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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

Commonwealth of Kentucky – MMIS New KY MMIS Interoperability Plan

Printed 3/7/2008 Page i

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


Printed 3/7/2008 Page ii

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


Printed: 3/7/2008 Page 1

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.



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



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



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

[email protected] Bill Ponder (502) 209-3145 [email protected] 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




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



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



2.1.2.2 CMS Output File ID Name Interface



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




Buy-in Input Data

CMS through Commonwealth Data Center

Greg Whitt (502) 564-0105 ext. 10234


EDB Finder CMS through Commonwealth Data Center

Greg Whitt (502) 564-0105 ext. 10234


Name Destination System Transaction Type

Transmission Type


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


80 Batch ELGJM153 buym_edbfinder_ccyymmdd_hhmmss.dat



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



2.1.2.3 First Health KMAA Output File ID Name Interface



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





EDS Contact Name




Buy-in Updates FIQM Bob Gaston (804) 527-5745 [email protected] Ponder (502) 209-3145 [email protected]

Contact Bob Gaston, if unreachable, call 800-453-8780, option 3, category – applications, type – FIQM, item – Data Loads/Extracts


Transmission Type


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.



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



2.1.2.4 HMS Input File Id Name Interface Type Description Subsystems


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



EDS Contact Name




Medicare Entitlement

HMS Chris Sallee (704) 372-9384 ext 8117

[email protected] Bill Ponder (502) 209-3145 [email protected] Contact Chris Sallee. After hours, dial the HMS Help Desk, (866) 857-0089


Transmission Type


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



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



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



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


Providers Medicaid Healthcare Providers

Transportation Kentucky Transportation Cabinet



2.2.2.1 COBC Input File ID Name Interface Type Description Subsystems


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



EDS Contact Name




Crossover Claims

COBC Becky Able (803) 772-0911 [email protected] Bill Ponder (502) 209-3145 [email protected] Contact COBC Help Desk Technical Support at (212) 615-4357


Transmission Type


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



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



2.2.2.2 DMS Output File ID Name Interface Type Description Subsystems


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




EDS Contact Name




ICF/MR Claims DMS Frances Wise (502) 564-5707 [email protected] Bill Ponder (502) 209-3145 [email protected] Contact Frances Wise

Nursing Facilities Claims

DMS Frances Wise (502) 564-5707 [email protected] Bill Ponder (502) 209-3145 [email protected] Contact Frances Wise

Ineligible Crossover Claims

DMS Evette Patton (502) 564-1012 [email protected] Bill Ponder (502) 209-3145 [email protected] Contact Evette Patton

Preventive Service Claims

DMS Patty Sewell (502) 564-6511 [email protected] Bill Ponder (502) 209-3145 [email protected] Contact Patty Sewell



Name Destination Transaction Type

Transmission Type


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



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



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



2.2.2.3 First Health PBA Input File ID Name Interface Type Description Subsystems


Data Owner

421 Pharmacy Claims File Pharmacy Claims from First Health Pharmacy Benefits Administrator

Claims interChange PBA

Name Source System

Source Contact Name



EDS Contact Name




Pharmacy Claims

PBA Bruce Slough (804) 934-4247 [email protected]

Bill Ponder (502) 209-3145 [email protected] Contact Bruce Slough or Steve Elkins ([email protected]) (804) 317-1991, if unreachable, call 800-453-8780, option 3, category – applications, type – First RX, item – Extract-claims


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



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.



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





EDS Contact Name




Non-pharmacy Claims



J-code Claims PBA Bruce Slough (804) 934-4247 [email protected]



Transmission Type


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




Transmission Type


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



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



2.2.2.5 McKesson Output File ID Name Interface Type Description Subsystems


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





EDS Contact Name




Dental Claims ClaimCheck Sarah Hawkins

(303) 346-7787 [email protected]

Bill Ponder (502) 209-3145 [email protected] Contact Sarah Hawkins


Transmission Type


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



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



2.2.2.6 Passport Input File ID Name Interface Type Description Subsystems


Data Owner

542 Professional Encounters

File Region 3 Managed Care Encounter batch file from the Passport Health Plan

Claims interChange Passport

540 Institutional Encounters



541 Dental Encounters File Region 3 Managed Care Encounter batch file from the Passport Health Plan


528 Pharmacy Encounters



Name Source System

Source Contact Name



EDS Contact Name




Professional Encounters

Passport Gail Gatto (215) 937-8474 [email protected] Ponder (502) 209-3145 [email protected] Contact Gail or after hours contact EDI Help Desk at (215) 937-8473

Institutional Encounters


Dental Encounters


Pharmacy Encounters





Transmission Type


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



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.


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



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.






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.


• Health Care Claim: Dental ASC X12N 837 (004010X097A1) National EDI Transaction Set Implementation Guide





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.



2.2.2.7 Passport Advantage Input File ID Name Interface Type Description Subsystems


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



EDS Contact Name




Crossover Claims Passport Advantage

Donna Everwine (215) 937-8695 [email protected]

Bill Ponder (502) 209-3145 [email protected] Contact Donna or after hours contact EDI Help Desk at (215) 937-8473


Transmission Type


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



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.








2.2.2.8 HMS Output File ID Name Interface Type Description Subsystems


555 Paid Claims File Paid claims file extract for HMS Claims HMS interChange





EDS Contact Name




Paid Claims HMS Chris Sallee (704) 372-9384 ext 8117



Transmission Type


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



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



2.2.2.9 Transportation Cabinet Input File ID Name Interface Type Description Subsystems


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



EDS Contact Name




Encounters Transportation Cabinet

Jeremy Thompson


Bill Ponder (502) 209-3145 [email protected] Contact Larry Pilcher (502) 564-8900


Transmission Type


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



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



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



2.3.2.1 eKASPER Input File ID Name Interface Type Description Subsystems


Data Owner

725 Member Eligibility File Member Eligibility Information DSS eKASPER interChange

Name Source System

Source Contact Name



EDS Contact Name




Member Eligibility eKASPER Michael Smithson

(502) 564-7985 ext 3829

[email protected]

Marilynn Hartman


Contact Michael Smithson, then Ashish Virmani 502-564-6479 x4547


Transmission Type


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



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



2.3.2.2 eKASPER Output File ID Name Interface Type Description Subsystems


807 Member Eligibility File Member Eligibility Information DSS eKASPER interChange





EDS Contact Name




Member Eligibility eKASPER Michael Smithson

(502) 564-7985 ext 3829

[email protected]

Marilynn Hartman


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



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



2.3.2.3 IPRO Output File ID Name Interface Type Description Subsystems


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





EDS Contact Name


EDS Contact Email Address Escalation Procedure

Managed Care Eligibility

IPRO Chuck Merlino (516) 326-7767 ext 334

[email protected] Marilynn Hartman

(502) 209-3128 [email protected] Contact Chuck Merlino

Encounter Files IPRO Chuck Merlino (516) 326-7767 ext 334



Provider IPRO Chuck Merlino (516) 326-7767 ext 334



Drug Codes IPRO Chuck Merlino (516) 326-7767 ext 334



Procedure Codes IPRO Chuck Merlino (516) 326-7767 ext 334






Transaction Type

Transmission Type


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



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



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



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



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





EDS Contact Name




Inpatient Claims DSS James Petterson (206) 292-2385 Marilynn Hartman


Contact James Petterson

Outpatient Claims DSS James Petterson (206) 292-2385 Marilynn Hartman


Contact James Petterson


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



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



2.3.2.5 PricewaterhouseCoopers Output File ID Name Interface Type Description Subsystems


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





EDS Contact Name



Budget Forecast Data

DSS Vanessa Sam (415) 498-5616 [email protected]

Marilynn Hartman

(502) 209-3128 [email protected] Contact Vanessa Sam

Managed Care Rate Setting

DSS Vanessa Sam (415) 498-5616 [email protected]

Marilynn Hartman

(502) 209-3128 [email protected] Contact Vanessa Sam


Transaction Type

Transmission Type


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



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



2.3.2.6 Vital Statistics Input File ID Name Interface Type Description Subsystems


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



EDS Contact Name




Date of Death File

Vital Stats Rebekah Collins (502) 564-0105 ext 10506

[email protected]

Marilynn Hartman (502) 209-3128 [email protected]

Call Rebekah Collins

Date of Birth File Vital Stats Rebekah Collins (502) 564-0105 ext 10506

[email protected]

Marilynn Hartman (502) 209-3128 [email protected]

Call Rebekah Collins


Transmission Type


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



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



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


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





EDS Contact Name




EPSDT Cases CDP Mike Combs (866) 237-4814 [email protected]

Bill Ponder (502) 209-3145 [email protected] Call Mike Combs

EPSDT Eligibility CDP Mike Combs (866) 237-4814 [email protected]

Bill Ponder (502) 209-3145 [email protected] Call Mike Combs




Transaction Type

Transmission Type


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



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



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



2.5.2.1 Dial-up Input File ID Name Interface Type Description Subsystems


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


Claims Dial-up User Trading Partner Database (Submitter ID Lookup)

EDI Help Desk 800-205-4696 [email protected] Call EDI Help Desk


Transmission Type


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



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.









2.5.2.2 Dial-up Output File ID Name Interface Type Description Subsystems


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


Remittance Advice

BBS Trading Partner Database (BBS Submitter ID Lookup)


Claim Status BBS Trading Partner Database (BBS Submitter ID Lookup)



Transmission Type


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



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.



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.



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.



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.



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.



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.





Name Source System

Source Contact Information EDS Contact Name EDS Contact Phone Number


Interactive Claims Internet Provider Contact Info can be retrieved by Provider ID


Batch Claims Internet Provider Contact Info can be retrieved by Provider ID


Interactive Eligibility Inquiry

Internet Provider Contact Info can be retrieved by Provider ID


Batch Eligibility Inquiry



Interactive Claim Status Inquiry



Batch Claim Status Inquiry




Transmission Type


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




Transmission Type


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



2.5.2.3.1 Interactive Claims Provider internet users submit claims interactively directly to interChange. InterChange responds interactively to the claim submitted.



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.



Internet Users will send ANSI X12N 837 standard transactions to interChange. Consult the following HIPAA Implementation Guides for more information.









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.



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.



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.



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.



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.



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.



2.5.2.4 Provider Output File ID Name Interface



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


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



Destination Contact Information EDS Contact Name



Remittance Advice Internet user Trading Partner Database (BBS Submitter ID Lookup)


Claim Status Internet user Trading Partner Database (BBS Submitter ID Lookup)



Transmission Type


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



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.



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.



2.5.2.4.2 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.



2.5.2.5 VAN Input File ID Name Interface Type Description Subsystems


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



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


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



Transmission Type


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



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.



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 [email protected] APS Medical Billing 5700 Southwyck Boulevard Toledo, Ohio 43614

CDP Don Downs (502) 695-1999 [email protected] Custom Data Processing 951 Industrial Road Frankfort, KY 40601

Emdeon Richard Medley (615) 565-2273 [email protected] Emdeon Business Services 1283 Murfreesboro Pike Nashville, TN 37217

HDX Rodney Childs (610) 210-1693 [email protected] Healthcare Data Exchange 65 Valley Steam Parkway Malvern, PA 19355

MedAccess Plus Tom Court (812) 923-9354 [email protected] MedAccess Plus 123 Town Square Manchester, KY 40962

NEBO Andrew Yaschuk (630) 916-8803 [email protected] Nebo Systems Inc. 1 South 376 Summit Ave. Court B Oakbrook Terrace, IL 60181-3985

Norton Healthcare Michael Cook (502) 629-8034 [email protected] Norton Healthcare P.O. Box 35070 Louisville, KY 40232-5070

PHC Pat Chelette (615) 261-2680 [email protected] Passport Health Communications 700 Cool Springs Blvd Suite 450 Franklin, TN 37067

ZirMed Bonita Nelson (502) 779-4387 [email protected] ZirMed 626 West Main Street 6th Floor Louisville, KY 40202



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


eMARS Commonwealth of Kentucky eMARS – Management Administrative & Reporting System



2.6.1.1 IMPACT Plus Output File ID Name Interface Type Description Subsystems


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





EDS Contact Name




Denials IMPACT Plus Victor Eleazor (502) 564-4797 [email protected] Bill Ponder (502) 209-3145 [email protected] Contact Victor Eleazor

Refunds IMPACT Plus Victor Eleazor (502) 564-4797 [email protected] Bill Ponder (502) 209-3145 [email protected] Contact Victor Eleazor

Transfers IMPACT Plus Victor Eleazor (502) 564-4797 [email protected] Bill Ponder (502) 209-3145 [email protected] Contact Victor Eleazor

DMH Payments

Commonwealth Mainframe

Gary McDonald (502) 564-8021 [email protected] Bill Ponder (502) 209-3145 [email protected] Contact Gary McDonald, After hours call (502) 564-7946

DCBS Payments

Commonwealth Mainframe

Gary McDonald (502) 564-8021 [email protected] Bill Ponder (502) 209-3145 [email protected] Contact Gary McDonald, After hours call (502) 564-7946



Name Destination SystemTransaction Type

Transmission Type


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



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



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



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



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


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


Name Destination Destination Contact Name



EDS Contact Name




Payment Data DMS Vance Juett (502) 564-5183 ext. 3182

[email protected] Bill Ponder (502) 209-3145 [email protected] Contact Vance Juett

Recoupment DMS Nellie Coleman (502) 564-1012 [email protected] Bill Ponder (502) 209-3145 [email protected] Contact Nellie Coleman

Contractor Recoupment

DMS Nellie Coleman (502) 564-1012 [email protected] Bill Ponder (502) 209-3145 [email protected] Contact Nellie Coleman


Transmission Type


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



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)



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



2.6.1.3 eMARS Output File ID Name Interface Type Description Subsystems


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





EDS Contact Name




On Demand Checks

eMARS Gary McDonald

(502) 564-8021 [email protected] Bill Ponder (502) 209-3145 [email protected] Contact Gary McDonald, After hours call (502) 564-7946

Weekly Checks eMARS Gary McDonald

(502) 564-8021 [email protected] Bill Ponder (502) 209-3145 [email protected] Contact Gary McDonald, After hours call (502) 564

Non-provider Checks

eMARS Gary McDonald








EDS Contact Name




KenPAC Checks eMARS Gary McDonald


Lock-in Checks eMARS Gary McDonald


Weekly EFT eMARS Gary McDonald


KenPAC EFT eMARS Gary McDonald


Lock-in EFT eMARS Gary McDonald


Provider Refunds eMARS Gary McDonald


Provider 1099 eMARS Gary McDonald



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





Transaction Type

Transmission Type

Frequency Record FormatRecord length

Batch or Real-time

Job Name File Name

Non-provider Checks


XML N/A Batch FINJREMAR C49R109B_580_yyyymmdd_hhmm.txt

KenPAC Checks



Lock-in Checks eMARS Flat file FTP Weekly, Friday


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


Lock-in EFT eMARS Flat file FTP Weekly, Friday


Provider Refunds


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



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



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



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




2.7.2.1 CMS Output File ID Name Interface Type Description Subsystems


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


375 MSIS OT Claims File Quarterly “All Other Claims” tape created for the CMS Medicaid Statistical Information System


376 MSIS RX Claims File Quarterly Pharmacy Claims tape created for the CMS Medicaid Statistical Information System






EDS Contact Name




MSIS Eligibility MSIS Kathy Ranshous

(410) 786-0958 [email protected] [email protected]

Bill Ponder (502) 209-3145 [email protected] Contact Kathy Ranshous

MSIS IP Claims MSIS Kathy Ranshous



MSIS LT Claims MSIS Kathy Ranshous









EDS Contact Name




MSIS OT Claims MSIS Kathy Ranshous



MSIS RX Claims MSIS Kathy Ranshous




Transmission Type


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



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.


Inpatient Record Layout can be found on the PWB Tech Design MAR Input/Output Files MSIS CLAIMIP Record Layout



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.


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.


All Other Claims Record Layout can be found on the PWB Tech Design MAR Input/Output Files MSIS CLAIMOT Record Layout



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.


Pharmacy Claims Record Layout can be found on the PWB Tech Design MAR Input/Output Files MSIS CLAIMRX Record Layout



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


PA-62 Kentucky Public Assistance 62 (Members enrolled by DCBS)


SDX Kentucky State Data Exchange (Members with SSI)



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



EDS Contact Name




Language File KAMES PA-62/SDX

Greg Whitt (502) 564-0105 ext. 10234

[email protected] Bill Ponder (502) 209-3145 [email protected]

Contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946


Transmission Type


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



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



2.8.2.2 KAMES Output File ID Name Interface Type Description Subsystems


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





EDS Contact Name




KenPAC Extract KAMES Greg Whitt (502) 564-0105 ext. 10234

[email protected] Bill Ponder (502) 209-3145 [email protected] Contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946


Transmission Type


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



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



2.8.2.3 Passport Output File ID Name Interface



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



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



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



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.



749 820 Transactions File An 820 transaction file is created and sent to Passport for capitation. This can occur weekly but typically occurs monthly







EDS Contact Name




Managed Care LTC Passport Judy Palmer (502) 585-7900 [email protected]

Bill Ponder

(502) 209-3145 [email protected] Contact Judy Palmer or Doris Goldstein at the Commonwealth

Managed Care Waiver

Passport Judy Palmer (502) 585-7900 [email protected]

Bill Ponder








EDS Contact Name




Managed Care KenPAC


Bill Ponder


Managed Care Lock-in


Bill Ponder


834 Transactions Passport Gail Gatto (215) 937-8474 [email protected] Bill Ponder

(502) 209-3145 [email protected] Contact Gail or after hours contact EDI Help Desk at (215) 937-8473

820 Transactions Passport Gail Gatto (215) 937-8474 [email protected] Bill Ponder

(502) 209-3145 [email protected] Contact Gail or after hours contact EDI Help Desk at (215) 937-8473


Transaction Type

Transmission Type


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



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



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



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



2.9.2 Member Entities Name Description

CDP Custom Data Processing


COBC CMS Medicare Coordination of Benefits Contractor, Group Health Incorporated (GHI)



KMAA Kentucky Medicaid Administrative Agent (First Health)

Myers & Stauffer Myers & Stauffer

PA-62 Kentucky Public Assistance 62 (Members enrolled by DCBS)


PBA Pharmacy Benefits Administrator (First Health)


SDX Kentucky State Data Exchange (Members with SSI)

Vital Statistics Kentucky CHFS Office of Vital Statistics



2.9.2.1 CDP Output File ID Name Interface Type Description Subsystems


Data Owner

721, 449

Long Term Care File Long Term Care Extract for Custom Data Processing Member interChange





EDS Contact Name




Long Term Care CDP Mike Combs (502) 695-6870 [email protected] Bill Ponder (502) 209-3145 [email protected] Contact Mike Combs


Transmission Type


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



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



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



EDS Contact Name




HIC Update CMS Greg Whitt (502) 564-0105 ext. 10234

[email protected] Bill Ponder (502) 209-3145 [email protected] During the day contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946


Transmission Type


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



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



2.9.2.3 CMS Output File ID Name Interface Type Description Subsystems


Data Owner

619 Part D Extract File Part D extract for CMS sent to CMS through the Commonwealth Data Center

Member CMS interChange





EDS Contact Name




Part D Extract CMS Greg Whitt (502) 564-0105 ext. 10234



Transmission Type


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



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



2.9.2.4 COBC Output File ID Name Interface Type Description Subsystems


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





EDS Contact Name




Medicaid Eligibility COBC Becky Able (803) 772-0911 [email protected] Bill Ponder (502) 209-3145 [email protected] Contact COBC Help Desk Technical Support at (212) 615-4357


Transmission Type


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



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



2.9.2.5 DMS Output File Name


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



EDS Contact Name




Child Medicaid Eligibility

DMS Jan Thornton (502) 564-5183 ext. 3182

[email protected] Bill Ponder (502) 209-3145 [email protected] Contact Jan Thornton

Presumptive Eligibility

DMS Don Bussell (502) 564-0105 [email protected] Bill Ponder (502) 209-3145 [email protected] Contact Nici Gaines


Transmission Type


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



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



2.9.2.6 KAMES, PA-62 and SDX Input File Name


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.


337, 367 Patient Liability Updates

File Patient Liability updates from the Commonwealth systems: KAMES, PA-62 and SDX.


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.


342, 371 KENPAC Recon 2 File KENPAC Eligibility Reconciliation 2nd Issuance from KAMES, PA-62 and SDX.


766, 587 Card Issuance File Card Issuance Information Member interChange interChange

Name Source System

Source Contact Name



EDS Contact Name




Member Updates KAMES PA-62 SDX

Greg Whitt (502) 564-0105 ext. 10234


LTC Updates KAMES PA-62/SDX

Greg Whitt (502) 564-0105 ext. 10234




Name Source System

Source Contact Name



EDS Contact Name




Patient Liability Updates

KAMES PA-62/SDX

Greg Whitt (502) 564-0105 ext. 10234


Member Recon 1 KAMES PA-62/SDX

Greg Whitt (502) 564-0105 ext. 10234



Greg Whitt (502) 564-0105 ext. 10234


KENPAC Recon 1 KAMES PA-62/SDX

Greg Whitt (502) 564-0105 ext. 10234



Greg Whitt (502) 564-0105 ext. 10234


Card Issuance PA-62/SDX Greg Whitt (502) 564-0105 ext. 10234





Transmission Type


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


100 Near Real-time

ELGJDLTC ELGJDLTP

eld0kltc_ccyymmdd_hhmmss.dat eld0pltc_ccyymmdd_hhmmss.dat

Patient Liability Updates

KAMES PA-62/SDX


190 Near Real-time

ELGJDPAT ELGJDPAP

eld0kpat_ccyymmdd_hhmmss.dat eld0ppat_ccyymmdd_hhmmss.dat



452 Batch ELGJM007 ELGJM008

elm0350i_ccyymmdd_hhmmss.dat elm0360i_ccyymmdd_hhmmss.dat



452 Batch ELGJM007 MGDJM665

elm0350i_ccyymmdd_hhmmss.dat comm_sdx_ken_enrl_mbr_1_ccyymmdd_hhmmss.dat



100 Batch MGDJM660MGDJM665

comm_kames_ken_enrl_mbr_1_ccyymmdd_hhmmss.dat comm_sdx_ken_enrl_mbr_1_ccyymmdd_hhmmss.dat



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



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



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



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



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



2.9.2.7 KAMES, PA-62 and SDX Output File ID Name Interface Type Description Subsystems


Data Owner

384 Lock-in Extract File Member lock-in updates from interChange to KAMES, PA-62/SDX. Member interChange interChange





EDS Contact Name




Lock-in Extract KAMES PA-62/SDX

Greg Whitt (502) 564-0105 ext. 10234



Transmission Type


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



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



2.9.2.8 First Health KMAA Input File ID Name Interface Type Description Subsystems


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



EDS Contact Name




Case Management FIQM Bob Gaston (804) 527-5745 [email protected] Ponder (502) 209-3145 [email protected]



Transmission Type


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



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



2.9.2.9 First Health KMAA Output File ID Name Interface Type Description Subsystems


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





EDS Contact Name




Member Update FIQM Bob Gaston (804) 527-5745 [email protected] Ponder (502) 209-3145 [email protected]


Spend-down Update

FIQM Bob Gaston (804) 527-5745 [email protected] Ponder (502) 209-3145 [email protected]



Transmission Type


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



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





656 Member Update File Member update transactions Member FIQM interChange





EDS Contact Name




Member Update PBA Bruce Slough (804) 934-4247 [email protected]

Bill Ponder (502) 209-3145 [email protected] Contact Bruce Slough or Steve Elkins ([email protected]) (804) 317-1991, if unreachable, call 800-453-8780, option 3, category – applications, type – First RX, item – Load-enrollment


Transmission Type


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



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



2.9.2.11 Passport Output File ID Name Interface Type Description Subsystems


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.


333, 589

Member Language File

File A language file from KAMES and PA-62/SDX is sent to Passport through interChange


Name Destination

System Destination Contact Name



EDS Contact Name




Member Update

Passport Gail Gatto (215) 937-8474 [email protected] Bill Ponder (502) 209-3145 [email protected] Contact Gail or after hours contact EDI Help Desk at (215) 937-8473




Transaction Type

Transmission Type


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


Passport Flat file FTP Monthly; first week

38 Batch FTS kames_lang_ccyymmdd_hhmmss.dat sdx_lang_ccyymmdd_hhmmss.dat



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.



2.9.2.12 SHPS Output File ID Name Interface Type Description Subsystems


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.


Name Destinatio

n System Destination Contact Name



EDS Contact Name




Member Update MaxMC Heidi Monroe [email protected]

Cheryl Hanna(502) 209-3000 [email protected]

Contact Heidi or Susy White ([email protected])


Transmission Type


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



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



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


SHPS SHPS, Inc.



2.10.2.1 SHPS Input File ID Name Interface Type Description Subsystems


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



EDS Contact Name




Prior Authorization MaxMC Heidi Monroe [email protected]

Cheryl Hanna (502) 209-3145 [email protected]

Contact Heidi Monroe


Transmission Type


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



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





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





EDS Contact Name




KAMES Pro Cert KAMES Greg Whitt (502) 564-0105 ext. 10234

[email protected] Bill Ponder (502) 209-3145 [email protected]

Contact Lorraine Moore at (502) 564-0105 ext. 10204. After hours call (502) 564-7946


Transmission Type


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



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



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





PBA Pharmacy Benefits Administrator (First Health)




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



EDS Contact Name




Provider Rates DMS Sandy Carter (502) 564-5707 [email protected] Bill Ponder (502) 209-3145 [email protected] Contact Sandy Carter

Name Source Transaction Type

Transmission Type


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



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





Data Owner

382, 364

Provider Updates File Provider Updates are sent to KAMES and to PA-62/SDX from interChange

Provider KAMES interChange





EDS Contact Name




Provider Updates KAMES Greg Whitt (502) 564-0105 ext. 10234



Transmission Type


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



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



2.11.2.3 Passport Output File ID Name Interface



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





EDS Contact Name




CLIA Data Passport Gail Gatto (215) 937-8474 [email protected] Bill Ponder (502) 209-3145 [email protected] Contact Gail or after hours contact EDI Help Desk at (215) 937-8473

Provider Extract Passport Gail Gatto (215) 937-8474 [email protected] Bill Ponder (502) 209-3145 [email protected] Contact Gail or after hours contact EDI Help Desk at (215) 937-8473

Provider License Passport Gail Gatto (215) 937-8474 [email protected] Bill Ponder (502) 209-3145 [email protected] Contact Gail or after hours contact EDI Help Desk at (215) 937-8473


Transmission Type


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



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



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





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





EDS Contact Name




Provider Data PBA Bruce Slough (804) 934-4247 [email protected]


Provider License




Transmission Type


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



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



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





EDS Contact Name




Provider Data HMS Chris Sallee (704) 372-9384 ext 8117



Transmission Type


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



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



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



EDS Contact Name




Provider Update MaxMC Heidi Monroe [email protected]

Cheryl Hanna(502) 209-3000 [email protected]

Contact Heidi or Susy White ([email protected])


Transmission Type


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



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



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


First Data Bank First Data Bank




2.12.2.1 CMS Input File ID Name Interface Type Description Subsystems


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.


724 Procedure Codes File The Procedure Codes file from CMS is sent to interChange through Commonwealth Data Center.


645 Clinical Lab Fee File

File The Clinical Lab Fee Schedule from CMS is sent to interChange through Commonwealth Data Center.


Name Source System Source Contact Name



EDS Contact Name




Diagnosis Codes


Greg Whitt (502) 564-0105 ext. 10234


DRG File CMS through Commonwealth Data Center

Greg Whitt (502) 564-0105 ext. 10234


Procedure Codes


Greg Whitt (502) 564-0105 ext. 10234


Clinical Lab Fee File


Greg Whitt (502) 564-0105 ext. 10234





Transmission Type


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


Flat file FTP Monthly Fixed width 140 Batch REFJA120 CLABccyy.txt



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



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



2.12.2.2 First Data Bank Input File ID Name Interface Type Description Subsystems


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



EDS Contact Name




Drug Data FDB Shama Pillai 800-633-3453 [email protected]

Bill Ponder (502) 209-3145 [email protected] Contact Shama Pillai

Drug Pricing FDB Shama Pillai 800-633-3453 [email protected]

Bill Ponder (502) 209-3145 [email protected] Contact Shama Pillai


Transmission Type


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



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



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



KASES Kentucky Automated Support and Enforcement System





2.13.2.1 DMS Output File ID Name Interface Type Description Subsystems


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




EDS Contact Name




Casualty Recovery DMS Kelli O’Brien (502) 564-5183 ext 3051

[email protected] Bill Ponder (502) 209-3145 [email protected] Contact Kelli O’Brien

Estate Recovery DMS Kelli O’Brien (502) 564-5183 ext 3051


Trust Recovery DMS Kelli O’Brien (502) 564-5183 ext 3051



Transmission Type


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



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



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



2.13.2.2 KAMES Input File ID Name Interface Type Description Subsystems


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



EDS Contact Name




Estate Recovery file

KAMES

Greg Whitt (502) 564-0105 ext. 10234


SSA Updates KAMES

Greg Whitt (502) 564-0105 ext. 10234


TPL Updates KAMES

Greg Whitt (502) 564-0105 ext. 10234



Transmission Type


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




Transmission Type


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



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



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





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





EDS Contact Name




TPL Adds KAMES

Greg Whitt (502) 564-0105 ext. 10234


TPL End Dates KAMES

Greg Whitt (502) 564-0105 ext. 10234



Transmission Type


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



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



2.13.2.4 KASES Input File ID Name Interface Type Description Subsystems


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



EDS Contact Name




Absent Parent KAMES

Greg Whitt (502) 564-0105 ext. 10234



Transmission Type


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



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



2.13.2.5 Passport Input File ID Name Interface Type Description Subsystems


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



EDS Contact Name




Commercial Insurance



Transmission Type


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



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



2.13.2.6 Passport Output File ID Name Interface Type Description Subsystems


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





EDS Contact Name




Member TPL Data


TPL Carrier File



Transaction Type

Transmission Type


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



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



2.13.2.7 HMS Input File ID Name Interface Type Description Subsystems


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



EDS Contact Name




TPL Billing HMS Chris Sallee (704) 372-9384 ext 8117


TPL Adds HMS Chris Sallee (704) 372-9384 ext 8117




Name Source System

Source Contact Name



EDS Contact Name




TPL Changes HMS Chris Sallee (704) 372-9384 ext 8117


TPL Cost Avoidance



TPL MSE Adds HMS Chris Sallee (704) 372-9384 ext 8117


TPL MSE Changes HMS Chris Sallee (704) 372-9384 ext 8117


TPL Enforcement HMS Chris Sallee ((704) 372-9384 ext 8117



Transmission Type


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




Transmission Type


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


TPL Enforcement




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



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



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



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



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





EDS Contact Name




Public Assistance File



Billing File HMS Chris Sallee (704) 372-9384 ext 8117


Carrier File HMS Chris Sallee (704) 372-9384 ext 8117


Resource File HMS Chris Sallee (704) 372-9384 ext 8117





Transmission Type


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



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



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



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



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



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



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




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



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



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



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



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



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




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



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




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




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



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




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




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



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



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



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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