NC DEPARTMENT OF HEALTH AND HUMAN SERVICES EIS MANUAL

ELIGIBILITY INFORMATION SYSTEM EIS 3350

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THIRD PARTY HEALTH AND ACCIDENT RESOURCES INFORMATION (DMA-2041)

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EIS 3350 – THIRD PARTY HEALTH AND ACCIDENT RESOURCES INFORMATION (DMA-2041)


I. GENERAL INFORMATION

I. GENERAL INFORMATION (cont’d)

II. Entering TPR Data in EIS

II. Entering TPR Data in EIS (cont’d)

II. Entering TPR Data in EIS (cont’d)

III. POLICY UPDATE

III. POLICY UPDATE (cont’d)

IV. INDIVIDUAL UPDATE

IV. INDIVIDUAL UPDATE (cont’d)

IV. INDIVIDUAL UPDATE (cont’d)

IV. INDIVIDUAL UPDATE (cont’d)

IV. INDIVIDUAL UPDATE (cont’d)

V. third party insurance REPORTING for nchc and bccm

V. third party insurance REPORTING for nchc and bccm (cont’d)

GLOSSARY OF TERMS


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EIS 3350 – THIRD PARTY HEALTH AND ACCIDENT RESOURCES INFORMATION (DMA-2041)

REVISED 02/01/11 – CHANGE NO. 03-11

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I. GENERAL INFORMATION

2. Transmits TPR information to the Medicaid claims processing contractor.

REVISED 02/01/11 – CHANGE NO. 03-11

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I. GENERAL INFORMATION (cont’d)

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II. Entering TPR Data in EIS

REISSUED 02/01/11 – CHANGE NO. 03-11

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II. Entering TPR Data in EIS (cont’d)

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II. Entering TPR Data in EIS (cont’d)

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III. POLICY UPDATE

REISSUED 02/01/11 – CHANGE NO. 03-11

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III. POLICY UPDATE (cont’d)

REISSUED 02/01/11 – CHANGE NO. 03-11

III. POLICY UPDATE (cont’d)

REISSUED 02/01/11 – CHANGE NO. 03-11

III. POLICY UPDATE (cont’d)

REISSUED 02/01/11 – CHANGE NO. 03-11

III. POLICY UPDATE (cont’d)

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IV. INDIVIDUAL UPDATE

REISSUED 02/01/11 – CHANGE NO. 03-11

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IV. INDIVIDUAL UPDATE (cont’d)

B. Enter TU in Selection and the EIS Individual ID in KEY. Press Enter. The INDIVIDUAL UPDATE (TU) screen displays.

REISSUED 02/01/11 – CHANGE NO. 03-11

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IV. INDIVIDUAL UPDATE (cont’d)

REVISED 02/01/11 – CHANGE NO. 03-11

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IV. INDIVIDUAL UPDATE (cont’d)

CLOSE INDIVIDUAL TPR ONLY IF THE INSURANCE COVERAGE TERMINATES. DO NOT CLOSE TPR JUST BECAUSE MEDICAID TERMINATES. DO NOT TERMINATE TPR IN EIS UNLESS TPR ACTUALLY TERMINATES.

REVISED 02/01/11 – CHANGE NO. 03-11

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IV. INDIVIDUAL UPDATE (cont’d)

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V. third party insurance REPORTING for nchc and bccm

    Two reports are generated based on third party resource information that is keyed into EIS by the vendor, TPR, and county workers on the TA Screens and TU Screens.

    The report DHREHC NCHC/BCCM TPR COUNTY Report is run each Friday evening and is available the first working day of each week. The county must review the weekly report to ensure that appropriate action is taken on the third party resource information.

    The report DHREHC NCHC/BCCM TPR STATE Report is run on the last working day of the month, and includes information from the weekly county reports. MPR’s will use the State report to ensure appropriate action is taken by county workers.

    A. County Responsibility for the NCXPTR County Report

      The title of the weekly report is DHREHC NCHC/BCCM TPR COUNTY REP and is based on the third party resource information that is keyed into TPR Screens.

REVISED 02/01/11 – CHANGE NO. 03-11

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V. third party insurance REPORTING for nchc and bccm (cont’d)

      1. Review the County Report. The report is sorted by county, EIS District number, and by who keyed the insurance. If the county keyed the insurance, no further review of that entry is necessary.
      2. The county must determine if the non-county entries on the report are valid or invalid/non-applicable third party resources.
        a. If the insurance reported is valid, the county must evaluate for all other Medicaid categories. If ineligible, start the process to terminate the BCCM or NCHC case. See MA-3250, Breast and Cervical Cancer Medicaid or MA-3255 NC Health Choice.
        b. If the insurance reported is verified invalid/non-applicable:
          (1) Terminate the insurance on the TA Screen/TU Screen.
            (a) If the insurance has ended, put the end date on TPR.
            (b) If the recipient never had the insurance, terminate the insurance in TPR.
          (2) For all invalid/non-applicable insurance complete the DMA-5055 entering information on the program affected, the recipient, the insurance, the reason not valid or non-applicable, and the county/worker. Fax the form, with attached verification, to Third Party Recovery Attn: Program Integrity Contract Administrator at (919) 715-4725. This information is needed by TPR to block further transmission of invalid insurance information.

    B. NCXPTR State Report

      The title of the report for state use is DHREHC NCHC/BCCM TPR STATE REP. This report runs on the last working day of the month, and is compiled from information on the weekly county reports. MPRs use this report to monitor the activity taken on the weekly county reports.

REISSUED 02/01/11 – CHANGE NO. 03-11

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GLOSSARY OF TERMS

TERM

DEFINITION

FIELD NAME CODE

BEGIN

The date the insured individual’s coverage begins on a specific policy.

BEGIN

COVERAGE PERIOD

A period of time an individual is covered by insurance.

BEGIN DATE

END DATE

LAST UPDATED

The date the policy/individual was last updated, in MMDDCCYY.

LAST UPDATED

POLICY ADDED

The date the insurance policy was first entered in EIS.

POLICY ADDED

END

The date the insured individual’s coverage ends on a specific policy.

END

GROUP ADDRESS

The mailing address of the group the insurance covers.

GROUP ADDRESS

GROUP NAME

The name of the group the insurance covers, usually an employer.

GROUP POLICY NAME

GROUP POLICY NUMBER

The number identifying the group the insurance covers, usually an employer.

GRP POLICY

INDIVIDUAL ID

The EIS Individual ID of the person who is covered by the insurance, the insured.

INDIVIDUAL

INSURANCE COMPANY CODE

The 3-digit code EIS uses to identify the insurance company.

INS COMP CD

INSURANCE POLICY NUMBER

The insurance policy/certificate number. If the insurance is Group Insurance, the insurance policy/certificate number is the policy holder’s specific certificate number.

POLICY NUMBER

INSURANCE TYPE CODE

The 2-digit code EIS uses to identify the type of insurance coverage.

INS TYPE CD

INSURED

The person covered by the insurance.

 

JULIAN

The date the policy/individual was last updated in EIS, in CCYYDDD format.

JULIAN

POLICY EFFECTIVE DATE

The earliest date the insurance policy was effective. EIS displays this date based on the earliest individual begin date.

POL EFF DATE

POLICY END OR TERM DATE

The date the insurance policy ended. EIS displays this date based on the latest individual end date.

POL TERM DATE

POLICY HOLDER NON-CUSTODIAL PARENT

Is the policy holder the non-custodial parent or his/her spouse?

POL HOLDER NON-CUSTODIAL PARENT?

POLICY HOLDER’S NAME

The name of the person who owns the insurance.

POLICY HOLDERS NAME

RELATIONSHIP

The relationship of the insured to the policy holder.

REL

Figure 1

REISSUED 02/01/11 – CHANGE NO. 03-11

      INSURANCE TYPE CODES

      Use the following list to determine the appropriate code. See below for a description of each type of coverage.

        00 - Major Medical

        01 - Basic Hospital/Surgical

        02 - Basic Hospital

        03 - Dental Only

        04 - Cancer Only

        05 - Accident (including school accident insurance)

        06 - Indemnity

        07 - Nursing Home

        08 - Medicare Supplement

        10 - Major Medical and Dental

        11 - Major Medical and Nursing Home

        12 - Intensive Care Only

        13 - Hospital Outpatient

        14 - Physician Only

        15 - Heart Attack Only

        16 - Prescription Drugs

        17 - Vision Care Only

TYPE CODE

INSURANCE TYPE

DESCRIPTION

00

Major Medical, including private HMOs

The Major Medical insurance policy provides comprehensive medical coverage. In most cases, it is a group insurance policy through an employer. The insurance policy usually pays for in-patient and out-patient care, doctors, hospital and office visits, and drugs, at the minimum. This policy may have a deductible or co-pay. The amount of the deductible varies from policy to policy. Use code 00 for TRICARE (CHAMPUS/CHAMP-VA).

NOTE: If the policy is both major medical and dental coverage, use code 10.

NOTE: If the policy is both major medical and nursing home coverage, use code 11.

01

Basic Hospital/Surgical

The Basic Hospital/Surgical insurance policy provides in-patient hospital care. The policy provides coverage for the surgeon’s bill based on a schedule attached to the policy. The amount of coverage is usually stated as a daily amount for room and board.

In addition, it usually pays on the ancillary in-patient hospital charges such as drugs, labs, x-rays, etc. The surgical coverage is usually stated on the insurance policy as a surgical limit.

Figure 2

REISSUED 02/01/11 – CHANGE NO. 03-11

TYPE CODE

INSURANCE TYPE

DESCRIPTION

02

Basic Hospital Insurance

The Basic Hospital insurance policy provides coverage for in-patient hospital care. The amount of coverage is usually stated as a daily amount for room and board. It also pays for ancillary charges such as drugs, labs, x-rays, etc. In most cases, it limits the number of days paid during any one benefit period.

03

Dental

The Dental insurance policy provides coverage for dental care only. There is usually a deductible and preset limits on the amount paid toward the cost of braces, dentures, etc. Dental insurance may be written as a separate policy or may be part of a Major Medical policy.

Use code 10 if the policy is both Major Medical and Dental.

04

Cancer

The Cancer Insurance policy provides coverage for cancer treatment.

05

Accident Insurance (including School Accident Insurance)

The Accident insurance policy provides coverage for specific occurrences. The medical coverage offered pays only for medical expenses related to the accident(s) specified in the policy.

Use code 05 for school accident policies. These are comprehensive group accident policies.

06

Indemnity Policies

The Indemnity insurance policy provides a specific dollar amount per day for an in-patient hospital stay. The indemnity policy is a hospital cost reimbursement policy and is treated as a third party resource. For example, payment is dependent upon hospitalization.

07

Nursing Home Insurance

The Nursing Home insurance policy provides for Skilled Nursing Home care.

Use code 11 if the policy is a Major Medical and Nursing Home policy.

Figure 2 (CONT’D)

REISSUED 02/01/11 – CHANGE NO. 03-11

TYPE CODE

INSURANCE TYPE

DESCRIPTION

08

Medicare Supplement

The Medicare Supplement insurance policy may pay the deductible and coinsurance for Medicare covered services. It may also pay for other charges (for example, prescription drugs, long term care, skilled nursing, etc.).

Do not code Medicare Supplement policies as Major Medical. If the policy pays for prescriptions, enter the prescription policy separately, using code 16.

NOTE: If the policy pays for long-term care skilled nursing, enter the long-term care portion as code 07. .

10

Major Medical and Dental Insurance

The Major Medical and Dental insurance policy provides comprehensive medical coverage and dental coverage. In most cases, it is a group insurance policy through an employer.

11

Major Medical and Nursing Home Insurance

The Major Medical and Nursing Home policy provides comprehensive medical coverage and nursing home coverage. In most cases, it is a group insurance policy through an employer.

12

Intensive Care Insurance

The Intensive Care insurance policy provides coverage only if the patient is confined in an Intensive Care Unit, and nothing else.

13

Hospital Outpatient Only Insurance

The Outpatient Only insurance policy provides coverage only if the patient is seen at a hospital as an outpatient and not admitted to the hospital.

14

Physician Only Insurance

The Physician Only insurance policy provides coverage if the patient is seen by a physician in the physician’s office.

15

Heart Attack Insurance

The Heart Attack only insurance policy provides coverage only if the diagnosis of the patient is heart attack and nothing else.

16

Prescription Drug Insurance

Provides coverage for all or a portion of prescription drug charges. In most cases it is a group policy through an employer when major medical and drug benefits are administered by separate administrators. Enter both policies.

NOTE: Pharmacy Benefit Managers (PBM’s) have become a prominent part of the insurance field. It is important that these be entered with code 16.

17

Vision Care Insurance

The Vision Care only insurance policy provides coverage for vision care.

Figure 2 (CONT’D)

REISSUED 02/01/11 – CHANGE NO. 03-11

CHECK ONE to select action.

TA-Add policy (Must include at least one individual.), add individual to a policy, update policy, delete policy.

TU-Update individual coverage.

WKR

CTY

DIST

DELETE POLICY

       

POLICY NUMBER

INS COMP CD

INS TYPE CD

   
         

POLICY HOLDERS NAME

GRP POLICY

GROUP POLICY NAME

     

GROUP ADDRESS

 

CITY

STATE

ZIP

       

INDIVIDUAL ID

(NAME FOR VERIFICATION ONLY)

REL

BEGIN

END

POL HOLDER NON-CUSTODIAL PARENT?

       

Y N

INDIVIDUAL ID
(NAME FOR VERIFICATION ONLY)

REL

BEGIN

END

POL HOLDER NON-CUSTODIAL PARENT?

       

Y N

INDIVIDUAL ID
(NAME FOR VERIFICATION ONLY)

REL

BEGIN

END

POL HOLDER NON-CUSTODIAL PARENT?

       

Y N

INDIVIDUAL ID
(NAME FOR VERIFICATION ONLY)

REL

BEGIN

END

POL HOLDER NON-CUSTODIAL PARENT?

       

Y N

INDIVIDUAL ID
(NAME FOR VERIFICATION ONLY)

REL

BEGIN

END

POL HOLDER NON-CUSTODIAL PARENT?

       

Y N

INDIVIDUAL ID
(NAME FOR VERIFICATION ONLY)

REL

BEGIN

END

POL HOLDER NON- CUSTODIAL PARENT?

       

Y N

INDIVIDUAL ID
(NAME FOR VERIFICATION ONLY)

REL

BEGIN

END

POL HOLDER NON-CUSTODIAL PARENT?

       

Y N

For filing purposes:

CASEHEAD NAME EIS CASE ID CO CASE WORKER DISTRICT

DMA-2041 (04/03)

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