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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I. GENERAL INFORMATION (cont’d)
II. Entering TPR Data in EIS (cont’d)
II. Entering TPR Data in EIS (cont’d)
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)
REVISED 02/01/11 – CHANGE NO. 03-11
When Medicaid pays claims for medical services, the Medicaid claims processor uses third party resource (TPR) information to ensure Medicaid claims are paid correctly. When an applicant/recipient (A/R) has any TPR for medical (health) and/or accident insurance, it is important to enter the TPR data in EIS. Include information about coverage by private HMOs, TRICARE (Champus), CHAMPVA, dental, vision, prescription and any other health insurance coverage. Do not enter Medicare A or Medicare B as TPR on these screens.
DMA contracts with a vendor to complete a data match with multiple insurance databases to search for comprehensive, pharmacy, and other types of insurance for Medicaid recipients. Effective January 1, 2011, this data match was expanded to include North Carolina Health Choice (NCHC) and Breast and Cervical Cancer (BCCM) Medicaid recipients. All third party resource information entered in EIS by the contractor for NCHC and BCCM recipients is written to a report in NCXPTR. This report replaced the letters from program integrity that previously notified counties of potential third party resource information that could affect NCHC and BCCM eligibility. See V. Third Party Insurance Reporting for NCHC and BCCM.
Child Support Enforcement uses information related to insurance provided by a non-custodial parent (NCP) to calculate Medicaid savings due to medical support. When the NCP or his/her spouse provides health insurance for a child on Medicaid, be sure to code this correctly in EIS. See IV. INDIVIDUAL UPDATE .
Use the instructions in this section to enter TPR data in EIS. If you have questions, please contact the Eligibility Information System (EIS) Unit in the Division of Medical Assistance (DMA). See EIS 1200 for contact information.
Inquire in EIS to identify TPR data for each person applying for Medicaid. Use the information as a lead to insurance benefits for the individual. You may need to add, modify or terminate TPR prior to application approval to ensure TPR is correct in EIS when benefits are approved.
REVISED 02/01/11 – CHANGE NO. 03-11
* DO NOT TERMINATE TPR IN EIS UNLESS THE INDIVIDUAL’S INSURANCE COVERAGE ENDS. *
This section contains general information needed to enter TPR data correctly in EIS. The insurance policy is the base record for TPR in EIS. A policy must have at least one individual associated with it. EIS automatically inserts policy effective dates and policy end dates based on the coverage periods of individuals on the policy.
See Figure 1, below, for a GLOSSARY OF TERMS related to TPR data.
Use the Policy Update function to add, change or delete insurance policy data in EIS. See III. POLICY UPDATE.
Use the Individual Update function to change individual TPR coverage when the individual is already associated with the policy. See IV. INDIVIDUAL UPDATE.
The insurance policy number is the key to policy data in EIS. The insurance policy number may be numeric, alpha, or both. Do not enter slashes, dashes or spaces in the number. EIS uses the insurance policy number, insurance company name code and insurance type code to uniquely identify insurance policies.
Example:
Insurance Policy Number |
Insurance Company Name Code |
Insurance Type Code |
12345 |
ABC |
00 |
12345 |
EFG |
04 |
12345 |
RQK |
16 |
All these policies are unique, even though the policy numbers are the same.
REISSUED 02/01/11 – CHANGE NO. 03-11
Enter the insurance policy number exactly as on the insurance policy or pocket ID card.
Enter the individual insurance policy number in the INSURANCE POLICY NUMBER field.
EIS uses the 3-digit insurance company code to uniquely identify an insurance company.
Refer to EIS 1200, State Contacts, for contact information. Mail the DMA-2053 (6/90) form which is available at http://info.dhhs.state.nc.us/olm/forms/dma/dma-2053-ia.pdf or by request from the DMA mailroom.
The following information is required when requesting a new code.
REISSUED 02/01/11 – CHANGE NO. 03-11
Confirm correct insurance policy number, insurance company code and insurance type code before updating.
If the policy is not already in EIS, EIS displays a blank TA screen.
REISSUED 02/01/11 – CHANGE NO. 03-11
III. POLICY UPDATE (cont’d)
The TA screen displays the question “POL HOLDER NON-CUSTODIAL PARENT?” (NCP indicator), for each individual.
EIS transmits non-custodial parent (NCP) data to the claims processor for reporting purposes.
Use the following function keys to enter policy updates.
Press PF5 after you update to display the Policy Update screen for this policy again.
Perform TP Inquiry to identify any existing policies with this policy number, as well as the individuals associated with each policy.
REISSUED 02/01/11 – CHANGE NO. 03-11
III. POLICY UPDATE (cont’d)
The following data is required to add a policy:
Insurance Policy Number
Insurance Company Code
Insurance Type Code
Policy Holder Name
Individual Data for at least one individual (EIS Individual ID, Begin Date, Relationship and Policy Holder Non-Custodial Parent indicator)
EXAMPLE:
Policy 123, Company XYZ, Type 00 is already in EIS. The individual also has prescription coverage with the same policy number with another company. Key ABC over XYZ in the INS COMP CODE field. Key 16 over 00 in the INS TYPE field. A message displays-such as “You are adding new coverage with another company and coverage type to this policy.”
Perform TI Inquiry to determine whether the individual is already associated with the policy.
The following data is required to add an individual to an existing policy:
EIS Individual ID
Individual TPR Begin Date
(Individual TPR End Date is optional when adding an individual to a policy.)
REISSUED 02/01/11 – CHANGE NO. 03-11
III. POLICY UPDATE (cont’d)
The following data can be added to or updated on an existing policy:
Individual Data-(Add an individual only)
Group Policy Data
The Insurance Policy Number cannot be changed.
Key over existing data to modify it.
Space out data to delete it.
Delete a policy ONLY IF IT WAS ENTERED IN ERROR. DELETING A POLICY REMOVES ALL TRACES OF IT FROM EIS. To close individual coverage, enter an individual End Date. See IV. E.
REISSUED 02/01/11 – CHANGE NO. 03-11
EXAMPLE:
EIS HAS: |
INSURANCE IS REALLY CONTINUOUS. CHANGE EIS TO: |
BEGIN END 01011999 06301999 12012000 05312001 08012002 |
BEGIN END 01011999 |
You cannot use this screen to add an individual to a policy for the first time. See III. POLICY UPDATE.
The following data can be added, updated or deleted:
Begin and End Date
Relationship Code
Policy Holder Non-Custodial Parent indicator
Confirm correct insurance policy number, insurance company code and insurance type code before updating.
REISSUED 02/01/11 – CHANGE NO. 03-11
The TU screen displays a question, IS POL HOLDER THE NON-CUSTODIAL PARENT? (NCP indicator) for each policy for the individual. EIS transmits NCP data to the claims processor for reporting purposes.
If you need to change the NCP indicator,
Use the following function keys to enter individual updates.
REVISED 02/01/11 – CHANGE NO. 03-11
Press PF5 after you update to display the Individual Update screen for this ID again.
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.
If there has been no break in insurance coverage, do not add a new coverage period. Space out the End Date in the appropriate coverage period.
REVISED 02/01/11 – CHANGE NO. 03-11
Press PF8. EIS displays each additional policy for this individual.
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.
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
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
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
TYPE CODE |
INSURANCE TYPE |
DESCRIPTION |
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. | |
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 |
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. | |
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. | |
Cancer |
The Cancer Insurance policy provides coverage for cancer treatment. | |
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. | |
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. | |
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 |
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. . | |
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. | |
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. | |
Intensive Care Insurance |
The Intensive Care insurance policy provides coverage only if the patient is confined in an Intensive Care Unit, and nothing else. | |
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. | |
Physician Only Insurance |
The Physician Only insurance policy provides coverage if the patient is seen by a physician in the physician’s office. | |
Heart Attack Insurance |
The Heart Attack only insurance policy provides coverage only if the diagnosis of the patient is heart attack and nothing else. | |
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. | |
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 |
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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? | ||||||
INDIVIDUAL ID |
REL |
BEGIN |
END |
POL HOLDER NON-CUSTODIAL PARENT? | ||||||
Y N | ||||||||||
INDIVIDUAL ID |
REL |
BEGIN |
END |
POL HOLDER NON-CUSTODIAL PARENT? | ||||||
Y N | ||||||||||
INDIVIDUAL ID |
REL |
BEGIN |
END |
POL HOLDER NON-CUSTODIAL PARENT? | ||||||
Y N | ||||||||||
INDIVIDUAL ID |
REL |
BEGIN |
END |
POL HOLDER NON-CUSTODIAL PARENT? | ||||||
Y N | ||||||||||
INDIVIDUAL ID |
REL |
BEGIN |
END |
POL HOLDER NON- CUSTODIAL PARENT? | ||||||
Y N | ||||||||||
INDIVIDUAL ID |
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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