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

REVISED 02/01/11 – CHANGE NO. 03-11

I. GENERAL INFORMATION (cont’d)

B. When TPR information changes, enter the change in EIS. EIS automatically:

1. Updates TPR information on EIS Individual Data.

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



* DO NOT TERMINATE TPR IN EIS UNLESS THE INDIVIDUAL’S INSURANCE COVERAGE ENDS. *

II. Entering TPR Data in EIS

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.

A. Insurance Policy Number

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

II. Entering TPR Data in EIS (cont’d)

Enter the insurance policy number exactly as on the insurance policy or pocket ID card.

1. Group Insurance

a. Enter the group number in the GROUP POLICY NUMBER field. Do not enter a group insurance policy number in the INSURANCE POLICY NUMBER field.

b. Enter the policy holder’s individual certificate number in the INSURANCE POLICY NUMBER field. If there is no individual certificate number, use the Social Security Number (SSN) of the policy holder. If the group insurance is with an employer, use the SSN of the policy holder, even if the policy holder is not in the case.

2. Individual Insurance

Enter the individual insurance policy number in the INSURANCE POLICY NUMBER field.

B. Insurance Company Name Code

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

1. Refer to Third Party Health and Accident Resource Information Inquiry, EIS 1055, for instructions on how to identify the correct code.

2. If you are unable to identify the correct insurance company code using either the DMA Internet site or SCC4CICS, contact the COST AVOIDANCE UNIT of the Third Party Recovery Section at DMA. The TPR Section assigns a code, updates the on-line table, and returns the code to you.

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.

a. Insurance company name, address and phone number

REISSUED 02/01/11 – CHANGE NO. 03-11

II. Entering TPR Data in EIS (cont’d)

b. Policy holder’s name, Social Security number, and policy number

c. Name and EIS Individual ID of the recipient

d. If insurance is through an employer, include the name, address, and phone number of the employer and the group policy number.

e. A copy of the front and back of the insurance card.

C. Insurance Type Code

1. EIS uses the insurance type code to identify the type of insurance coverage. See INSURANCE TYPE CODES, Figure 2, for a listing and description of the insurance type codes.

2. Do not enter the following types of policies:

a. Loss of Life/Limb

b. Worker’s Compensation

c. Disability

d. Automobile

3. When an individual has more than one type of coverage, EIS displays the type code for the greatest coverage on the ID inquiry screen.

III. POLICY UPDATE

A. Use the ADD/CHANGE POLICY OR ADD INDIVIDUAL (TA) screen to:

1. add a new insurance policy number,

2. add a policy with another company or another insurance type to an existing insurance policy number,

3. update or delete an existing policy, and

4. add an individual to an existing policy.

5. If a policy terminates, enter an individual end date for all individuals associated with the policy. See IV. E. Close an Open Coverage Period.

B. Enter TA in SELECTION and the policy number in KEY. Press Enter. The ADD/CHANGE POLICY OR ADD INDIVIDUAL (TA) screen displays.

REISSUED 02/01/11 – CHANGE NO. 03-11

III. POLICY UPDATE (cont’d)

1. EIS displays the first policy with the number you entered. Press PF8 to scroll forward through other policies with that number until you see the one you wish to update.

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.

2. Enter or update data. Always enter your worker number, county number, and district number. Press Enter. Always check data before pressing Enter to update. When you press Enter to update policy data, EIS displays the data that will update EIS to allow you to confirm it. If data is correct, press Enter again to update EIS. If data is not as you intended, press PF3 to exit without updating. Key the action again.

3. If there are errors, EIS displays error messages at the bottom of the screen, one at a time. Correct each error and press Enter to update.

4. Press PF3 to exit without updating.

REISSUED 02/01/11 – CHANGE NO. 03-11

III. POLICY UPDATE (cont’d)

C. Non-Custodial Parent Indicator

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.

1. If the insurance policy holder is the non-custodial parent (NCP) or his/her spouse, enter Y to the right of the EIS Individual ID, under the question.

2. If the insurance policy holder is NOT the non-custodial parent (NCP) or his/her spouse, enter N to the right of the EIS Individual ID, under the question.

D. Function keys and online messages display at the bottom of the screen.

Use the following function keys to enter policy updates.

ENTER Press ENTER when you have keyed your data and are ready to update EIS. EIS edits the screen for errors and displays them one at a time.

PF2 Press PF2 to return to the EIS INQUIRY MENU.

PF3 Press PF3 to exit without updating.

PF5 Press PF5 to clear the screen before you press ENTER to update. EIS erases the data you entered and displays the original screen.

Press PF5 after you update to display the Policy Update screen for this policy again.

PF8 Press PF8 to display the next policy with the same policy number.

E. Add a New Policy

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)

1. Enter required data. Key over existing data to add coverage with another company and/or another insurance type for this policy number.

2. Press Enter to update. EIS displays the screen again, including the name of the individual associated with the individual id you entered. Always check data before pressing Enter to update.

3. Press Enter to update.

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.”

F. Add an Individual to an Existing 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.)

1. Enter individual data. You may add up to 8 individuals on one screen.

2. Press Enter to update. EIS displays the screen again, including the name of the individual(s) associated with the individual id(s) you entered.

3. Press Enter to update.

REISSUED 02/01/11 – CHANGE NO. 03-11

III. POLICY UPDATE (cont’d)

G. Update Policy Data

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.

1. Enter data to add it.

Key over existing data to modify it.

Space out data to delete it.

2. Press Enter to update. EIS displays the screen again, including the name of the individual associated with the individual ID you entered. Always check data before pressing Enter to update.

3. Press Enter to update.

H. Delete a Policy

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.

1. Enter Y under DELETE POLICY to delete the policy.

2. Press Enter to update. EIS displays the screen again with a message to confirm you wish to delete the policy. Always check data before pressing Enter to update.

3. Press Enter to delete the policy.

4. Press PF3 if you do NOT want to delete the policy.

IV. INDIVIDUAL UPDATE

A. Use the INDIVIDUAL UPDATE screen to:

1. add a new coverage period,

2. delete the end date of a coverage period to re-open the insurance coverage,

3. change a begin or end date, and

4. delete a coverage period.

REISSUED 02/01/11 – CHANGE NO. 03-11

IV. INDIVIDUAL UPDATE (cont’d)

5. combine coverage periods in EIS. In the past, TPR was often entered in EIS to match Medicaid coverage periods. If the insurance coverage is continuous, you may wish to combine periods of coverage into one continuous period.

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

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

1. EIS displays the first policy for the individual, including all Begin and End Dates for this individual on this policy. Scroll forward (PF8) until the correct policy displays.

Confirm correct insurance policy number, insurance company code and insurance type code before updating.

REISSUED 02/01/11 – CHANGE NO. 03-11

IV. INDIVIDUAL UPDATE (cont’d)

2. Enter or update data. Always enter your worker number, county number and district number. Press Enter. Always check data before pressing Enter to update. When you press Enter to update individual data, EIS displays the data that will update EIS. Always check data before pressing Enter to update. If data is correct, press Enter again to update EIS.

If data is not as you intended, press PF3 to exit without updating. Key the action again.

3. If there are errors, EIS displays error messages at the bottom of the screen, one at a time. Correct each error and press Enter to update.

4. Press PF3 to exit without updating.

C. Non-Custodial Parent Indicator

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,

1. and the insurance policy holder is the non-custodial parent (NCP) or his/her spouse, enter Y to the right of the question.

2. and the insurance policy holder is NOT the non-custodial parent (NCP) or his/her spouse, enter N to the right of the question.

D. Function keys and online messages display at the bottom of the screen.

Use the following function keys to enter individual updates.

ENTER Press ENTER when you have keyed your data and are ready to update EIS. EIS edits the screen for errors and displays them one at a time.

PF2 Press PF2 to return to the EIS INQUIRY MENU.

PF3 Press PF3 to exit without updating.

PF5 Press PF5 to clear the screen before you press ENTER to update. EIS erases the data you entered and displays the original screen.

REVISED 02/01/11 – CHANGE NO. 03-11

IV. INDIVIDUAL UPDATE (cont’d)

Press PF5 after you update to display the Individual Update screen for this ID again.

PF8 Press PF8 to display the next policy for the individual.

E. Close an Open Coverage Period

1. Key an End Date to the right of the Begin Date for the open coverage period in the END column.

2. Press Enter to update. EIS displays the screen again. Always check data before pressing Enter to update.

3. Press Enter to update.

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.

F. Add a New Coverage Period

1. Key the new Begin Date and End Date (if appropriate) at the bottom of the screen to the right of ADD.

2. Press Enter to update. EIS displays the screen again to allow you to confirm the data. Always check data before pressing Enter to update.

3. Press Enter to update.

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.

G. Reopen Coverage

1. Space out the End Date for the appropriate coverage period.

2. Press Enter to update. EIS displays the screen again. Always check data before pressing Enter to update.

3. Press Enter to update.

REVISED 02/01/11 – CHANGE NO. 03-11

IV. INDIVIDUAL UPDATE (cont’d)

H. Change a Begin or End Date

1. Key over it.

2. Press Enter to update. EIS displays the screen again. Always check data before pressing Enter to update.

3. Press Enter to update.

I. Delete a Coverage Period

1. Enter X in the DEL column to the left of the coverage period you wish to delete.

2. Press Enter to update. EIS displays the screen again. Always check data before pressing Enter to update.

3. Press Enter to update.

J. Make Changes to Additional Policies for the Individual

Press PF8. EIS displays each additional policy for this individual.

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

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

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)