application available through the Internet.
Provider Internet, Claims
Internet interChange
772 Interactive Claim Status Inquiry
File Claims inquiry requests are submitted interactively by providers using Provider Internet. A RAS Server will be in place for dial-up to the same Provider Internet application available through the Internet.
Provider Internet, Claims
Internet interChange
695 Batch Claim Status Inquiry
File Claim status inquiry batches (276 batch files) are submitted using the Provider Internet Batch Interface. These can be submitted by a provider, a billing agent or software vendor application. A RAS Server will be in place for dial-up to the same Provider Internet application available through the Internet.
Provider Internet, Claims
Internet interChange
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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Name Source System
Source Contact Information EDS Contact Name EDS Contact Phone Number
EDS Contact Email Address Escalation Procedure
Interactive Claims Internet Provider Contact Info can be retrieved by Provider ID
EDI Help Desk 800-205-4696 KY_EDI_HelpDesk@eds.com Call EDI Help Desk
Batch Claims Internet Provider Contact Info can be retrieved by Provider ID
EDI Help Desk 800-205-4696 KY_EDI_HelpDesk@eds.com Call EDI Help Desk
Interactive Eligibility Inquiry
Internet Provider Contact Info can be retrieved by Provider ID
EDI Help Desk 800-205-4696 KY_EDI_HelpDesk@eds.com Call EDI Help Desk
Batch Eligibility Inquiry
Internet Provider Contact Info can be retrieved by Provider ID
EDI Help Desk 800-205-4696 KY_EDI_HelpDesk@eds.com Call EDI Help Desk
Interactive Claim Status Inquiry
Internet Provider Contact Info can be retrieved by Provider ID
EDI Help Desk 800-205-4696 KY_EDI_HelpDesk@eds.com Call EDI Help Desk
Batch Claim Status Inquiry
Internet Provider Contact Info can be retrieved by Provider ID
EDI Help Desk 800-205-4696 KY_EDI_HelpDesk@eds.com Call EDI Help Desk
Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Interactive Claims Internet Data Entry HTTPS Request XML n/a Real-time n/a n/a
Batch Claims Internet 837 HTTPS Request 837 X12 n/a Batch PAUJD278 sak.278.xml
Interactive Eligibility Inquiry
Internet Data Entry HTTPS Request XML n/a Real-time n/a n/a
Batch Eligibility Inquiry
Internet 837 HTTPS Request 270 X12 n/a Batch PAUJD278 sak.278.xml
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Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Interactive Claim Status Inquiry
Internet Data Entry HTTPS Request XML n/a Real-time n/a n/a
Batch Claim Status Inquiry
Internet 837 HTTPS Request 276 X12 n/a Batch X12 276/277 276\tpid_sak.dat
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2.5.2.3.1 Interactive Claims Provider internet users submit claims interactively directly to interChange. InterChange responds interactively to the claim submitted.
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2.5.2.3.2 Batch Claims Provider internet users submit an 837 claims batch. The batch is sent to the interChange (ODC) EDI environment where it is translated by BizTalk and sent on to interChange. BizTalk responds with a 997. RAS dial-up users gain access through the RAS Server to Provider Internet to submit claims.
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Internet Users will send ANSI X12N 837 standard transactions to interChange. Consult the following HIPAA Implementation Guides for more information.
• Health Care Claim: Dental ASC X12N 837 (004010X097A1) National EDI Transaction Set Implementation Guide
o Appendix B EDI Control Directory - B.2 Functional Acknowledgment Transaction Set, 997
• Health Care Claim: Institutional ASC X12N 837 (004010X096A1) National EDI Transaction Set Implementation Guide
o Appendix B EDI Control Directory - B.2 Functional Acknowledgment Transaction Set, 997
• Health Care Claim: Professional ASC X12N 837 (004010X098A1) National EDI Transaction Set Implementation Guide
o Appendix B EDI Control Directory - B.2 Functional Acknowledgment Transaction Set, 997
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2.5.2.3.3 Interactive Eligibility Inquiry Provider internet users check member eligibility directly in interChange. InterChange responds interactively to the request. RAS Users gain access to Provider internet by dialing the RAS Server.
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2.5.2.3.4 Batch Eligibility Inquiry Provider internet users submit a 270 eligibility inquiry batch. The batch is sent to the interChange (ODC) EDI environment where it is translated by BizTalk and sent on to interChange. BizTalk responds with a 997. InterChange responds with a 271 batch. Users can gain access to Provider Internet through the dial-up RAS Server.
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Internet Users will send ANSI X12N 270 standard transactions to interChange and will receive back an ANSI X12N 271 standard transaction response. Consult the Health Care Eligibility Benefit Inquiry and Response ASC X12N 270/271 (004010X092A1) National EDI Transaction Set Implementation Guide for more information. Check Appendix B for the 997 transaction set information.
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2.5.2.3.5 Interactive Claim Status Inquiry Provider internet users check the status of a claim directly to interChange. InterChange responds interactively to the request.
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2.5.2.3.6 Batch Eligibility Inquiry Provider internet users submit a 276 claim status inquiry batch. The batch is sent to the interChange (ODC) EDI environment where it is translated by BizTalk and sent on to interChange. BizTalk responds with a 997. InterChange responds with a 277 batch.
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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Internet Users will send ANSI X12N 276 standard transactions to interChange and will receive back an ANSI X12N 277 standard transaction response. Consult the Health Care Claim Status Request and Response ASC X12N 276/277 (004010X093A1) National EDI Transaction Set Implementation Guide for more information.
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2.5.2.4 Provider Output File ID Name Interface
Type Description Subsystems
Impacted System Entry Point
Data Owner
759 Remittance Advice File A Remittance Advice for a provider can be viewed as part of Provider Internet. The RA can be reviewed in report form through an ONBASE web interface. An 835 also can be downloaded for Provider Internet batch claim submitters. RAS Users can gain the same functionality through dial-up with the RAS Server
Provider Internet, Financial
Internet interChange
758 Claim Status File A 277U file is created along with the 835 that can be downloaded for Provider Internet batch claim submitters.
Provider Internet, Financial
Internet interChange
Name Destination System
Destination Contact Information EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address Escalation Procedure
Remittance Advice Internet user Trading Partner Database (BBS Submitter ID Lookup)
EDI Help Desk 800-205-4696 KY_EDI_HelpDesk@eds.com Call EDI Help Desk
Claim Status Internet user Trading Partner Database (BBS Submitter ID Lookup)
EDI Help Desk 800-205-4696 KY_EDI_HelpDesk@eds.com Call EDI Help Desk
Name Destination System Transaction Type
Transmission Type
Frequency Record Format Record length
Batch or Real-time
Job Name File Name
Remittance Advice Internet user 835 HTTPS Weekly 835 X12 n/a Batch X12 835 835\tpid_sak.dat
Claim Status Internet user 277 HTTPS Weekly 277 X12 n/a Batch X12 277U 277u\tpid_sak.dat
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2.5.2.4.1 Remittance Advice Remittance Advice reports are loaded weekly into ONBASE. Provider Internet users can view or download the remittance advice, made possible by an ONBASE API that runs on the Provider Internet server. Batch 835 files can also be downloaded from Provider Internet if 835’s are requested by the provider. RAS Users have the same functionality after dialing up the RAS Server and connecting to Provider Internet.
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InterChange will create ANSI X12N 835 standard transactions. Consult the Health Care Claim Payment/Advice ASC X12N 835 (004010X091A1) National EDI Transaction Set Implementation Guide for more information.
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2.5.2.4.2 Claim Status InterChange will send claim status for suspended claims weekly to Provider Internet in conjunction with 835. Within the interChange (ODC) EDI Environment, BizTalk will translate the claim status records into an unsolicited 277 file and forward it to Provider Internet where it is available for download by the Internet User.
InterChange will create ANSI X12N 277 standard transactions. Consult the Health Care Payer Unsolicited Claims Status ANSI ASC X12.317 277 (003070X070) National EDI Transaction Set Implementation Guide for more information.
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2.5.2.5 VAN Input File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
572 - 577
Eligibility Inquiry X12 Transaction Service Providers use a Value-added network (VAN) to submit HIPAA 270 eligibility inquiry transactions. A 271 response transaction is returned interactively
BizTalk, Member BizTalk interChange
572-577 Claim Status Inquiry
X12 Transaction Service Providers use a Value-added network (VAN) to submit HIPAA 276 claim status inquiry transactions. A 277 response transaction is returned interactively.
BizTalk, Member BizTalk interChange
Name Source System
Source Contact Information EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address Escalation Procedure
Eligibility Inquiry BizTalk Trading Partner Database (BBS Submitter ID Lookup), contact for trading partner id may be the health care provider or the transaction service provider
EDI Help Desk 800-205-4696 KY_EDI_HelpDesk@eds.com Call EDI Help Desk
Claim Status Inquiry
BizTalk Trading Partner Database (BBS Submitter ID Lookup), contact for trading partner id may be the health care provider or the transaction service provider
EDI Help Desk 800-205-4696 KY_EDI_HelpDesk@eds.com Call EDI Help Desk
Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length Batch or Real-time
Job Name File Name
Eligibility Inquiry BizTalk 270 Sockets Request 270 X12 n/a Real-time X12 270/271 interactive
Claim Status Inquiry BizTalk 276 Sockets Request 276 X12 n/a Real-time X12 276/277 interactive
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2.5.2.5.1 Eligibility Inquiry Transaction Service Providers use their VAN to send interactive eligibility transactions formatted in an X12 270 transaction using an IP socket connection. The response is sent back formatted in an X12 271 transaction.
The Transaction Service Providers will send ANSI X12N 270 standard transactions. InterChange will create ANSI X12N 271 standard transactions. Consult the Health Care Eligibility Benefit Inquiry and Response ASC X12N 270/271 (004010X092A1) National EDI Transaction Set Implementation Guide for more information.
2.5.2.5.2 Claim Status Inquiry Transaction Service Providers use their VAN to send interactive eligibility transactions formatted in an X12 276 transaction using an IP socket connection. The response is sent back formatted in an X12 277 transaction.
The Transaction Service Providers will send ANSI X12N 276 standard transactions. InterChange will create ANSI X12N 277 standard transactions. Consult the Health Care Claim Status Request and Response ASC X12N 276/277 (004010X093A1) National EDI Transaction Set Implementation Guide for more information.
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2.5.2.5.3 VAN Contact List Name Contact Name Contact Phone Number Contact Email Address Contact Address
APS Medical Billing JIm Wheeler (419) 866-6227 ex 6477 jhwheeler@apsmedbill.com APS Medical Billing 5700 Southwyck Boulevard Toledo, Ohio 43614
CDP Don Downs (502) 695-1999 Don.Downs@cdp-ky.com Custom Data Processing 951 Industrial Road Frankfort, KY 40601
Emdeon Richard Medley (615) 565-2273 RMedley@emdeon.com Emdeon Business Services 1283 Murfreesboro Pike Nashville, TN 37217
HDX Rodney Childs (610) 210-1693 Rodney.Childs@siemens.com Healthcare Data Exchange 65 Valley Steam Parkway Malvern, PA 19355
MedAccess Plus Tom Court (812) 923-9354 TECourt@medaccessplus.com MedAccess Plus 123 Town Square Manchester, KY 40962
NEBO Andrew Yaschuk (630) 916-8803 Andrew@nebo.com Nebo Systems Inc. 1 South 376 Summit Ave. Court B Oakbrook Terrace, IL 60181-3985
Norton Healthcare Michael Cook (502) 629-8034 mcook@nortonhealthcare.org Norton Healthcare P.O. Box 35070 Louisville, KY 40232-5070
PHC Pat Chelette (615) 261-2680 Patricia.Chelette@passporthealth.com Passport Health Communications 700 Cool Springs Blvd Suite 450 Franklin, TN 37067
ZirMed Bonita Nelson (502) 779-4387 Bonita.Nelson@zirmed.com ZirMed 626 West Main Street 6th Floor Louisville, KY 40202
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2.6 Financial Functional Area Interfaces
2.6.1 Financial Interface Diagram A context diagram for entities within the functional area is shown below.
Financial Entities
Name Description
IMPACT Plus Behavioral Health Program for Medicaid eligible children
DMS Kentucky CHFS Department for Medicaid Services
eMARS Commonwealth of Kentucky eMARS – Management Administrative & Reporting System
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.6.1.1 IMPACT Plus Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
467 Denials File MHMR EFT Denials extract is sent to the Impact Plus system. Financial IMPACT Plus interChange
468 Refunds File MHMR EFT Refunds extract is sent to the Impact Plus system. Financial IMPACT Plus interChange
469 Transfers File MHMR EFT Transfers file is sent to the Impact Plus system. Financial IMPACT Plus interChange
352 DMH Payments File Payment Extract File for DMH Providers is sent to the Commonwealth Mainframe where it is reviewed by Commonwealth personell prior to being sent to eMARS
Financial Commonwealth Mainframe
interChange
351 DCBS Payments File Payment Extract File for DCBS Providers is sent to the Commonwealth Mainframe where it is reviewed by Commonwealth personell prior to being sent to eMARS
Financial Commonwealth Mainframe
interChange
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Denials IMPACT Plus Victor Eleazor (502) 564-4797 Victor.Eleazor@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Victor Eleazor
Refunds IMPACT Plus Victor Eleazor (502) 564-4797 Victor.Eleazor@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Victor Eleazor
Transfers IMPACT Plus Victor Eleazor (502) 564-4797 Victor.Eleazor@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Victor Eleazor
DMH Payments
Commonwealth Mainframe
Gary McDonald (502) 564-8021 Gary.McDonald@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Gary McDonald, After hours call (502) 564-7946
DCBS Payments
Commonwealth Mainframe
Gary McDonald (502) 564-8021 Gary.McDonald@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Gary McDonald, After hours call (502) 564-7946
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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Name Destination SystemTransaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Denials IMPACT Plus Flat file FTP Weekly Fixed width 190 Batch FINJREMAR c7510sk.denytran_ccyymmdd_hhmmss.dat
Refunds IMPACT Plus Flat file FTP Weekly Fixed width 151 Batch FINJREMAR c7510sl.refunds_ccyymmdd_hhmmss.dat
Transfers IMPACT Plus Flat file FTP Weekly Fixed width 106 Batch FINJREMAR c7510sb.transfer_ccyymmdd_hhmmss.dat
DMH Payments IMPACT Plus Flat file FTP Weekly Fixed width 363 Batch FINJREMAR C7520SA.DMH291.EMARS
DCBS Payments IMPACT Plus Flat file FTP Weekly Fixed width 363 Batch FINJREMAR C7520SA.DCBS292.EMARS
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2.6.1.1.1 Denials InterChange creates an extract of mental health denied claims, and imports the file into ONBASE where it can be viewed or downloaded.
Denial Record Layout can be found on the PWB Tech Design Financial Input/Output Files Impact Plus Deny Record Layout
2.6.1.1.2 Refunds InterChange creates an extract of mental health refunded claims, and imports the file into ONBASE where it can be viewed or downloaded.
Refunds Record Layout can be found on the PWB Tech Design Financial Input/Output Files Impact Plus Refunds Record Layout
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.6.1.1.3 Transfers InterChange creates an extract of mental health transfers, and imports the file into ONBASE where it can be viewed or downloaded.
EFT Record Layout can be found on the PWB Tech Design Financial Input/Output Files Impact Plus Transfers Record Layout
2.6.1.1.4 DMH Payments InterChange creates a payment file for DMHMR providers that is sent to the Commonwealth Mainframe system through the Commonwealth Data Center and interChange (ODC) EDI environments.
DMH Payment Record Layout can be found on the PWB Tech Design Financial Input/Output Files Impact Plus DMH payment Record Layout
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2.6.1.1.5 DCBS Payments InterChange creates a payment file for DCBS providers, which is sent to the Commonwealth Mainframe system through the Commonwealth Data Center and interChange (ODC) EDI environments.
DCBS Payment Record Layout can be found on the PWB Tech Design Financial Input/Output Files Impact Plus DCBS payment Record Layout
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.6.1.2 DMS Output File ID Name Interface Type Description Subsystems Impacted System Entry
Point Data Owner
714 Payment Data File Capitation payment information for Passport for evaluation by DMS Internal Policy before final payment is made
Financial interChange
459 Recoupment File Recoupment data (code MS) is extracted from interChange and sent to DMS as a comma separated file for spreadsheet import
Financial interChange
460 Contractor Recoupment
File Contractor Recoupment data (non lockbox) is extracted from interChange and sent to DMS as a comma separated file for spreadsheet import
Financial interChange
Name Destination Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Payment Data DMS Vance Juett (502) 564-5183 ext. 3182
Vance.Juett@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Vance Juett
Recoupment DMS Nellie Coleman (502) 564-1012 Nellie.Coleman@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Nellie Coleman
Contractor Recoupment
DMS Nellie Coleman (502) 564-1012 Nellie.Coleman@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Nellie Coleman
Name Destination Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Payment Data DMS Flat file FTP Weekly Fixed width 60 Batch MGDJM690 eds_cap_pymt_ccyymmdd_hhmmss.dat
Recoupment DMS Flat file FTP Weekly Fixed width 116 Batch FINJM87E FIN-807E1
Contractor Recoupment
DMS Flat file FTP Weekly Fixed width 116 Batch FINJM87E FIN-807E2
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.6.1.2.1 Payment Data InterChange creates a CSV file of capitation payments and imports the file into ONBASE where it can be viewed or downloaded.
Capitation Payment CSV Record Layout can be found on the PWB Tech Design Managed Care Input/Output Files Capitation Payments File
2.6.1.2.2 Recoupment Recoupment data is extracted and formatted as a delimited field import file and imported to ONBASE where an ONBASE client user can view or download.
Recoupment Record Layout can be found on the PWB Tech Design Financial Input/Output Files Contractor Recoupment Extract (code MS)
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2.6.1.2.3 Contractor Recoupment Contractor Recoupment data is extracted and formatted as a delimited field import file and imported to ONBASE where an ONBASE client user can view or download.
Contractor Recoupment Record Layout can be found on the PWB Tech Design Financial Input/Output Files Contractor Recoupment Extract (non_lockbox)
2.6.1.2.4 Provider Reimbursement Provider Reimbursement data is extracted and formatted as a fixed width field import file and imported to ONBASE where an ONBASE client user can view or download.
Provider Reimbursement Record Layout can be found on the PWB Tech Design Financial Input/Output Files Provider Reimbursement
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2.6.1.3 eMARS Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point Data Owner
578 On Demand Checks File On Demand Checks Financial eMARS interChange
350 Weekly Checks File Weekly Checks Financial eMARS interChange
580 Non-provider Checks File Non-provider Checks Financial eMARS interChange
354 KenPAC Checks File KenPAC Checks Financial eMARS interChange
355 Lock-in Checks File Lock-in Checks Financial eMARS interChange
356 Weekly EFT File Weekly Electronic Funds Transfer file Financial eMARS interChange
579 KenPAC EFT File KenPAC Electronic Funds Transfer file Financial eMARS interChange
357 Lock-in EFT File Lock-in Electronic Funds Transfer file Financial eMARS interChange
353 Provider Refunds File Provider Refunds Financial eMARS interChange
359 Provider 1099 File Provider 1099 Financial eMARS interChange
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
On Demand Checks
eMARS Gary McDonald
(502) 564-8021 Gary.McDonald@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Gary McDonald, After hours call (502) 564-7946
Weekly Checks eMARS Gary McDonald
(502) 564-8021 Gary.McDonald@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Gary McDonald, After hours call (502) 564
Non-provider Checks
eMARS Gary McDonald
(502) 564-8021 Gary.McDonald@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Gary McDonald, After hours call (502) 564
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
KenPAC Checks eMARS Gary McDonald
(502) 564-8021 Gary.McDonald@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Gary McDonald, After hours call (502) 564
Lock-in Checks eMARS Gary McDonald
(502) 564-8021 Gary.McDonald@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Gary McDonald, After hours call (502) 564
Weekly EFT eMARS Gary McDonald
(502) 564-8021 Gary.McDonald@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Gary McDonald, After hours call (502) 564
KenPAC EFT eMARS Gary McDonald
(502) 564-8021 Gary.McDonald@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Gary McDonald, After hours call (502) 564
Lock-in EFT eMARS Gary McDonald
(502) 564-8021 Gary.McDonald@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Gary McDonald, After hours call (502) 564
Provider Refunds eMARS Gary McDonald
(502) 564-8021 Gary.McDonald@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Gary McDonald, After hours call (502) 564
Provider 1099 eMARS Gary McDonald
(502) 564-8021 Gary.McDonald@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Gary McDonald, After hours call (502) 564
Name Destination System
Transaction Type
Transmission Type
Frequency Record FormatRecord length
Batch or Real-time
Job Name File Name
On Demand Checks
eMARS Flat file FTP Weekly, Friday
XML N/A Batch FINJREMAR C49R109A_578_yyyymmdd_hhmm.txt
Weekly Checks eMARS Flat file FTP Weekly, Friday
XML N/A Batch FINJREMAR C49R109A_350_yyyymmdd_hhmm.txt
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Name Destination System
Transaction Type
Transmission Type
Frequency Record FormatRecord length
Batch or Real-time
Job Name File Name
Non-provider Checks
eMARS Flat file FTP Weekly, Friday
XML N/A Batch FINJREMAR C49R109B_580_yyyymmdd_hhmm.txt
KenPAC Checks
eMARS Flat file FTP Weekly, Friday
XML N/A Batch FINJREMAR C49R109A_354_yyyymmdd_hhmm.txt
Lock-in Checks eMARS Flat file FTP Weekly, Friday
XML N/A Batch FINJREMAR C49R109A_355_yyyymmdd_hhmm.txt
Weekly EFT eMARS Flat file FTP Weekly, Friday
XML N/A Batch FINJREMAR C49R109C_356_yyyymmdd_hhmm.txt
KenPAC EFT eMARS Flat file FTP Weekly, Friday
XML N/A Batch FINJREMAR C49R109C_579_yyyymmdd_hhmm.txt
Lock-in EFT eMARS Flat file FTP Weekly, Friday
XML N/A Batch FINJREMAR C49R109C_357_yyyymmdd_hhmm.txt
Provider Refunds
eMARS Flat file FTP Weekly, Friday
XML N/A Batch FINJREMAR C49R216B_353_yyyymmdd_hhmm.txt
Provider 1099 eMARS Flat file FTP Annual, end of year
XML N/A Batch FINJREMAR C53R1099_359_yyyymmdd_hhmm.txt
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 95
2.6.1.3.1 Checks InterChange creates checks files that are sent to the Commonwealth using the Commonwealth Data Center and interChange (ODC) EDI environments. The file just passes through the interChange (ODC) EDI Environment but the file on the Commonwealth Data Center EDI Environment is translated into XML by CDC BizTalk and then sent to eMARS.
Check Header Record Layout, Check Accounting Record Layout, Check Payment Record Layout can be found on the PWB Tech Design Financial Input/Output Files emar Payment Record Layout
Advantage 3 Check Writer XML Input File Layout can be found on the PWB Tech Design Financial Input/Output Files KY_eMARS_Checkwriter
2.6.1.3.2 EFT InterChange creates checks files that are sent to the Commonwealth using the Commonwealth Data Center and interChange (ODC) EDI environments. The file just passes through the interChange (ODC) EDI Environment but the file on the Commonwealth Data Center EDI Environment is translated into XML by CDC BizTalk and then sent to eMARS.
EFT Header Record Layout, EFT Provider Record Layout, EFT Check Issue Record Layout and EFT Record Layout can be found on the PWB Tech Design Financial Input/Output Files emar Payment Record Layout
Advantage 3 Check Writer XML Input File Layout can be found on the PWB Tech Design Financial Input/Output Files KY_eMARS_Checkwriter
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 96
2.6.1.3.3 Provider Refunds InterChange creates a Provider Refund file that is sent to the Commonwealth using the interChange and Commonwealth Data Center EDI environments. The file just passes through the interChange (ODC) EDI Environment but the file on the Commonwealth Data Center EDI Environment is translated into XML by CDC BizTalk and then sent to eMARS.
Refund Document Record Layout, Refund Header Record Layout, Refund Vendor Record Layout, Refund Accounting Record Layout can be found on the PWB Tech Design Financial Input/Output Files eMAR Refund Record Layout
Refund XML can be found on the PWB Tech Design Financial Input/Output Files KY_eMARS_GAX
2.6.1.3.4 Provider 1099 InterChange creates a 1099 file that is sent to the Commonwealth using the interChange and Commonwealth Data Center EDI environments. The file just passes through the interChange (ODC) EDI Environment but the file on the Commonwealth Data Center EDI Environment is translated into XML by CDC BizTalk and then sent to eMARS.
1099 Record Layout can be found on the PWB Tech Design Financial Input/Output Files emar 1099 Record Layout
1099 XML can be found on the PWB Tech Design Financial Input/Output Files KY_eMARS_1099
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 97
2.7 MAR Functional Area Interfaces
2.7.1 MAR Interface Diagram A context diagram for entities within the functional area is shown below.
2.7.2 MAR Entities Name Description
CMS Centers for Medicare and Medicaid Services
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 98
2.7.2.1 CMS Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
377 MSIS Eligibility File Quarterly Member eligibility tape created for the CMS Medicaid Statistical Information System
Member MSIS interChange
638 MSIS IP Claims File Quarterly Inpatient Claims tape created for the CMS Medicaid Statistical Information System
Claims MSIS interChange
374 MSIS LT Claims File Quarterly Long Term Care Claims tape created for the CMS Medicaid Statistical Information System
Claims MSIS interChange
375 MSIS OT Claims File Quarterly “All Other Claims” tape created for the CMS Medicaid Statistical Information System
Claims MSIS interChange
376 MSIS RX Claims File Quarterly Pharmacy Claims tape created for the CMS Medicaid Statistical Information System
Claims MSIS interChange
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
MSIS Eligibility MSIS Kathy Ranshous
(410) 786-0958 Kathy.Ranshous@cms.hhs.gov MSIS@cms.hhs.gov
Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Kathy Ranshous
MSIS IP Claims MSIS Kathy Ranshous
(410) 786-0958 Kathy.Ranshous@cms.hhs.gov MSIS@cms.hhs.gov
Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Kathy Ranshous
MSIS LT Claims MSIS Kathy Ranshous
(410) 786-0958 Kathy.Ranshous@cms.hhs.gov MSIS@cms.hhs.gov
Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Kathy Ranshous
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 99
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
MSIS OT Claims MSIS Kathy Ranshous
(410) 786-0958 Kathy.Ranshous@cms.hhs.gov MSIS@cms.hhs.gov
Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Kathy Ranshous
MSIS RX Claims MSIS Kathy Ranshous
(410) 786-0958 Kathy.Ranshous@cms.hhs.gov MSIS@cms.hhs.gov
Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Kathy Ranshous
Name Destination System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
MSIS Eligibility MSIS Flat file Tape Quarterly Fixed width 375 Batch MARJQ971 MW00.YR$$$$.QTR$.ELIGIBLE
MSIS IP Claims MSIS Flat file Tape Quarterly Fixed width 725 Batch MARJQ972 MW00.YR$$$$.QTR$.CLAIMIP
MSIS LT Claims MSIS Flat file Tape Quarterly Fixed width 200 Batch MARJQ973 MW00.YR$$$$.QTR$.CLAIMLT
MSIS OT Claims MSIS Flat file Tape Quarterly Fixed width 175 Batch MARJQ974 MW00.YR$$$$.QTR$.CLAIMOT
MSIS RX Claims MSIS Flat file Tape Quarterly Fixed width 175 Batch MARJQ975 MW00.YR$$$$.QTR$.CLAIMRX
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 100
2.7.2.1.1 MSIS Eligibility InterChange creates an eligibility extract for MSIS, sends it to the EDS Frankfort FTP Server where a tape cartridge is created and shipped to CMS.
MSIS Header Record Layout can be found on the PWB Tech Design MAR Input/Output Files MSIS Header Record Layout
Eligibility Record Layout can be found on the PWB Tech Design MAR Input/Output Files MSIS ELIGIBLE Record Layout
2.7.2.1.2 Inpatient Claims InterChange creates an Inpatient Claim extract for MSIS, sends it to the EDS Frankfort FTP Server where a tape cartridge is created and shipped to CMS.
MSIS Header Record Layout can be found on the PWB Tech Design MAR Input/Output Files MSIS Header Record Layout
Inpatient Record Layout can be found on the PWB Tech Design MAR Input/Output Files MSIS CLAIMIP Record Layout
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 101
2.7.2.1.3 Long Term Care Claims InterChange creates a Long Term Care Claim extract for MSIS, sends it to the EDS Frankfort FTP Server where a tape cartridge is created and shipped to CMS.
MSIS Header Record Layout can be found on the PWB Tech Design MAR Input/Output Files MSIS Header Record Layout
Long Term Care Record Layout can be found on the PWB Tech Design MAR Input/Output Files MSIS CLAIMLT Record Layout
2.7.2.1.4 Other Claims InterChange creates an “All Other Claim” extract for MSIS, sends it to the EDS Frankfort FTP Server where a tape cartridge is created and shipped to CMS.
MSIS Header Record Layout can be found on the PWB Tech Design MAR Input/Output Files MSIS Header Record Layout
All Other Claims Record Layout can be found on the PWB Tech Design MAR Input/Output Files MSIS CLAIMOT Record Layout
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 102
2.7.2.1.5 Pharmacy Claims InterChange creates a Pharmacy Claim extract for MSIS, sends it to the EDS Frankfort FTP Server where a tape cartridge is created and shipped to CMS.
MSIS Header Record Layout can be found on the PWB Tech Design MAR Input/Output Files MSIS Header Record Layout
Pharmacy Claims Record Layout can be found on the PWB Tech Design MAR Input/Output Files MSIS CLAIMRX Record Layout
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 103
2.8 Managed Care Functional Area Interfaces
2.8.1 Managed Care Interface Diagram A context diagram for entities within the functional area is shown below.
2.8.2 Managed Care Entities Name Description
KAMES Kentucky Automated Management and Eligibility System
PA-62 Kentucky Public Assistance 62 (Members enrolled by DCBS)
Passport Passport Health Plan – Medicaid Managed Care
SDX Kentucky State Data Exchange (Members with SSI)
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 104
2.8.2.1 KAMES, PA-62 and SDX Input File Name
Name Interface Type Description Subsystems Impacted
System Entry Point
Data Owner
589, 333 Language File File The Language files are sent to Passport through interChange. There’s a KAMES Language file and a PA-62/SDX Language file.
None None KAMES,
PA-62/SDX
Name Source System
Source Contact Name
Source Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Language File KAMES PA-62/SDX
Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com
Contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946
Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Language File KAMES
PA-62/SDX
Flat file FTP Monthly Fixed width 38 Batch FTS kames_lang_ccyymmdd_hhmmss.dat
sdx_lang_ccyymmdd_hhmmss.dat
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 105
2.8.2.1.1 Language File Language Data from KAMES and PA-62/SDX are sent to interChange from the Commonwealth Data Center. It is not processed, just forwarded to Passport.
Language File Record Layouts are not known. The files are just passed to Passport
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 106
2.8.2.2 KAMES Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
385 KenPAC Extract File A KenPAC Provider extract file is created daily and sent to KAMES. Provider changes from First Health flow through this extract to KAMES.
Member, Managed Care
KAMES interChange
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
KenPAC Extract KAMES Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946
Name Destination System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
KenPAC Extract KAMES Flat file FTP Monthly Fixed width 6514 Batch MGDJD680 eds_ken_extract_file_ccyymmdd_hhmmss.dat
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 107
2.8.2.2.1 KenPAC Extract KenPAC Data is extracted from interChange and sent to KAMES through the interChange (ODC) EDI environment and Commonwealth Data Center EDI environment.
KenPac Extract Record Layout can be found on the PWB Tech Design Managed Care Input/Output Files KenPAC Extract File
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 108
2.8.2.3 Passport Output File ID Name Interface
Type Description Subsystems
Impacted System Entry Point
Data Owner
495 Managed Care LTC File InterChange will create a Managed Care Long Term Care report monthly. The raw data from this report will go to Passport in a semicolon delimited file for spreadsheet import
Managed Care, Member
Passport interChange
492 Managed Care Waiver File InterChange will create a Managed Care Waiver report monthly. The raw data from this report will go to Passport in a semicolon delimited file for spreadsheet import
Managed Care, Member
Passport interChange
490 Managed Care KenPAC File InterChange will create a Managed Care KenPAC report monthly. The raw data from this report will go to Passport in a semicolon delimited file for spreadsheet import
Managed Care, Member
Passport interChange
489 Managed Care Lock-in File InterChange will create a Managed Care Lock-in report monthly. The raw data from this report will go to Passport in a semicolon delimited file for spreadsheet import
Managed Care, Member
Passport interChange
754 834 Transactions File Daily, Monthly and for 2 Reconciliation cycles per month, 834 transactions are sent to Passport for synchronization of their Managed Care Member Eligibility file with the MMIS.
Managed Care, Member
Passport interChange
749 820 Transactions File An 820 transaction file is created and sent to Passport for capitation. This can occur weekly but typically occurs monthly
Managed Care, Member
Passport interChange
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Managed Care LTC Passport Judy Palmer (502) 585-7900 Judy.Palmer@amerihealthmercy.org
Bill Ponder
(502) 209-3145 Bill.Ponder@eds.com Contact Judy Palmer or Doris Goldstein at the Commonwealth
Managed Care Waiver
Passport Judy Palmer (502) 585-7900 Judy.Palmer@amerihealthmercy.org
Bill Ponder
(502) 209-3145 Bill.Ponder@eds.com Contact Judy Palmer or Doris Goldstein at the Commonwealth
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 109
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Managed Care KenPAC
Passport Judy Palmer (502) 585-7900 Judy.Palmer@amerihealthmercy.org
Bill Ponder
(502) 209-3145 Bill.Ponder@eds.com Contact Judy Palmer or Doris Goldstein at the Commonwealth
Managed Care Lock-in
Passport Judy Palmer (502) 585-7900 Judy.Palmer@amerihealthmercy.org
Bill Ponder
(502) 209-3145 Bill.Ponder@eds.com Contact Judy Palmer or Doris Goldstein at the Commonwealth
834 Transactions Passport Gail Gatto (215) 937-8474 Gail.Gatto@kmhp.com Bill Ponder
(502) 209-3145 Bill.Ponder@eds.com Contact Gail or after hours contact EDI Help Desk at (215) 937-8473
820 Transactions Passport Gail Gatto (215) 937-8474 Gail.Gatto@kmhp.com Bill Ponder
(502) 209-3145 Bill.Ponder@eds.com Contact Gail or after hours contact EDI Help Desk at (215) 937-8473
Name Destination System
Transaction Type
Transmission Type
Frequency Record Format Record length
Batch or Real-time
Job Name File Name
Managed Care LTC
Passport Flat file FTP Monthly, first Friday Delimited field 165 Batch MGDJM650 eds_mc_ltc_ccyymmdd_hhmmss.dat
Managed Care Waiver
Passport Flat file FTP Monthly, first Friday Delimited field 182 Batch MGDJM650 eds_mc_waiv_ccyymmdd_hhmmss.dat
Managed Care KenPAC
Passport Flat file FTP Monthly, first Friday Delimited field 165 Batch MGDJM650 eds_mc_ken_ccyymmdd_hhmmss.dat
Managed Care Lock-in
Passport Flat file FTP Monthly, first Friday Delimited field 162 Batch MGDJM650 eds_mc_lok_ccyymmdd_hhmmss.dat
N/A KYDELIG_0_ccyymmdd.hhmmss.X12 834 Transactions Passport Flat file FTP Daily & Recon X12
Batch X12 834
KYRELIG_0_ccyymmdd.hhmmss.X12
820 Transactions Passport Flat file FTP Monthly; last Friday
X12 N/A Batch X12 820 KYWRA___0_ccyymmdd.hhmmss.X12
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 110
2.8.2.3.1 Managed Care LTC On a monthly basis, the MMIS creates a Managed Care LTC Report and a data only version of the report. The data only version will be sent to Passport via FTP.
Managed Care LTC Record Layout can be found on the PWB Tech Design Managed Care Input/Output Files Managed Care Vs Long Term Care
2.8.2.3.2 Managed Care Waiver On a monthly basis, the MMIS creates a Managed Care Waiver Report and a data only version of the report. The data only version will be sent to Passport via FTP.
Managed Care Waiver Record Layout can be found on the PWB Tech Design Managed Care Input/Output Files Managed Care Vs Waiver
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 111
2.8.2.3.3 Managed Care KenPAC On a monthly basis, the MMIS creates a Managed Care KenPAC Report and a data only version of the report. The data only version will be sent to Passport via FTP.
Managed Care KenPAC Record Layout can be found on the PWB Tech Design Managed Care Input/Output Files Managed Care Vs KenPAC
2.8.2.3.4 Managed Care Lock-in On a monthly basis, the MMIS creates a Managed Care Lock-in Report and a data only version of the report. The data only version will be sent to Passport via FTP.
Managed Care Lock-in Record Layout can be found on the PWB Tech Design Managed Care Input/Output Files Managed Care Vs Lockin
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 112
2.9 Member Data Functional Area Interfaces
2.9.1 Member Data Interface Diagram A context diagram for entities within the functional area is shown below.
CMS
PA-62
SDX
Vital Statistics
interChange
KAMES
KMAA
PBA
COBC
DMS
HMS
Passport
Myers & Stauffer
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 113
2.9.2 Member Entities Name Description
CDP Custom Data Processing
CMS Centers for Medicare and Medicaid Services
COBC CMS Medicare Coordination of Benefits Contractor, Group Health Incorporated (GHI)
DMS Kentucky CHFS Department for Medicaid Services
KAMES Kentucky Automated Management and Eligibility System
KMAA Kentucky Medicaid Administrative Agent (First Health)
Myers & Stauffer Myers & Stauffer
PA-62 Kentucky Public Assistance 62 (Members enrolled by DCBS)
Passport Passport Health Plan – Medicaid Managed Care
PBA Pharmacy Benefits Administrator (First Health)
HMS Health Management Systems
SDX Kentucky State Data Exchange (Members with SSI)
Vital Statistics Kentucky CHFS Office of Vital Statistics
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 114
2.9.2.1 CDP Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
721, 449
Long Term Care File Long Term Care Extract for Custom Data Processing Member interChange
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Long Term Care CDP Mike Combs (502) 695-6870 MikeCombs@cdp-ky.com Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Mike Combs
Name Destination System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Long Term Care CDP Flat file FTP Monthly Fixed width 190 Batch ELGPM055 eldmmcx_pp_ccyymmdd_hhmmss.dat
eldmmcx_ccyymmdd_hhmmss.dat
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 115
2.9.2.1.1 Long Term Care Extract Long Term Care Eligibility information is extracted monthly and sent to Mike Combs at Custom Data Processing via FTP.
Long Term Care Extract Layout can be found on the PWB Tech Design Member Data Maintenance Input/Output Files Output – LTC Extract
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 116
2.9.2.2 CMS Input File ID Name Interface Type Description Subsystems Impacted System Entry
Point Data Owner
771, 450
HIC Update File Medicare HIC Number Reconciliation file sent to interChange from CMS through Commonwealth Data Center
Member CMS interChange
Name Source System
Source Contact Name
Source Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
HIC Update CMS Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com During the day contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946
Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
HIC Update CMS Flat file FTP Request Fixed width 126 Batch X12 837P
X12 837I
PCOB.BA.N0945.PARTB.sssssss
PCOB.BA.N0944.PARTA.sssssss
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 117
2.9.2.2.1 HIC Update CMS sends the MMIS Medicare HIC Number updates through the Commonwealth. They reach interChange from the Commonwealth Data Center via the CDC EDI environment and interChange environment to facilitate the file transfer.
HIC Number Update Record Layout can be found on the PWB Tech Design Member Data Maintenance Input/Output Files Input HIC Updates Record Layout
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 118
2.9.2.3 CMS Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
619 Part D Extract File Part D extract for CMS sent to CMS through the Commonwealth Data Center
Member CMS interChange
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Part D Extract CMS Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com During the day contact Cliff Robey at (502) 564-5183. After hours call (502) 564-7946
Name Destination System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Part D Extract CMS Flat file FTP Monthly Fixed width 180 Batch ELGJM653 elm600p_ccyymmdd_hhmmss.dat
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 119
2.9.2.3.1 Part D Extract interChange will create the Part D Extract for CMS and send it to CMS through the interChange (ODC) EDI and Commonwealth Data Center EDI environments to facilitate the file transfer.
Part D MMA Record Layout can be found on the PWB Tech Design Buy-in Data Maintenance Input/Output Files Part D MMA Enrollment Response File
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 120
2.9.2.4 COBC Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
721 Medicaid Eligibility File Medicaid Eligibility file sent to the COBC so eligibility based Medicare Crossovers can be identified and sent to interChange for processing
Member COBC interChange
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Medicaid Eligibility COBC Becky Able (803) 772-0911 beckyable1@aol.com Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact COBC Help Desk Technical Support at (212) 615-4357
Name Destination System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Medicaid Eligibility COBC Flat file FTP Monthly Fixed width 200 Batch ELGPM055 eldmmcx_pp_ccyymmdd_hhmmss.dat
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 121
2.9.2.4.1 Medicaid Eligibility The COBC will receive the dual eligibility information from interChange via SFTP through the interChange (ODC) EDI environment.
Medicaid Eligibility Record Layout can be found on the PWB Tech Design Member Data Management Input/Output Files Output – Medicare Member Eligibility File
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 122
2.9.2.5 DMS Output File Name
Name Interface Type Description Subsystems Impacted
System Entry Point
Data Owner
610 Child Medicaid Eligible
File Medicaid eligible members between ages 5 and 18 – text file created for spreadsheet import.
Member interChange
559 Presumptive Eligibility
File Medicaid Eligibility report extract of all recipients that have presumptive eligibility for the month – text file created for spreadsheet import
Member interChange
Name Destination Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Child Medicaid Eligibility
DMS Jan Thornton (502) 564-5183 ext. 3182
Jan.Thornton@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Jan Thornton
Presumptive Eligibility
DMS Don Bussell (502) 564-0105 Don.Bussell@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Nici Gaines
Name Destination Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job name File Name
Child Medicaid Eligibility
DMS Flat file FTP Quarterly Fixed width
31 Batch ELGJQ001 ELG-0200-Q
Presumptive Eligibility DMS Flat file FTP Monthly Fixed width
132 Batch ELGJMPCG elm_mem_pcg_ccyymmdd_hhmmss.dat
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 123
2.9.2.5.1 Child Medicaid Eligibility The MMIS creates an extract of Medicaid eligible children, and imports the file into ONBASE where it can be viewed or downloaded.
Child Medicaid Record Layout can be found on the PWB Tech Design Member Data Management Input/Output Files Output – Child Medicaid
2.9.2.5.2 Presumptive Eligibility Presumptive Eligibility information is extracted and imported to ONBASE where it can be viewed or downloaded.
Presumptive Eligibility Extract Record Layout can be found on the PWB Tech Design Member Data Management Input/Output Files Output – Presumptive Eligibility Extract
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 124
2.9.2.6 KAMES, PA-62 and SDX Input File Name
Name Interface Type Description Subsystems Impacted
System Entry Point
Data Owner
601, 365 Member Updates File Member updates from the Commonwealth systems: KAMES, PA-62 and SDX.
Member interChange interChange
336, 366 LTC Updates File Member Long Term Care updates from the Commonwealth systems: KAMES, PA-62 and SDX.
Member interChange interChange
337, 367 Patient Liability Updates
File Patient Liability updates from the Commonwealth systems: KAMES, PA-62 and SDX.
Member interChange interChange
339, 372 Member Recon 1 File Eligibility Reconciliation 1st Issuance from KAMES, PA-62 and SDX. Member interChange interChange
340, 373 Member Recon 2 File Eligibility Reconciliation 2nd Issuance from KAMES, PA-62 and SDX. Member interChange interChange
341, 370 KENPAC Recon 1 File KENPAC Eligibility Reconciliation 1st Issuance from KAMES, PA-62 and SDX.
Member interChange interChange
342, 371 KENPAC Recon 2 File KENPAC Eligibility Reconciliation 2nd Issuance from KAMES, PA-62 and SDX.
Member interChange interChange
766, 587 Card Issuance File Card Issuance Information Member interChange interChange
Name Source System
Source Contact Name
Source Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Member Updates KAMES PA-62 SDX
Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946
LTC Updates KAMES PA-62/SDX
Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com During the day contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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Name Source System
Source Contact Name
Source Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Patient Liability Updates
KAMES PA-62/SDX
Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com During the day contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946
Member Recon 1 KAMES PA-62/SDX
Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com During the day contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946
Member Recon 2 KAMES PA-62/SDX
Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com During the day contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946
KENPAC Recon 1 KAMES PA-62/SDX
Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com During the day contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946
KENPAC Recon 2 KAMES PA-62/SDX
Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com During the day contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946
Card Issuance PA-62/SDX Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com During the day contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Member Updates KAMES PA-62 SDX
Flat file FTP Fixed width
452 Near Real-time
ELGJD004 ELGJD006
eld0kadi_ccyymmdd_hhmmss.dat eld0ppai_ccyymmdd_hhmmss.dat
LTC Updates KAMES PA-62/SDX
Flat file FTP Fixed width
100 Near Real-time
ELGJDLTC ELGJDLTP
eld0kltc_ccyymmdd_hhmmss.dat eld0pltc_ccyymmdd_hhmmss.dat
Patient Liability Updates
KAMES PA-62/SDX
Flat file FTP Fixed width
190 Near Real-time
ELGJDPAT ELGJDPAP
eld0kpat_ccyymmdd_hhmmss.dat eld0ppat_ccyymmdd_hhmmss.dat
Member Recon 1 KAMES PA-62/SDX
Flat file FTP Monthly Fixed width
452 Batch ELGJM007 ELGJM008
elm0350i_ccyymmdd_hhmmss.dat elm0360i_ccyymmdd_hhmmss.dat
Member Recon 2 KAMES PA-62/SDX
Flat file FTP Monthly Fixed width
452 Batch ELGJM007 MGDJM665
elm0350i_ccyymmdd_hhmmss.dat comm_sdx_ken_enrl_mbr_1_ccyymmdd_hhmmss.dat
KENPAC Recon 1 KAMES PA-62/SDX
Flat file FTP Monthly Fixed width
100 Batch MGDJM660MGDJM665
comm_kames_ken_enrl_mbr_1_ccyymmdd_hhmmss.dat comm_sdx_ken_enrl_mbr_1_ccyymmdd_hhmmss.dat
KENPAC Recon 2 KAMES PA-62/SDX
Flat file FTP Monthly Fixed width
100 Batch MGDJM660MGDJM665
comm_kames_ken_enrl_mbr_2_ccyymmdd_hhmmss.dat comm_sdx_ken_enrl_mbr_2_ccyymmdd_hhmmss.dat
Card Issuance KAMES PA-62/SDX
Flat file FTP Daily Fixed width
120 Batch ELGJMIDC elgmidk_ccyymmdd_hhmmss.dat elgmidc_ccyymmdd_hhmmss.dat
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2.9.2.6.1 Member Updates Member updates from KAMES, PA-62 and SDX are sent to interChange through the Commonwealth Data Center EDI environment and interChange (ODC) EDI Environment. The process is a batch process that can run multiple times per day.
Member Update Record Layout can be found on the PWB Tech Design Member Data Management Input/Output Files Input – KAMES, SDX and PA62 Update Record Layout
2.9.2.6.2 Long Term Care Updates Member Long Term Care updates from KAMES and PA-62/SDX are sent to interChange through the Commonwealth Data Center EDI environment and interChange (ODC) EDI Environment. The process is a batch process that can run multiple times per day.
Long Term Care Update Record Layout can be found on the PWB Tech Design Member Data Management Input/Output Files Input – KAMES and PA62 Long Term Care Record Layout
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.9.2.6.3 Patient Liability Updates Member Patient Liability updates from KAMES and PA-62/SDX are sent to interChange through the Commonwealth Data Center EDI environment and interChange (ODC) EDI Environment. The process is a batch process that can run multiple times per day.
Patient Liability Update Record Layout can be found on the PWB Tech Design Member Data Management Input/Output Files Input – KAMES and PA62 Patient Liability Record Layout
2.9.2.6.4 Member Recon 1 KAMES and PA-62/SDX member reconciliation first issuance files are sent to interChange for processing, utilizing the Commonwealth Data Center EDI environment and interChange (ODC) EDI environment.
Member Update Recon 1 Record Layout can be found on the PWB Tech Design Member Data Management Input/Output Files Input – KAMES, SDX and PA62 Update Record Layout
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.9.2.6.5 Member Recon 2 KAMES and PA-62/SDX member reconciliation second issuance files are sent to the MMIS for processing, utilizing the Commonwealth Data Center EDI Environment and interChange (ODC) EDI environment.
Member Update Recon 2 Record Layout can be found on the PWB Tech Design Member Data Management Input/Output Files Input – KAMES, SDX and PA62 Update Record Layout
2.9.2.6.6 KenPAC Recon 1 KAMES and PA-62/SDX KENPAC member reconciliation first issuance files are sent to interChange for processing, using the Commonwealth Data Center EDI environment and the interchange EDI environment.
KENPAC Recon 1st Issuance Record Layout can be found on the PWB Tech Design Managed Care Input/Output Files KenPAC Update Transactions
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.9.2.6.7 KenPAC Recon 2 KAMES and PA-62/SDX KENPAC member reconciliation second issuance files are sent to interChange for processing, using the Commonwealth Data Center EDI environment and the interchange EDI environment.
KENPAC Recon 2nd Issuance Record Layout can be found on the PWB Tech Design Member Input/Output Files KenPAC Update Transactions
2.9.2.6.8 Card Issuance KAMES and PA-62/SDX Medicaid card issuance files are sent to interChange for processing, using the Commonwealth Data Center EDI environment and the interchange EDI environment.
Card Issuance Record Layout can be found on the PWB Tech Design Member Data Management Input/Output Files Input - Medicaid ID Card ISSUANCE
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2.9.2.7 KAMES, PA-62 and SDX Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
384 Lock-in Extract File Member lock-in updates from interChange to KAMES, PA-62/SDX. Member interChange interChange
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Lock-in Extract KAMES PA-62/SDX
Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946
Name Destination System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Lock-in Extract KAMES PA-62/SDX
Flat file FTP Daily Fixed width 256 Batch ELGJD950 eld0loce_ccyymmdd_hhmmss.dat
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2.9.2.7.1 Lock-in Extract interChange sends Lock-in changes to KAMES and to PA-62/SDX utilizing the interChange (ODC) EDI environment and Commonwealth Data Center EDI environment to facilitate the file transfer.
Lock-in Update Record Layout can be found on the PWB Tech Design Member Data Management Input/Output Files Output – KAMES Lockin Extract Record Layout
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.9.2.8 First Health KMAA Input File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
389 Case Management File Case Management and Disease Management data from First Health KMAA
Member, Case Management
interChange KMAA
Name Source System
Source Contact Name
Source Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Case Management FIQM Bob Gaston (804) 527-5745 BGaston@fhsc.comBill Ponder (502) 209-3145 Bill.Ponder@eds.com
Contact Bob Gaston, if unreachable, call 800-453-8780, option 3, category – applications, type – FIQM, item – Data Loads/Extracts
Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Case Management FIQM Flat file FTP Multiple times/day
Fixed width 75 Near real-time
ELGJD021 eldfhlti_ccyymmdd_hhmmss.dat
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2.9.2.8.1 Case Management InterChange receives Case/Disease Management Updates from KMAA through the Commonwealth Data Center and interChange (ODC) EDI Environments.
Case Management Update Record Layout can be found on the PWB Tech Design Member Data Management Input/Output Files Input – Case and Disease Mgmt from KMAA
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.9.2.9 First Health KMAA Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
657 Member Update File Member update transactions Member FIQM interChange
599 Spend-down Update
File Spend-down update from interChange to KMAA FIQM Member FIQM interChange
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Member Update FIQM Bob Gaston (804) 527-5745 BGaston@fhsc.comBill Ponder (502) 209-3145 Bill.Ponder@eds.com
Contact Bob Gaston, if unreachable, call 800-453-8780, option 3, category – applications, type – FIQM, item – Data Loads/Extracts
Spend-down Update
FIQM Bob Gaston (804) 527-5745 BGaston@fhsc.comBill Ponder (502) 209-3145 Bill.Ponder@eds.com
Contact Bob Gaston, if unreachable, call 800-453-8780, option 3, category – applications, type – FIQM, item – Data Loads/Extracts
Name Destination System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Member Update FIQM Flat file FTP Daily Monthly
Fixed width 236 Near Real-time
ELGJDKMA eld0kmbr_ccyymmdd_hhmmss.dat
Spend-down Update
FIQM Flat file FTP Daily Fixed width 121 Batch ELGJD044 elgpdspd_ccyymmdd_hhmmss.dat
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2.9.2.9.1 Member Update Adds and changes that occur on the eligibility master file are sent to KMAA multiple once per day. Also a full eligibility file will be sent to KMAA monthly.
Member Update Record Layout can be found on the PWB Tech Design Member Data Management Input/Output Files Output – KMAA Member Feed
2.9.2.9.2 Spend-down Update Medicaid spend-down changes are sent daily to KMAA.
Spend-down Record Layout can be found on the PWB Tech Design Member Data Management Input/Output Files Output – Spend Down Extract to KMAA
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.9.2.10 First Health PBA Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point Data Owner
656 Member Update File Member update transactions Member FIQM interChange
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Member Update PBA Bruce Slough (804) 934-4247 Bruce.Slough@firsthealth.com
Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Bruce Slough or Steve Elkins (ElkinsSt@fhsc.com) (804) 317-1991, if unreachable, call 800-453-8780, option 3, category – applications, type – First RX, item – Load-enrollment
Name Destination System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Member Update FIQM Flat file FTP Daily Weekly
Fixed width 236 Near Real-time
ELGJDFHX eld0kelg_ccyymmdd_hhmmss.dat
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2.9.2.10.1 Member Update Adds and changes that occur on the eligibility master file are sent to PBA once per day. Also a full eligibility file will be sent to PBA weekly.
Member Update Record Layout can be found on the PWB Tech Design Member Data Management Input/Output Files Output – 1st Health Member Eligibility PBA
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.9.2.11 Passport Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point Data Owner
549 Member Update File The managed care region 3 member update to Passport is accomplished by creating and transmitting 834 HIPAA transaction batches. A daily update file 834 batch is sent to Passport. A recon update 834 batch is sent to Passport. A monthly 834 batch is sent to Passport that reflects all region 3 managed care eligible members for the next month.
Member interChange interChange
333, 589
Member Language File
File A language file from KAMES and PA-62/SDX is sent to Passport through interChange
Member interChange interChange
Name Destination
System Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Member Update
Passport Gail Gatto (215) 937-8474 Gail.Gatto@kmhp.com Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Gail or after hours contact EDI Help Desk at (215) 937-8473
Member Language File
Passport Gail Gatto (215) 937-8474 Gail.Gatto@kmhp.com Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Gail or after hours contact EDI Help Desk at (215) 937-8473
Name Destination System
Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Member Update Passport Flat file FTP Daily 834 N/A Batch TPLJD080 KYDTPL_ccyymmdd_hhmmss.dat
Member Language File
Passport Flat file FTP Monthly; first week
38 Batch FTS kames_lang_ccyymmdd_hhmmss.dat sdx_lang_ccyymmdd_hhmmss.dat
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.9.2.11.1 Member Update InterChange will create a flat file of managed care member eligibility updates to the interChange (ODC) EDI environment where the file is translated into 834 transactions. The 834 batch file is then sent to Passport for processing. Passport’s sends back 997’s when the file is received.
834 transactions are created during Member Reconciliation using the same process.
Once a month, 834 transactions are created just to show eligibility for the coming month. These monthly 834 transactions are different than the daily and recon 834 transaction files because they only show a roster, not all eligibility data.
InterChange will send ANSI X12N 834 standard transactions to Passport. Consult the Benefit Enrollment and Maintenance ASC X12N 834 (004010X095A1) National EDI Transaction Set Implementation Guide for more information. The 997 transaction is described in Appendix B.
2.9.2.11.2 Language File Language Data from KAMES and PA-62/SDX are sent to interChange from the Commonwealth Data Center. It is not processed, just forwarded to Passport.
File Layout is unknown. The file is a pass-through from the Commonwealth systems to Passport.
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2.9.2.12 SHPS Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
709 Member Update File MaxMC needs member data to be able to process prior authorization transactions. Member update data is sent to SHPS for MaxMC from the daily cycle.
Member interChange interChange
Name Destinatio
n System Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Member Update MaxMC Heidi Monroe HJMonroe@landacorp.com
Cheryl Hanna(502) 209-3000 Cheryl.Hanna@eds.com
Contact Heidi or Susy White (susy.white@shps.com)
Name Destination System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Member Update MaxMC Flat file FTP Daily Flat File 1205 Batch ELGJDSHP eld0selg_ccyymmdd_hhmmss.dat
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.9.2.12.1 Member Update Member Updates are sent to SHPS daily.
The Member Update Record Layout can be found on the PWB Tech Design Member Data Management Input/Output Files Output – KY MMIS Member Feed to MaxMC
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.10 Prior Authorization Functional Area Interfaces
2.10.1 Prior Authorization Interface Diagram A context diagram for entities within the functional area is shown below.
2.10.2 Prior Authorization Entities Name Description
KAMES Kentucky Automated Management and Eligibility System
SHPS SHPS, Inc.
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.10.2.1 SHPS Input File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
802 Prior Authorization File Prior Authorization ttransactions come from SHPS, more specifically the MaxMC system.
Prior Auth interChange interChange
Name Source System
Source Contact Name
Source Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Prior Authorization MaxMC Heidi Monroe HJMonroe@landacorp.com
Cheryl Hanna (502) 209-3145 Cheryl.Hanna@eds.com
Contact Heidi Monroe
Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Prior Authorization MaxMC Flat file FTP XML N/A Real-time DSSJ claims_ccyymmdd_hhmmss.dat
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.10.2.1.1 Prior Authorization Update Prior Authorization requests will come to interChange from MaxMC.
The Service Authorization documentation and XSD can be found on the PWB Tech Design Prior Auth Input/Output Files SHPS Interface Docs
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.10.2.2 KAMES Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
710 KAMES Pro Cert File A Pro Cert Extract file is sent to KAMES. This data originates with SHPS. Patients who are not members yet can get a pending PA which needs level of care review by KAMES. These transactions from SHPS are forwarded on to KAMES. Eventually they come back to the MMIS from KAMES when eligibility is given.
Provider KAMES interChange
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
KAMES Pro Cert KAMES Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com
Contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946
Name Destination System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
KAMES Pro Cert KAMES Flat file FTP Daily Fixed width 177 Batch PRVJD868 prd86801_ccyymmdd_hhmmss.dat
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.10.2.2.1 KAMES PA Extract Pro Cert Data is extracted from interChange and sent to KAMES.
Pro Cert Record Layout can be found on the PWB Tech Design Member Data Management Input/Output Files Output – KAMES Pending Eligible Members
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.11 Provider Functional Area Interfaces
2.11.1 Provider Interface Diagram A context diagram for entities within the functional area is shown below.
2.11.2 Provider Interface Entities Name Description
DMS Kentucky CHFS Department for Medicaid Services
KAMES Kentucky Automated Management and Eligibility System
KMAA Kentucky Medicaid Administrative Agent (First Health)
Passport Passport Health Plan – Medicaid Managed Care
PBA Pharmacy Benefits Administrator (First Health)
HMS Health Management Systems
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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Name Description
SHPS SHPS, Inc.
2.11.2.1 DMS Input File ID Name Interface Type Description Subsystems Impacted System Entry
Point Data Owner
640 Provider Rates File Nursing Facilities rates data is delivered to interChange on CD from DMS. This CD is used to update rates information in interChange. The data originates from Myers & Stauffer but is delivered by DMS.
Provider, Financial interChange DMS
Name Source Source Contact Name
Source Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Provider Rates DMS Sandy Carter (502) 564-5707 Sandy.Carter@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Sandy Carter
Name Source Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Provider Rates DMS Flat file FTP Monthly Fixed width 160 Batch PRVJR770 prrate_ccyymmdd_hhmmss.dat
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2.11.2.1.1 Provider Rates Provider Rates data is delivered to EDS on CD. The CD is copied to the EDS Frankfort FTP Server and then sent to the MMIS using FTP.
Provider Rates Record Layout can be found on the PWB Tech Design Provider Data Management Input/Output Files DMS Rate Input
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.11.2.2 KAMES Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
382, 364
Provider Updates File Provider Updates are sent to KAMES and to PA-62/SDX from interChange
Provider KAMES interChange
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Provider Updates KAMES Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946
Name Destination System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Provider Updates KAMES Flat file FTP Monthly Fixed width 4114 Real-time PRVJD840 PRVJD866
prd84001_ccyymmdd_hhmmss.dat prd86601_ccyymmdd_hhmmss.dat
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2.11.2.2.1 Provider Updates Extract Provider Updates are extracted from interChange and sent to KAMES and PA/62/SDX.
KAMES Provider Update Record Layout can be found on the PWB Tech Design Provider Data Management Input/Output Files KAMES Output file layout
PA-62 Provider Update Record Layout can be found on the PWB Tech Design Provider Data Management Input/Output Files PA-62 Output file layout
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.11.2.3 Passport Output File ID Name Interface
Type Description Subsystems
Impacted System Entry Point
Data Owner
606 CLIA Data File CLIA Data is downloaded into a file that is sent to Passport Provider Passport interChange
524 Provider Extract File Provider Extract is created by interChange and sent to Passport Provider Passport interChange
525 Provider License File Provider License data is extracted by interChange and sent to Passport
Provider Passport interChange
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
CLIA Data Passport Gail Gatto (215) 937-8474 Gail.Gatto@kmhp.com Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Gail or after hours contact EDI Help Desk at (215) 937-8473
Provider Extract Passport Gail Gatto (215) 937-8474 Gail.Gatto@kmhp.com Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Gail or after hours contact EDI Help Desk at (215) 937-8473
Provider License Passport Gail Gatto (215) 937-8474 Gail.Gatto@kmhp.com Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Gail or after hours contact EDI Help Desk at (215) 937-8473
Name Destination System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
CLIA Data Passport Flat file FTP Monthly Fixed width 2149 Batch PRVJM846 prm84602_ccyymmdd_hhmmss.dat
Provider Extract Passport Flat file FTP Monthly Fixed width 4692 Batch PRVJM862 prm86201_ccyymmdd_hhmmss.dat
Provider License Passport Flat file FTP Monthly Fixed width 165 Batch PRVJM861 prm86101_ccyymmdd_hhmmss.dat
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2.11.2.3.1 CLIA Data On a monthly basis, interChange will create a Provider CLIA Extract to send to Passport.
CLIA Record Layout can be found on the PWB Tech Design Provider Data Management Input/Output Files CLIA Layout
2.11.2.3.2 Provider Data On a monthly basis, interChange will create a Provider Extract to send to Passport.
Provider Extract Record Layout can be found on the PWB Tech Design Provider Data Management Input/Output Files Passport Consolidated Provider file
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.11.2.3.3 Provider License Data On a monthly basis, interChange will create a Provider License Extract to send to Passport.
Provider License Extract Record Layout can be found on the PWB Tech Design Provider Data Management Input/Output Files Provider License Ffile for Passport
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2.11.2.4 First Health PBA Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
420 Provider Data File interChange will extract provider information and send the data to First Health PBA
Provider PBA Claims
427 Provider License File interChange will extract provider license information and send the data to First Health PBA
Provider PBA Claims
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Provider Data PBA Bruce Slough (804) 934-4247 Bruce.Slough@firsthealth.com
Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Bruce Slough or Steve Elkins (ElkinsSt@fhsc.com) (804) 317-1991, if unreachable, call 800-453-8780, option 3, category – applications, type – First RX, item – Load-enrollment
Provider License
PBA Bruce Slough (804) 934-4247 Bruce.Slough@firsthealth.com
Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Bruce Slough or Steve Elkins (ElkinsSt@fhsc.com) (804) 317-1991, if unreachable, call 800-453-8780, option 3, category – applications, type – First RX, item – Load-enrollment
Name Destination System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Provider Data PBA Flat file FTP Daily Fixed width Batch PRVJD865 prd86501_ccyymmdd_hhmmss.dat
Provider License PBA Flat file FTP Daily Fixed width Batch PRVJD867 prd86702_ccyymmdd_hhmmss.dat
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2.11.2.4.1 Provider Data Provider data is extracted daily and sent to the PBA from interChange.
Provider Record Layout can be found on the PWB Tech Design Provider Data Management Input/Output Files PBA Provider Extract
2.11.2.4.2 Provider License Data Provider license data is extracted daily and sent to the PBA from interChange.
Provider License Record Layout can be found on the PWB Tech Design Provider Data Management Input/Output Files PBA License Extract
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.11.2.5 HMS Output File ID Name Interface Type Description Subsystems Impacted System Entry Point Data Owner
524 Provider Data File interChange will extract provider information and send the data to HMS
Provider HMS Claims
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Provider Data HMS Chris Sallee (704) 372-9384 ext 8117
CSallee@Hmsy.com Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Chris Sallee. After hours, dial the HMS Help Desk, (866) 857-0089
Name Destination System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Provider Data HMS Flat file FTP Monthly Fixed width 414 Batch PRVJM862 prm86201_ccyymmdd_hhmmss.dat
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2.11.2.5.1 Provider Data Provider File is sent to HMS monthly.
Provider Record Layout can be found on the PWB Tech Design Provider Data Management Input/Output Files PCG File Layout
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.11.2.6 SHPS Output File ID Name Interface Type Description Subsystems Impacted System Entry
Point Data Owner
710 Provider Update File MaxMC needs provider data to be able to process prior authorization transactions. Provider update data is sent to SHPS for MaxMC from the daily cycle.
Provider interChange interChange
Name Destinatio
n System Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Provider Update MaxMC Heidi Monroe HJMonroe@landacorp.com
Cheryl Hanna(502) 209-3000 Cheryl.Hanna@eds.com
Contact Heidi or Susy White (susy.white@shps.com)
Name Destination System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Provider Update MaxMC Flat file FTP Daily Flat File 986 Batch PRVJD868 prd86801_ccyymmdd_hhmmss.dat
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2.11.2.6.1 Provider Update Provider Updates are sent to SHPS daily.
The Provider Layout can be found on the PWB Tech Design Provider Data Management Input/Output Files MaxMC Provider Extract
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2.12 Reference Functional Area Interfaces
2.12.1 Reference Interface Diagram A context diagram for entities within the functional area is shown below.
2.12.2 Reference Interface Entities Name Description
CMS Centers for Medicare and Medicaid Services
First Data Bank First Data Bank
KMAA Kentucky Medicaid Administrative Agent (First Health)
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2.12.2.1 CMS Input File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
743 Diagnosis Codes File The Diagnosis Code file from CMS is sent to interChange through Commonwealth Data Center.
Reference interChange CMS
647 DRG File File The Drug Related Group Relative Weight file from CMS is sent to interChange through Commonwealth Data Center.
Reference interChange CMS
724 Procedure Codes File The Procedure Codes file from CMS is sent to interChange through Commonwealth Data Center.
Reference interChange CMS
645 Clinical Lab Fee File
File The Clinical Lab Fee Schedule from CMS is sent to interChange through Commonwealth Data Center.
Reference interChange CMS
Name Source System Source Contact Name
Source Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Diagnosis Codes
CMS through Commonwealth Data Center
Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946
DRG File CMS through Commonwealth Data Center
Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946
Procedure Codes
CMS through Commonwealth Data Center
Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946
Clinical Lab Fee File
CMS through Commonwealth Data Center
Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Diagnosis Codes CMS through Commonwealth Data Center
Flat file FTP Monthly Fixed width 30 Batch REFJA100 I9diagnosis.txt
DRG File CMS through Commonwealth Data Center
Flat file FTP Monthly Fixed width 103 Batch REFJA150 table5 fn07.xls
Procedure Codes CMS through Commonwealth Data Center
Flat file FTP Monthly Fixed width 30 Batch REFJA100 I9surgery.txt
Clinical Lab Fee File
CMS through Commonwealth Data Center
Flat file FTP Monthly Fixed width 140 Batch REFJA120 CLABccyy.txt
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2.12.2.1.1 Diagnosis Codes The Diagnosis Code file comes from CMS. It is delivered to the Commonwealth Data Center where it is resent to interChange.
Diagnosis Code record layout can be found on the PWB Tech Design Reference Input/Output Files ICD-9 Diagnosis CMS File Layout
2.12.2.1.2 DRG File The DRG file comes from CMS. It will be delivered to, and transmitted by Commonwealth Data Center to interChange.
DRG Relative Weight Record Layout can be found on the PWB Tech Design Reference Input/Output Files DRG Relative Weight File Layout
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2.12.2.1.3 HCPCS File The Procedure Code file comes from CMS. It is delivered to the Commonwealth Data Center and then transmitted by Commonwealth Data Center to interChange.
Procedure Code Record Layout can be found on the PWB Tech Design Reference Input/Output Files CMS HCPCS Update File Layout
2.12.2.1.4 Clinical Lab Fee File The Clinical Lab Fee file comes from CMS. It is delivered to the Commonwealth Data Center and then transmitted by Commonwealth Data Center to interChange.
Clinical Lab Fee Record Layout can be found on the PWB Tech Design Reference Input/Output Files Lab Fee File Layout
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.12.2.2 First Data Bank Input File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
419 Drug Data File EDS has a contract with First Data Bank to receive drug updates. Reference interChange FDB
644 Drug Pricing File EDS has a contract with First Data Bank to receive drug pricing updates.
Reference interChange FDB
Name Source System
Source Contact Name
Source Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Drug Data FDB Shama Pillai 800-633-3453 Shiamala_Pillai@firstdatabank.com
Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Shama Pillai
Drug Pricing FDB Shama Pillai 800-633-3453 Shiamala_Pillai@firstdatabank.com
Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Shama Pillai
Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Drug Data FDB Flat file FTP Weekly Fixed width 413 Batch REFJFTPFDB rndc14_ndc_mstr
Drug Pricing FDB Flat file FTP Weekly Fixed width 33 Batch RBTJQ320 LabelerMCCYY.txt
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2.12.2.2.1 Drug Data The Drug Data will be sent to interChange via FTP.
Drug Data Record Layout can be found on the PWB Tech Design Reference Input/Output Files FirstDataBank (FDB) Drug File Layout
2.12.2.2.2 Drug Pricing Data The Drug Pricing Data will be sent to interChange via FTP.
Drug Pricing Record Layout can be found on the PWB Tech Design Reference Input/Output Files FirstDataBank (FDB) Drug Pricing File Layout
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.13 Third Party Liability Functional Area Interfaces
2.13.1 Third Party Liability Interface Diagram A context diagram for entities within the functional area is shown below.
KASES
Passport
HMS
interChange
DMS
KAMES
2.13.2 Third Party Liability Entities Name Description
DMS Kentucky CHFS Department for Medicaid Services
KAMES Kentucky Automated Management and Eligibility System
KASES Kentucky Automated Support and Enforcement System
Passport Passport Health Plan – Medicaid Managed Care
HMS Health Management Systems
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2.13.2.1 DMS Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
484 Casualty Recovery File TPL Casualty Recovery data is extracted by interChange and written to a delimited file for spreadsheet import.
TPL interChange
482 Estate Recovery File TPL Estate Recovery data is extracted by interChange and written to a delimited file for spreadsheet import.
TPL interChange
Trust Recovery File TPL Trust Recovery data is extracted by interChange and written to a delimited file for spreadsheet import.
TPL interChange
Name Destination
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Casualty Recovery DMS Kelli O’Brien (502) 564-5183 ext 3051
Kelli.OBrien@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Kelli O’Brien
Estate Recovery DMS Kelli O’Brien (502) 564-5183 ext 3051
Kelli.OBrien@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Kelli O’Brien
Trust Recovery DMS Kelli O’Brien (502) 564-5183 ext 3051
Kelli.OBrien@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Kelli O’Brien
Name Destination Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Casualty Recovery DMS Flat file FTP Monthly Fixed width 103 Batch TPLJM305 tpl0305m_ccyymmdd_hhmmss.dat
Estate Recovery DMS Flat file FTP Monthly Fixed width 103 Batch TPLJM305 tpl0307m_ccyymmdd_hhmmss.dat
Trust Recovery DMS Flat file FTP Monthly Fixed width 103 Batch
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2.13.2.1.1 Casualty Recovery TPL Casualty Recovery data is extracted and formatted as a delimited field import file and imported to ONBASE where an ONBASE client user can view or download.
Casualty Recovery Record Layout can be found on the PWB Tech Design Third Party Liability Input/Output Files Output – Casualty Recovery to DMS
2.13.2.1.2 Estate Recovery TPL Estate Recovery data is extracted and formatted as a delimited field import file and imported to ONBASE where an ONBASE client user can view or download.
Estate Recovery Record Layout can be found on the PWB Tech Design Third Party Liability Input/Output Files Output – Estate Recovery to DMS
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.13.2.1.3 Trust Recovery TPL Trust Recovery data is extracted and formatted as a delimited field import file and imported to ONBASE where an ONBASE client user can view or download.
Trust Recovery Record Layout can be found on the PWB Tech Design Third Party Liability Input/Output Files Output – Trust Recovery to DMS
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.13.2.2 KAMES Input File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
686 Estate Recovery file File An Estate Recovery file is sent to interChange for processing TPL None interChange
338 SSA Updates File Social Security TPL Updates are extracted and sent to interChange for processing
TPL None interChange
332 TPL Updates File TPL Updates are extracted and sent to interChange for processing TPL None interChange
Name Source System
Source Contact Name
Source Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Estate Recovery file
KAMES
Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946
SSA Updates KAMES
Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946
TPL Updates KAMES
Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946
Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Estate Recovery KAMES Flat file FTP Monthly Fixed width
1013 Batch TPLJD310 tpl0310d.tpl
SSA Updates KAMES Flat file FTP Weekly Fixed width
1800 Batch TPLJW320 tpl0320w_ccyymmdd_hhmmss.dat
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Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
TPL Updates KAMES Flat file FTP Weekly Fixed width
370 Batch TPLJW330 tpl330w1_ccyymmdd_hhmmss.dat
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2.13.2.2.1 Estate Recovery File The Estate Recovery file will come from KAMES to interChange through the Commonwealth Data Center EDI environment and the interChange (ODC) EDI environments.
The Estate Recovery Record Layout can be found on the PWB Tech Design Third Party Liability Input/Output Files Input – KAMES Estate Recovery
2.13.2.2.2 SSA Updates InterChange receives an SSA Data Update through Commonwealth Data Center. It is sent through Commonwealth Data Center EDI and the interChange (ODC) EDI Environments.
SSA Update Record Layout can be found on the PWB Tech Design Third Party Liability Input/Output Files Input – SSA-8019-U2
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.13.2.2.3 TPL Updates InterChange receives a TPL Update through Commonwealth Data Center. It is sent through Commonwealth Data Center EDI and the interChange (ODC) EDI Environments.
TPL Resource Update Record Layout can be found on the PWB Tech Design Third Party Liability Input/Output Files Input – KAMES Resource Info
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.13.2.3 KAMES Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
690 TPL Adds File TPL Segments added during the previous month are extracted and sent to KAMES.
TPL KAMES interChange
691 TPL End Dates File TPL Segments “end dated” during the previous month are extracted and sent to KAMES.
TPL KAMES interChange
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
TPL Adds KAMES
Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946
TPL End Dates KAMES
Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946
Name Destination System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
TPL Adds KAMES Flat file FTP Monthly Fixed width 312 Batch TPLJM170 tpl0170m_ccyymmdd_hhmmss.dat
TPL Ends KAMES Flat file FTP Monthly Fixed width 69 Batch TPLJM170 tpl0171m_ccyymmdd_hhmmss.dat
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2.13.2.3.1 TPL SSI Adds InterChange will send TPL adds to KAMES through the interChange and Commonwealth Data Center EDI Environments.
TPL Adds Record Layout can be found on the PWB Tech Design Third Party Liability Input/Output Files Output – TPL Resource Information to DCBS
2.13.2.3.2 TPL SSI Ends InterChange will send TPL adds to KAMES through the interChange and Commonwealth Data Center EDI Environments.
TPL Ends Record Layout can be found on the PWB Tech Design Third Party Liability Input/Output Files Output – TPL Member End Dated Segments to DCBS
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.13.2.4 KASES Input File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
617 Absent Parent File Child Services sends interChange a file with Absent Parent information for TPL update.
TPL None interChange
Name Source System
Source Contact Name
Source Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Absent Parent KAMES
Greg Whitt (502) 564-0105 ext. 10234
Greg.Whitt@ky.gov Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946
Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Absent Parent KAMES Flat file FTP Monthly Fixed width 282 Batch TPLJM420 tpl420m1_ccyymmdd_hhmmss.dat
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2.13.2.4.1 Absent Parent File Absent Parent Data from KASES is sent to interChange for processing through the Commonwealth Data Center and interChange (ODC) EDI Environments. After processing, the file is sent to HMS.
Child Support Record Layout can be found on the PWB Tech Design Third Party Liability Input/Output Files Input – Absent Parent Information from DCSE
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.13.2.5 Passport Input File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
543 Commercial Insurance
File Commercial Insurance Data is sent to interChange from Passport. This data is not used. It is forwarded to HMS.
TPL interChange Passport
Name Source System
Source Contact Name
Source Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Commercial Insurance
Passport Gail Gatto (215) 937-8474 Gail.Gatto@kmhp.com Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Gail or after hours contact EDI Help Desk at (215) 937-8473
Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Commercial Insurance
Passport Flat file FTP Monthly, first week
Fixed width 251 Batch FTS PASSMTPLmmyy.txt
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2.13.2.5.1 Commercial Insurance Passport sends Commercial Insurance Data to interchange. This data is forwarded to HMS.
Record layout is unknown. The file is not processed by interChange. It is only forwarded to HMS
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2.13.2.6 Passport Output File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
549 Member TPL Data File Member Eligibility TPL changes are sent daily to Passport. This data is too extensive to fit on an 834. That’s why it’s a separate daily feed
TPL interChange Passport
547 TPL Carrier File File A TPL insurance carrier file is sent to Passport monthly. TPL interChange Passport
Name Destination System
Destination Contact Name
Destination Contact Phone Number
Destination Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Member TPL Data
Passport Gail Gatto (215) 937-8474 Gail.Gatto@kmhp.com Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Gail or after hours contact EDI Help Desk at (215) 937-8473
TPL Carrier File
Passport Gail Gatto (215) 937-8474 Gail.Gatto@kmhp.com Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Gail or after hours contact EDI Help Desk at (215) 937-8473
Name Destination System
Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Member TPL Data Passport Flat file FTP Daily Fixed width 894 Batch TPLJD080 KYDTPL_ccyymmdd_hhmmss.dat
TPL Carrier File Passport Flat file FTP Monthly Fixed width 600 Batch TPLJM079 tpl0079m_ccyymmdd_hhmmss.dat
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2.13.2.6.1 Member TPL Data interChange sends TPL updates daily to Passport.
Member TPL Update Record Layout can be found on the PWB Tech Design Third Party Liability Input/Output Files Output – TPL Resource File to Passport
2.13.2.6.2 TPL Carrier File InterChange sends TPL insurance carrier updates to Passport.
TPL Carrier Record Layout can be found on the PWB Tech Design Third Party Liability Input/Output Files Output – TPL Carrier File sent to Passport
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 185
2.13.2.7 HMS Input File ID Name Interface Type Description Subsystems
Impacted System Entry Point
Data Owner
567 TPL Billing File Third Party Liability Billing transactions are sent to interchange from HMS. TPL interChange HMS
561 TPL Adds File Third Party Liability Add transactions are sent to interchange from HMS. TPL interChange HMS
564 TPL Changes File Third Party Liability Change transactions are sent to interchange from HMS.
TPL interChange HMS
560 TPL Cost Avoidance
File Third Party Cost Avoidance transactions are sent to interchange from HMS.TPL interChange HMS
562 TPL MSE Adds File Third Party Cost MSE Adds transactions are sent to interchange from HMS.
TPL interChange HMS
566 TPL MSE Changes File Third Party Cost MSE Changes transactions are sent to interchange from HMS.
TPL interChange HMS
563 TPL Enforcement File Third Party Cost MSE Enforcement transactions are sent to interchange from HMS.
TPL interChange HMS
Name Source System
Source Contact Name
Source Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
TPL Billing HMS Chris Sallee (704) 372-9384 ext 8117
CSallee@Hmsy.com Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Chris Sallee. After hours, dial the HMS Help Desk, (866) 857-0089
TPL Adds HMS Chris Sallee (704) 372-9384 ext 8117
CSallee@Hmsy.com Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Chris Sallee. After hours, dial the HMS Help Desk, (866) 857-0089
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 186
Name Source System
Source Contact Name
Source Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
TPL Changes HMS Chris Sallee (704) 372-9384 ext 8117
CSallee@Hmsy.com Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Chris Sallee. After hours, dial the HMS Help Desk, (866) 857-0089
TPL Cost Avoidance
HMS Chris Sallee (704) 372-9384 ext 8117
CSallee@Hmsy.com Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Chris Sallee. After hours, dial the HMS Help Desk, (866) 857-0089
TPL MSE Adds HMS Chris Sallee (704) 372-9384 ext 8117
CSallee@Hmsy.com Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Chris Sallee. After hours, dial the HMS Help Desk, (866) 857-0089
TPL MSE Changes HMS Chris Sallee (704) 372-9384 ext 8117
CSallee@Hmsy.com Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Chris Sallee. After hours, dial the HMS Help Desk, (866) 857-0089
TPL Enforcement HMS Chris Sallee ((704) 372-9384 ext 8117
CSallee@Hmsy.com Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Chris Sallee. After hours, dial the HMS Help Desk, (866) 857-0089
Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
TPL Billing HMS Flat file FTP Request Fixed width 156 Batch TPLJO110 tpl01110_ccyymmdd_hhmmss.dat
TPL Adds HMS Flat file FTP Request Fixed width 215 Batch TPLJO490 tpl0490r_rec_code_5_ccyymmdd_hhmmss.dat
TPL Changes HMS Flat file FTP Request Fixed width 215 Batch TPLJO520 tpl0490r_rec_code_6_ccyymmdd_hhmmss.dat
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Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
TPL Cost Avoidance
HMS Flat file FTP Request Fixed width 215 Batch TPLJO900 tpl0490r_rec_code_4_ccyymmdd_hhmmss.dat
TPL MSE Adds HMS Flat file FTP Request Fixed width 215 Batch TPLJO500 tpl0490r_rec_code_7_ccyymmdd_hhmmss.dat
TPL MSE Changes
HMS Flat file FTP Request Fixed width 215 Batch TPLJO530 tpl0490r_rec_code_8_ccyymmdd_hhmmss.dat
TPL Enforcement
HMS Flat file FTP Request Fixed width 215 Batch TPLJO510 tpl0490r_rec_code_9_ccyymmdd_hhmmss.dat
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 188
2.13.2.7.1 TPL Billing HMS sends a TPL Billing File to interChange for processing.
HMS
ODC EDI
Flatfile
interChange
TPL Billing Record Layout can be found on the PWB Tech Design Third Party Liability Input/Output Files Input – Billing File from HMS
2.13.2.7.2 TPL Adds TPL Add transactions are sent by HMS to interChange for processing.
HMS
ODC EDI
Flatfile
interChange
TPL Adds Record Layout can be found on the PWB Tech Design Third Party Liability Input/Output Files Input – TPL Resource Info from PCG
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 189
2.13.2.7.3 TPL Changes The TPL Change Transactions file is sent to interChange for processing.
HMS
ODC EDI
Flatfile
interChange
TPL Changes Record Layout can be found on the PWB Tech Design Third Party Liability Input/Output Files Input - TPL Resource Info from PCG
2.13.2.7.4 TPL Cost Avoidance The TPL Cost Avoidance file is sent by HMS to interChange for processing.
TPL Cost Avoidance Record Layout can be found on the PWB Tech Design Third Party Liability Input/Output Files Input - TPL Resource Info from PCG
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 190
2.13.2.7.5 TPL MSE Adds The TPL MSE Adds transactions are sent to interChange for processing.
HMS
ODC EDI
Flatfile
interChange
TPL MSE Adds Record Layout can be found on the PWB Tech Design Third Party Liability Input/Output Files Input - TPL Resource Info from PCG
2.13.2.7.6 TPL MSE Changes The TPL MSE Change transactions are sent by HMS to interChange for processing.
HMS
ODC EDI
Flatfile
interChange
TPL MSE Changes Record Layout can be found on the PWB Tech Design Third Party Liability Input/Output Files Input - TPL Resource Info from PCG
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 191
2.13.2.7.7 TPL Enforcement The TPL MSE (Enforcement) transactions are sent by HMS to interChange for processing.
HMS
ODC EDI
Flatfile
interChange
TPL MSE (Enforcement) Record Layout can be found on the PWB Tech Design Third Party Liability Input/Output Files Input - TPL Resource Info from PCG
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 192
2.13.2.8 HMS Output File ID Name Interface Type Description Subsystems Impacted System Entry Point Data Owner
550 Public Assistance File
File A public assistance file is sent from interChange to HMS Claims HMS interChange
549 Billing File File A TPL Billing file is sent from interChange to HMS Claims HMS interChange
552 Carrier File File A TPL Carrier file is sent from interChange to HMS Claims HMS interChange
551 Resource File File A TPL Resource file is sent from interChange to HMS Claims HMS interChange
Name Destination System
Destination Contact Name
Source Contact Phone Number
Source Contact Email Address
EDS Contact Name
EDS Contact Phone Number
EDS Contact Email Address
Escalation Procedure
Public Assistance File
HMS Chris Sallee (704) 372-9384 ext 8117
CSallee@Hmsy.com Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Chris Sallee. After hours, dial the HMS Help Desk, (866) 857-0089
Billing File HMS Chris Sallee (704) 372-9384 ext 8117
CSallee@Hmsy.com Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Chris Sallee. After hours, dial the HMS Help Desk, (866) 857-0089
Carrier File HMS Chris Sallee (704) 372-9384 ext 8117
CSallee@Hmsy.com Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Chris Sallee. After hours, dial the HMS Help Desk, (866) 857-0089
Resource File HMS Chris Sallee (704) 372-9384 ext 8117
CSallee@Hmsy.com Bill Ponder (502) 209-3145 Bill.Ponder@eds.com Contact Chris Sallee. After hours, dial the HMS Help Desk, (866) 857-0089
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 193
Name Source System Transaction Type
Transmission Type
Frequency Record Format
Record length
Batch or Real-time
Job Name File Name
Public Assistance File
HMS Flat file FTP Weekly Fixed width
360 Batch TPLJW330 tpl330w2_ccyymmdd_hhmmss.dat
Billing File HMS Flat file FTP Monthly Fixed width
2360 Batch TPLJD080 KYDTPL_ccyymmdd_hhmmss.dat
Carrier File HMS Flat file FTP Monthly Fixed width
500 Batch TPLJM140 tpl0140m_ccyymmdd_hhmmss.dat
Resource File HMS Flat file FTP Monthly Fixed width
846 Batch TPLJM141 tpl0141m_ccyymmdd_hhmmss.dat
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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2.13.2.8.1 Public Assistance File The TPL Public Assistance file is sent to HMS using the interChange (ODC) EDI Environment to facilitate the file transfer.
Public Assistance Record Layout can be found on the PWB Tech Design Third Party Liability Input/Output Files Output – Public Assistance File
2.13.2.8.2 Billing File TPL Billing data is extracted and sent to HMS using the interChange (ODC) EDI Environment to facilitate the file transfer.
TPL Billing Record Layout can be found on the PWB Tech Design Third Party Liability Input/Output Files Output – TPL BIlling File to PCG
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 195
2.13.2.8.3 Carrier File TPL Carrier data is extracted and sent to HMS using the interChange (ODC) EDI Environment to facilitate the file transfer.
TPL Carrier Record Layout can be found on the PWB Tech Design Third Party Liability Input/Output Files Output – TPL Carrier File to PCG
2.13.2.8.4 Resource File TPL Resource data is extracted and sent to HMS using the interChange (ODC) EDI Environment to facilitate the file transfer.
TPL Resource Record Layout can be found on the PWB Tech Design Third Party Liability Input/Output Files Output – TPL Resource File to PCG
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 196
3 Entity Interface Cross-Reference List
This section will list interfaces by entity.
3.1 CMS Interfaces Name Input/Output Frequency Description Functional Area
Clinical Lab Fee Schedule Input Request Lab Fee Schedule Reference
Diagnosis Code File Input Request Diagnosis Codes from CMS Reference
Drug Labeler file Input Request Drug Labeler download from CMS Reference
HCPCS Update Input Annual Procedure Code Update Reference
MSIS Quarterly Eligibility Tape Output Quarterly MSIS Tapes MAR
MSIS Tapes IP Output Quarterly MSIS Tapes MAR
MSIS Tapes LT Output Quarterly MSIS Tapes MAR
MSIS Tapes OT Output Quarterly MSIS Tapes MAR
MSIS Tapes RX Output Quarterly MSIS Tapes MAR
Buy-in Billing Part A Input Monthly State Buy In Part A from CMS Buy-in
Buy-in Billing Part B Input Monthly State Buy In Part B from CMS Buy-in
Buy-in Part D MMA Input Monthly Part D Buy In CMS to UNISYS (MMA PHASE DOWN FILE) Member
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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Name Input/Output Frequency Description Functional Area
Buy-in Input Part A Output Monthly Buy-in Input file created by HMS Buy-in
Buy-in Input Part B Output Monthly Buy-in Input file created by HMS Buy-in
EDB Finder Output Monthly Monthly EDB Finder file Buy-in
Monthly Part D Extract for CMS
Output Monthly Response to Part D Extract Member
3.2 COBC Interfaces Name Input/Output Frequency Description Functional Area
Crossover Claims Input Request Crossover claims from CMS contractor for COBA Claims
Recipient Eligibility File Output Monthly Recipient Eligibility file sent to COBC Member
3.3 Custom Data Processing Interfaces Name Input/Output Frequency Description Functional Area
EPSDT Claims Output Every Other Month
EPSDT (under 21 report) Claims EPSDT
Recipient Eligibility/EPSDT Output Monthly Recipient Eligibility/EPSDT (under 21 report) EPSDT
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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3.4 DMS Interfaces Name Input/ Output Frequency Description Functional Area
Child Medicaid Eligible
Output Quarterly Extract of children 5 to 18 for Ky Dept of Education Member
ICFMR PROV TYPE 11 Claim Stats
Output Monthly ICF and MR claim statistics by month Claims
Ineligible Part A Crossover Claims (followup)
Output Quarterly Evette Patton - pharmaceutical claim overpayments for nursing facility residents where payment was included in the Medicare Part A nursing facility coverage
Claims
Ineligible Part A Crossover Claims (prelim)
Output Quarterly Evette Patton - pharmaceutical claim overpayments for nursing facility residents where payment was included in the Medicare Part A nursing facility coverage
Claims
NURSING FACILITES Claims Extract
Output Monthly Nursing Facilities claim statistics by month Claims
PRESUMPITIVE ELIGIBILITY EXTRACT
Output Monthly Extract of members with presumptive eligibility Member
Preventive Services Claims Extract
Output Monthly Preventive Services Providers claim statistics by month Claims
Provider Rate Information
Input Daily Nursing Home Rate Updates Provider
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 199
Name Input/ Output Frequency Description Functional Area
TPL CASUALTY RECOVERY ASCII FILE
Output Monthly TPL Casualty Recovery data for DMS TPL
TPL Contractor Recoupment Extract (code 52)
Output Monthly TPL Code 52 data for DMS Financial
TPL Contractor Recoupment Extract (non lock-box)
Output Monthly TPL non lock-box data for DMS Financial
TPL ESTATE RECOVERY ASCII FILE
Output Monthly TPL Extate Recovery data for DMS TPL
TPL TRUST RECOVERY ASCII FILE
Output Monthly TPL Trust Recovery data for DMS TPL
FINAL PAYMENT PROCESSING
Output Weekly Capitation Extract Financial
3.5 eKASPER Interfaces Name Input/Output Frequency Description Functional Area
Medicaid Member Response Input Bi-Weekly Member response from eKASPER to the DSS DSS
Medicaid Member Request Output Bi-Weekly Member request from the DSS DSS
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 200
Name Input/Output Frequency Description Functional Area
Medicaid Provider Response Input Bi-Weekly Provider response from eKASPER to the DSS DSS
Medicaid Provider Request Output Bi-Weekly Provider request from the DSS DSS
3.6 eMARS Interfaces Name Input/Output Frequency Description Functional Area
KenPAC Financial Check Writer
Output Weekly KenPAC Financial Check Writer Financial
KenPAC Financial EFT Output Monthly KenPAC EFT transactions Financial
Lock-in check Writer Output Monthly Lock-in check Writer Financial
Lock-in EFT transactions Output Monthly Loc-kin EFT transactions Financial
Non-provider Check Writer Output Weekly Non-provider Check Writer Financial
On Demand Check Writer Output Daily Daily On Demand Check Writer Financial
Provider 1099 Updates Output Annual Provider 1099 Updates Financial
Stars/Mars Refund file Output Weekly Stars/Mars Refund file Financial
Warrant check Writer Output Weekly Warrant check Writer Financial
Weekly EFT transactions Output Weekly Weekly EFT transactions Financial
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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3.7 First Data Bank Interfaces Name Input/Output Frequency Description Functional Area
Drug Data Input Weekly Drug Data Reference
Drug Pricing File Input Weekly Drug Pricing Reference
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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3.8 First Health KMAA Interfaces Name Input/Output Frequency Description Functional Area
Buy-in Output Daily Buy-in Updates Buy-in
Case/Disease Mgmt Updates Input Daily Case & Disease Mangement Updates Member
Lock-in Updates Input Daily Lock-in Updates Member
CLIA OSCAR File Input Daily CLIA data passed on to interchange from KMAA Provider
Prescribing License File Input Request Prescribing license data passed on to interchange from KMAA
Provider
Provider Enrollment Update Input Interactive Provider adds and updates from KMAA Provider
Recipient Eligibility Output Daily Daily member updates from interchange Member
Recipient Eligibility Full File Output Monthly Weekly full file member data from interchange Member
Recipient Waiver Eligibility Updates Input Daily Recipient Waiver Eligibility Updates PA
Spenddown Output Daily Spend-down daily changes extracted for KMAA Member
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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3.9 First Health PBA Interfaces Name Input/Output Frequency Description Functional Area
J-Code Claims Output Quarterly J-Code Claims for PBA drug rebate Claims
MTD Paid Claims Output Monthly MTD Paid Claims from interchange Claims
Pharmacy Claims Input Every other week Pharmacy Claims, adjudicated by PBA Claims
Provider Data Output Daily Provider Data daily updates Provider
Provider License Address Output Daily Provider License Address daily updates Provider
Provider License File Output Daily Provider License Base records daily updates Provider
Provider License Speciality Output Daily Provider License specialty code daily updates Provider
Recipient Eligibility Output Daily Daily member updates from interchange Member
Recipient Eligibility (full File) Output Monthly Monthly member full file form interchange Member
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 204
3.10 Impact Plus Interfaces Name Input/Output Frequency Description Functional Area
BIWEEKLY CLAIMS PAID Output Monthly BIWEEKLY CLAIMS PAID DATA FOR IMPACT PLUS Claims
Denials - FINAL PAYMENT PROCESSING
Output Weekly EFT Denials - FINAL PAYMENT PROCESSING. Financial
Refunds - FINAL PAYMENT PROCESSING
Output Weekly EFT Refunds - FINAL PAYMENT PROCESSING. Financial
Transfers - FINAL PAYMENT PROCESSING
Output Weekly EFT Transfers - FINAL PAYMENT PROCESSING. Financial
3.11 IPRO Interfaces Name Input/Output Frequency Description Functional Area
IPRO Drug Code Extract Output Monthly NDC code extract DSS
IPRO Eligibility Extract Output Monthly Medicaid member extract DSS
IPRO Encounter Extract Output Monthly Processed encounter extract DSS
IPRO Procedure Code Extract Output Monthly Procedure code extract DSS
IPRO Provider Extract Output Monthly Provider list extract DSS
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 205
3.12 KAMES Interfaces Name Input/Output Frequency Description Functional Area
Estate Recovery File Input Weekly TPL
KAMES Eligibility File for DSS Input Weekly accum file of US triggers DSS
KAMES Lock-in Extract Output KAMES Lock-in Extract occurring multiple times per day Member
KENPAC - 1st Issuance Input Monthly Recip KenPAC Eligibility - 1st Issuance Member
KENPAC - 2nd Issuance Input Monthly Recip KenPAC Eligibility - 2nd Issuance Member
KENPAC Extract File Output Daily KENPAC Extract File Managed Care
LTC Updates Input Long Term Care updates occurring multiple times per day Member
Managed Care KAMES Language Input Monthly EXTRACT MANAGE CARE LANG/ETHN Managed Care
Patient Liability Updates Input Recipient Updates occurring multiple times per day Member
Pro Cert Extracts Output Daily Pro Cert Extract KAMES
Provider Master File Daily Changes Output Daily Provider Master File Daily Changes Provider
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 206
Name Input/Output Frequency Description Functional Area
Recipient Date of Death Output Monthly Recipient Date of Death Member
RECON - 1st Issuance Input Monthly Member Eligibility Reconciliation - 1st Issuance Member
RECON - 2nd Issuance Input Monthly Member Eligibility Reconciliation - 2nd Issuance Member
SSA Updates Input Weekly Social Security Administration Updates TPL
TPL to MMIS Input Weekly Third party liability to MMIS TPL
3.13 KASES Interfaces Name Input/Output Frequency Description Functional Area
Child Services Data Match Input Monthly Child Services Absent Parent Data TPL
Child Support Extract Input Monthly Child Support Extract from KASES DSS
3.14 McKesson Interfaces Name Input/Output Frequency Description Functional Area
McKesson Dental Claims Output TBD Claim-check extract Claims
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 207
3.15 Myers & Stauffer Interfaces Name Input/Output Frequency Description Functional Area
LTC EXTRACT Output Monthly Member
3.16 Navigant Interfaces Name Input/Output Frequency Description Functional Area
Inpatient Claims Output Request Inpatient Claims Extract for DRG Rate Setting DSS
Outpatient Claims Output Request Outpatient Claims Extract for DRG Rate Setting DSS
3.17 PA-62 Interfaces Name Input/Output Frequency Description Functional Area
Recipient Updates Input Recipient Updates occurring multiple times per day Member
3.18 PA-62/SDX Combined Interfaces Name Input/Output Frequency Description Functional Area
Cards Issued from PA & SDX Input Daily Cards Issued from PA & SDX for month Member
HIC Updates Input Request HIC Updates Member
KenPAC Address Information Input Weekly KenPAC Address Information Provider
LTC Updates Input Long Term Care Updates Member
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 208
Name Input/Output Frequency Description Functional Area
Managed Care SDX Language Input Daily Eligible Managed Care Recipients Managed Care
PA62 Extract Input Weekly PA Applications and Discontinuances DSS
Patient Liability Updates Input Patient Liability Updates occurring multiple times per day Member
Recip Eligibility RECON - 1st Issuance
Input Monthly Member Eligibility Reconciliation - 1st Issuance Member
Recip Eligibility RECON - 2nd Issuance
Input Monthly Member Eligibility Reconciliation - 2nd Issuance Member
Recip KenPAC Eligibility - 1st Issuance
Input Monthly KenPAC Member Eligibility Reconciliation - 1st Issuance Member
Recip KenPAC Eligibility - 2nd Issuance
Input Monthly KenPAC Member Eligibility Reconciliation- 2nd Issuance Member
Pro Cert Extracts Output Daily Recipient Extracts PA
Provider Master Extract Output Daily Provider Long Term Care Extract Provider
3.19 Passport Health Plan (AmeriHealth Mercy) Interfaces Name Input/Output Frequency Description Functional Area
Cards Issued from PA & SDX Input Daily Cards Issued from PA & SDX for month Member
HIC Updates Input Request HIC Updates Member
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 209
Name Input/Output Frequency Description Functional Area
KenPAC Address Information Input Weekly KenPAC Address Information Provider
LTC Updates Input Long Term Care Updates Member
Managed Care SDX Language Input Daily Eligible Managed Care Recipients Managed Care
PA62 Extract Input Weekly PA Applications and Discontinuances DSS
Patient Liability Updates Input Patient Liability Updates occurring multiple times per day Member
Recip Eligibility RECON - 1st Issuance
Input Monthly Member Eligibility Reconciliation - 1st Issuance Member
Recip Eligibility RECON - 2nd Issuance
Input Monthly Member Eligibility Reconciliation - 2nd Issuance Member
Recip KenPAC Eligibility - 1st Issuance
Input Monthly KenPAC Member Eligibility Reconciliation - 1st Issuance Member
Recip KenPAC Eligibility - 2nd Issuance
Input Monthly KenPAC Member Eligibility Reconciliation- 2nd Issuance Member
Pro Cert Extracts Output Daily Recipient Extracts PA
Provider Master Extract Output Daily Provider Long Term Care Extract Provider
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 210
3.20 HMS Interfaces Name Input/Output Frequency Description Functional Area
Commercial TPL data Input Monthly Outbound changes to commercial TPL data TPL
Dental Encounters Input Daily Dental Encounters Claims
HCFA Encounters Input Daily HCFA Encounters Claims
Pharmacy Encounters Input Request NCPDP Encounters Claims
UB-92 Encounters Input Request UB-92 Encounters Claims
820 Transactions Output Weekly 820 Transactions Managed Care
834 Transaction Output Daily Managed Care Eligibility Update Managed Care
834 Transaction Run
During Recon
Output During Recon Twice a month extract during Recon Managed Care
834 Transaction Run
Monthly
Output Monthly Monthly eligibility roster for all managed care region 3 members eligible in the upcoming month
Managed Care
CLIA Data Output Weekly CLIA Data Provider
Daily Member TPL changes Output Daily Inbound Daily TPL changes TPL
Encounter Activity Output Weekly Weekly Encounter Activity Results Claims
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 211
Name Input/Output Frequency Description Functional Area
MANAGED CARE KenPAC Output Monthly Mgd care extract for excel Managed Care
MANAGED CARE Lock-in Output Monthly Mgd care extract for excel Managed Care
MANAGED CARE LTC Output Monthly Mgd care extract for excel Managed Care
MANAGED CARE Waiver Output Monthly Mgd care extract for excel Managed Care
Monthly Member TPL changes Output Monthly Inbound Monthly Capitation Enrollment TPL file TPL
Part A Encounter Crossovers Output Weekly Part A Encounter Crossover Results Claims
Part B Encounter Crossovers Output Daily Part B Crossovers Claims
Provider Extract File Output Monthly Provider Extract File Provider
Provider License File Output Monthly Provider License File Provider
Recon Member TPL changes Output Monthly Inbound Monthly Reconciliation TPL File TPL
TPL Carrier File Output Quarterly TPL Carrier File TPL
3.21 Price Waterhouse Coopers Interfaces Name Input/Output Frequency Description Functional Area
Budget Forecast Files Output Request Extracts for budget forecasting DSS
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 212
Name Input/Output Frequency Description Functional Area
Passport Rate Setting Files Output Request Set of managed care data for rate setting DSS
3.22 Provider Interfaces Name Input/Output Frequency Description Functional Area
837 Institutional Input Request BBS Submissions - 837 Institutional EDI
837 Dental Input Request BBS Submissions - 837 Dental EDI
837 Professional Input Request BBS Submissions - 837 Professional EDI
835 Remittance Advice Output Weekly BBS Retrieval - Remittance Advice EDI
837 Dental Input Request Provider Internet Submissions - 837 Institutional Internet
837 Institutional Input Request Provider Internet Submissions - 837 Dental Internet
837 Professional Input Request Provider Internet Submissions - 837 Professional Internet
835 Remittance Advice Output Weekly Provider Internet Retrieval - Remittance Advice Internet
837 Dental Batch Input Request Provider Internet Batch Submissions - 837 Institutional Internet
837 Institutional Batch Input Request Provider Internet Batch Submissions - 837 Dental Internet
837 Professional Batch Input Request Provider Internet Batch Submissions - 837 Professional Internet
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 213
3.23 SHPS Interfaces Name Input/Output Frequency Description Functional Area
Prior Auth Transactions Input Daily Prior Auth Updates PA
Provider Updates Output Daily Provider Updates for MaxMC Provider
Member Updates Output Daily Member Updates for MAxMC Member
3.24 SDX Interfaces Name Input/Output Frequency Description Functional Area
Recipient Updates Input SDX MMIS F3 File – multiple updates occurring per day Member
3.25 Transportation Cabinet Interfaces Name Input/Output Frequency Description Functional Area
Transportation Encounters Input Request Private Transportation Encounters Claims
Transportation Remit File Output Weekly Private Transportation Remit Financial
Transportation Encounter Activity
Output Weekly Encounter Activity - Private Transportation Claims
Transportation Encounter Response
Output Request Results of Private Transportation Claims
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
Printed: 3/7/2008 Page 214
3.26 VAN (Transaction Service Providers) Interfaces Name Input/Output Frequency Description Functional Area
270 / 271 Transaction Input/Output APS Billing EDI
270 / 271 Transaction Input/Output Custom Data Processing EDI
270 / 271 Transaction Input/Output HDX EDI
270 / 271 Transaction Input/Output MedAccess Plus EDI
270 / 271 Transaction Input/Output NEBO Systems EDI
270 / 271 Transaction Input/Output Norton Healthcare EDI
270 / 271 Transaction Input/Output Passport Health Communications EDI
270 / 271 Transaction Input/Output WebMD/Emdeon EDI
270 / 271 Transaction Input/Output ZIRMED EDI
276 / 277 Transaction Input/Output HDX EDI
276 / 277 Transaction Input/Output Norton Healthcare EDI
276 / 277 Transaction Input/Output Passport Health Communications EDI
276 / 277 Transaction Input/Output WebMD/Emdeon EDI
276 / 277 Transaction Input/Output ZIRMED EDI
Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan
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3.27 Vital Stats Interfaces Name Input/Output Frequency Description Functional Area
Birth Record Extract Input Weekly Birth Data for DSS DSS
Death Record Extract Input Bi-Weekly Death Data for DSS DSS
Recipient Date of Death Input Monthly Recipient Date of Death for Member Updates Member
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