NEW YORK STATE
MEDICAID PROGRAM
MANAGED CARE REFERENCE GUIDE:
ENROLLEE ROSTERS
Managed Care Reference Guide: Enrollee Rosters –Appendices
Version 2019 – 1 (2/1/2019)
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TABLE OF CONTENTS
Section I – Purpose Statement .................................................................... 2
Section II –Enrollee Rosters ........................................................................ 3
Monthly Managed Care Roster File Layout and Field Descriptions ........................... 4
Monthly Disenrollment Report ................................................................................. 17
Monthly Error Report ............................................................................................... 19
Medicaid Eligibility Verification System (MEVS) ...................................................... 21
Section III – Appendices .............................................................................. 22
Appendix A – County / District Codes ...................................................................... 22
Appendix B – Insurance Coverage Codes ............................................................... 23
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Section I – Purpose Statement
The purpose of this document is to assist participating managed care organizations in
understanding and complying with the New York State Medicaid (NYS-Medicaid)
requirements.
The guide addresses Enrollee Rosters.
This document is customized for managed care providers as an instructional as well as a
reference tool.
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Section II –Enrollee Rosters
Enrollee information is contained in rosters compiled by the State Department of Health
(SDOH) for the Plans. The enrollee roster is the vehicle by which data such as Plan
enrollment, and county of fiscal responsibility are distributed to the Plan.
Rosters are available on the HCS (Health Commerce System) for the Plan according to
the SDOH Medicaid Monthly Schedule which is produced in November for the year ahead.
All plans are required to utilize an Internet Service Provider (ISP) to access the HCS for
purposes of accessing the Medicaid and roster site.
The Internet site through which to access the HCS is:
https://commerce.health.state.ny.us/hcs/index.html
The HCS requires each user to possess a User ID and password to enter the roster
application. This is a secure site with access granted by the Commerce Accounts
Management Unit (CAMU). If you do not have a User ID and password, you should email
the CAMU at camu@its.ny.gov, or call 1-866-529-1890, option 1. You will not be granted
access to this site without proper authorization.
Enter your User ID and password
Once you are signed in, select My Content, All Applications, and then Managed Care
Roster/Report Download. Once you have selected the Rosters Home Page, you will
be able to select the files you have access to.
The specifications for the enrollee rosters are on the following pages.
A list of the County/District codes is provided in Appendix A and a list of Insurance
Coverage codes can be found in Appendix B at the end of this document. These lists of
codes will help you to interpret information included on your enrollee rosters.
Questions about information contained in a Roster, receipt date for Rosters, or the
Medicaid Monthly Schedule may be directed to the State Department of Health’s Division
of Health Plan Contracting and Oversight at (518) 473-1134.
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Monthly Managed Care Roster File Layout and Field Descriptions
The Monthly Managed Care Recipient Roster lists every Medicaid recipient who is eligible
for Medicaid as of the pulldown or processing date and enrolled in a managed care plan for
the upcoming month.
There are two roster reports generated each month. One (Primary) is produced around ten
days prior to the beginning of the effective month of the report, which is the weekend of the
pulldown (for example, June 22
nd
for the July roster).
A second roster is produced the first full weekend after the beginning of the effective month
(for example, July 6
th
for the July roster). The second report shows only additional
enrollees who were not included on the first roster. These enrollees generally are added
because their Medicaid eligibility recertification occurred later than the processing date
(pulldown date) of the first roster, but was completed before the first day of the effective
month. As a result, they were not reflected on the first roster, but added via the second
roster production.
Data Elements
The following data is reported for each enrollee on the roster:
CIN – Enrollee’s Medicaid Client Identification Number
Social Security Number – Enrollee’s Social Security Number
Enrollee’s Name
Enrollee’s Sex
F – Female
M – Male
U - Unborn
Language Code
Enrollee’s Date of Birth
Case Name – Name of the adult the assistance case is authorized under
Enrollee’s Address
Care of Name – Name of the person in care of the enrollee
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Mailing Address – Mailing address associated with the “Care of” contact
Case Number – Case number assigned by the local district
Local Office Code
Expiration Date – End of the month in which the roster expires
Medicaid Coverage
Code which defines the enrollee’s type of Medicaid eligibility.
A
Full Medicaid Coverage
B
Full Medicaid Coverage except Long Term Care (LTC)
G
PCP Guarantee Coverage
L
Perinatal Family
P
Prepaid Capitation Plan (PCP) Coverage
Q
PCP/HR Coverage
R
PCP Guarantee/HR
T
HR/UT
U
Family Health Plus
W
Family Health Plus/Guarantee
Y
Aliessa Alien
1
Community Coverage w/Community Based LTC
2
Community Coverage without LTC
6
Community Coverage without LTC (legal alien during 5-year
ban)
Note
1
: Generally local districts are expected to change recipients’ fee for service
coverage code from “A”, “B”, “L”, “T”, “Y”, “1”, “2” or “6” to “P” when enrolled in a
Medicaid managed care plan; however, failure to do so does not change the validity
of plan enrollment.
Note
2
: Coverage Codes G, R, U, W are no longer active.
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Aid Category - Defines the type of medical assistance the enrollee is eligible for with the
Medicaid program. This code is used to derive the rate code under which the capitation
claim is paid (Aid to Dependent Children, HR, SSI).
01
58
Infant – Continuous Coverage (200% FPL (FP)
10
59
CAP/MA Guarantee (FNP) State/Local (Disabled
10/22/07)
11
60
Safety Net – Aged (FP)
12
61
Safety Net – Blind (FP)
16
62
Safety Net – Disabled (FP)
17
63
Safety Net – (FP)
18
64
Colorectal and Prostate Treatment Program (FNP)
19
66
Emergency Shelter (FP)
20
67
Safety Net w/deprivation (FP)
21
68
FHP Singles/Childless Couples (FP)
22
69
FHP Parents/19-20 years olds (FP)
23
70
FHP Pregnant Woman 100%
24
71
Child 6-18 (110-154% FPL) (FP)
25
72
FHP Pregnant Woman 200% FPL (FP)
26
74
Breast and Cervical Cancer Treatment Program
(under 65)
27
75
Breast and Cervical Cancer Treatment Program (65
and over)
28
76
Legal Alien (FNP)
30
77
Breast Cancer Treatment Program (Male (FNP)
31
78
LIF/SN/TL – Cash (FP)
32
79
LIF/SN/TL – NC (FP)
35
81
Child Continuous Coverage (100-133% FPL) (FP)
36
82
Medicaid Buy In – Disabled Basic Group
37
83
Medicaid Buy In – Medically Improved
38
86
Child 6-18 (111-154% FPL) (FP)
39
87
Family Planning Extension Program Post-Partum
(FNP)
40
88
Inpatient OMH (FNP)
41
89
Inpatient Prisoner (FP)
42
90
FHP S/CC 0 < 100% or S/CC (FP)
43
91
TANF/SN/LIF w/out deprivation and SN NC/SCC
(FP)
44
92
MA Formerly Foster Care (effective October 2018)
45
H0
Adult Group (19-64) S/CC 101-138% (FP) (100/0/0)
47
H1
Adult Group (19-64) Parent + Caretaker Relatives >
LIF <133 OR 19-20 > LIF < 133
48
OR
138-155% MOE (FP) (50/25/25)
49
P1
LIF W/OUT Depriv (FP)
50
P2
LIF Related W/Depriv (FP)
51
P5
Safety Net W/Out Depriv (FP)
52
P7
ADC Medically Needy (FP)
53
P8
LIF/SN/TL – CASH (FP)
54
P9
LIF/SN/TL – NC (FP)
55
56
57
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Individual Disposition Status Code - Indicates whether recipient’s case is active or
closed. Valid code values are:
07
Active
08
Inactive
10
Inactive/Sanctioned
11
Denied
13
Deceased
15
Deleted
20
Case Closed
Medicaid Exception Code - There are two occurrences of Recipient Restriction Exception
codes on the roster. The hierarchy below determines which code(s) appear on the roster
when a client has more than two codes.
H1-H9
N1-N7
30
05
08
11
06
12
02
03
04
09
10
13
55
56
58
59
Note: The above list reflects the hierarchy as of June 2018.
Medicare Code - Indicates the type of Medicare coverage for an enrollee.
2 Part A,
3 Part B,
1 Both Part A and B
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Note: Any enrollee with Medicare coverage in a mainstream managed care plan or
special needs plan must be disenrolled prospectively (based on the pulldown dates).
Health Insurance Claim Number (HICN) or MCR Number (MBI) – Enrollee’s Medicare
Number
Note: Prior to June 2018, this field always displayed the HICN. As a result of CMS’ Social
Security Number Removal Initiative, HICN was replaced by MBI. For the transition period
of April 1, 2018 through December 31, 2019, a MBI or HICN may be displayed in this field.
After December 31, 2019, the MBI will be displayed in this field, or a “MBI Pending”
message will be displayed if an enrollee has Medicare but the MBI has not yet been
provided.
Benefit Package - Benefit package number according to the list below.
BP code
Description
70
Family Health Plus
*Note: FHP ended 12/31/2014
71
Medicaid Advantage (NYC)
72
Medicaid Advantage Plus (NYC)
73
Medicaid Advantage (Upstate)
74
Medicaid Advantage Plus (Upstate)
75
PACE
76
Reserved for future use for MLTC Partials
77
FIDA
78
Health and Recovery Plan (OMH HARP)
79
Reserved for Developmental Disabilities Individualized
Services and Supports Coordination Organization (OPWDD
People First Waiver)
80
Reserved for FIDA-IDD
97
Prepaid Mental Health Plan
01-62, 66
Benefit Package Code for County (all other programs not
listed above)
Capitation Code – Indicates enrollment in plan. “3” = enrolled
PCP Begin Date – Enrollee’s most recent effective enrollment date
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Rate Code and Derivation Chart - Four-digit code assigned during claims processing
which represents enrollee’s age, sex and aid categories. This corresponds to the capitation
premium group. This field is suppressed for Special Needs, Medicaid Advantage, and
Integrated Care Plans.
Case Type
Aid Category
Age
Months
Sex
Age
Year
Rate
Code
TANF/SN
10, 11, 12,16, 17, 18, 19, 21, 23, 27, 31, 32,
39, 43, 44, 45, 48, 49, 57, 58, 63, 67, 78, 79,
81, 86, 90, 91, 92, H0, H1, P1, P2, P5, P7,
P8, P9
0-251
M/F
0-20
2201
TANF/SN
10, 11, 12,16, 17, 18, 19, 21, 23, 27, 31, 32,
39, 43, 44, 45, 48, 49, 57, 58, 63, 67, 78, 79,
90, 91, 92, H0, H1 P1, P2, P5, P7, P8, P9
252-999
M/F
21+
2205
SSI
24, 25, 26, 50, 51, 52, 53, 54, 55, 60, 61, 62,
82, 83
0 - 999
M/F
0+
2209
Default (When the
above rules are not
met)
2200
FHP*
*FHP program
ended 12/31/14
68, 69, 70, 72
228-785
M/F
19-65
2232
Guarantee Date - The date through which capitation payments are guaranteed to the plan
(calculated as 6 months subsequent to the initial enrollment date).
Note: Guarantee Dates were no longer populated after 12/31/2013.
Authorization Through Date - The date through which the enrollee is eligible for Medicaid
benefits
Recertification Date - The date of the onset of the recertification process for an enrollee.
This date is available for New York City enrollees only.
Transaction Date - The date of the most recent capitation transaction for the enrollee on
file
Copay Exempt Flag – Indicates whether the enrollee is copay exempt
Excess Income - The amount taken from enrollee’s current budget.
Note: If the Family Indicator is 'F', all the AC clients on the roster with the same case
number enrolled in the same plan will have same surplus amount on the surplus
field, but the provider should collect the surplus only once for the whole house hold.
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Note: This field will be populated only for MLTC program plans that have spend
down consumers.
Family Indicator
I - There is only one AC client on the roster with a particular case number and no other
active client on the roster with that same case number enrolled in the same plan
F - There are more than one AC client on the roster with the same case number enrolled in
the same plan.
Insurance Code - Indicates any third-party insurance for which the enrollee is eligible
Begin Date – The date third-party insurance is applicable
End Date – The date third-party insurance is terminated
Note: This section repeats twice in the roster.
Reason Code – Code indicates reason recipient is enrolled
1 Enrollment Override
2 Voluntary Enrollment (all input methods)
05 Mandatory
7 Automated Enrollment of a Newborn
8 HX to WMS Enrollment (Entry limited to State MC Staff Only)
Fee Flag
New Indicator - Indicated for enrollees whose most recent enrollment effective date on file
is equal to the roster effective date.
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Monthly Managed Care Recipient Roster File Layout
Field Name
Record
Positions
Field
Size
Explanation
From
To
Trans-Dist
1
2
2
2 digit county/district code assigned by NYS to county of fiscal
responsibility for enrollee.
Provider ID
3
10
8
MMIS ID number of plan in which recipient is enrolled.
Recipient ID
11
18
8
MMIS ID number of the enrollee.
Filler
19
21
3
Spaces
SSN
22
30
9
The SSN of enrollee (Provider Rosters).
The Worker Id of enrollee (County Rosters).
Last Name
31
46
16
Last name of enrollee.
First Name
47
56
10
First name of enrollee.
Middle Initial
57
57
1
Middle initial of enrollee.
Sex Code
58
58
1
Sex of enrollee.
Language
59
60
2
Language spoken.
Race/Ethnicity
61
66
6
Race/Ethnicity
Date of Birth
67
74
8
Date of birth of enrollee. MMDDCCYY
Case Name
75
102
28
Name of the adult the assistance case is authorized under.
Street
103
137
35
Street address of enrollee.
City
138
152
15
City address of enrollee.
State
153
154
2
State of enrollee.
Zip Code
155
159
5
Zip Code of enrollee.
Care of Name
160
187
28
Name of person in care of enrollee.
Street
188
222
35
Street address of person in care of enrollee.
City
223
237
15
City address of person in care of enrollee.
State
238
239
2
State address of person in care of enrollee.
Zip Code
240
244
5
Zip code of person in care of enrollee.
Phone
Number
245
254
10
Phone number of person in care of enrollee
Case Number
255
264
10
Case number assigned by County DSS.
Loc Off
265
267
3
Code which indicates the local DSS office.
Expiration
Date
268
275
8
The date the roster expires. MMDDCCYY
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Record
Positions
Medicaid
Coverage
276
276
1
Code defining whether the recipient is eligible for services
through a MC plan.
Aid Category
Code
277
278
2
Defines the type of medical assistance for which the enrollee is
eligible within the MA program. This code is used to derive the
rate code under which the capitation claim is paid.
Category
Code
279
280
2
Defines the category of assistance the enrollee's eligibility is based
on.
Individual
Disposition
Status Code
281
282
2
Code indicating if recipient's case is active or closed.
State/Federal
Charge Code
283
284
2
Code indicating State/Federal charges that are in effect.
Medicaid
Exception
Code
285
286
2
Code used to restrict types of medical services or to place processing
constraints which require claims review.
Medicaid
Exception
Code
287
288
2
Same as above.
Medicare
Code
289
289
1
Indicates the type of Medicare coverage for the enrollee.
MCR Number
290
301
12
Enrollee's Medicare Number.
Benefit Pkg
302
303
2
Benefit package number assigned to a plan.
Capitation
Code
304
304
1
Indicates recipient's enrollment/disenrollment in a plan. Always
'03' for rosters.
PCP Begin
Date
305
312
8
Recipient's most recent effective enrollment date. CCYYMMDD
Rate Code
313
316
4
4-digit code assigned during claims processing which represents
the age, sex, and aid category of enrollee and corresponds to the
capitation payment amount.
Guarantee
Date
317
324
8
Date through which capitation payments are guaranteed to the
plan. CCYYMMDD
Authorization
Date
325
332
8
Date through which enrollee is eligible for MA benefits (indicates
when recertification is necessary). CCYYMMDD
Recertification
Date
333
340
8
The date of the onset of the recertification process for an enrollee
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Record
Positions
Transaction
Date
341
348
8
The most recent transaction date for enrollee on
file. CCYYMMDD
Co-Pay
Exempt Flag
349
349
1
Indicates if the client is co-pay exempt or not.
Values are 'Y' or 'N'.
Excess
Income
350
359
10
The amount taken from client’s current budget.
Also, If the Family Indicator is 'F', all the AC clients on the roster
with the same case number enrolled in the same plan will have
same surplus amount on the surplus field, but the provider should
collect the surplus only once for the whole house hold.
Note: This field will be populated only for MLTC program plans
that have spend down consumers.
Family
Indicator
360
360
1
Note: This field will be populated only for MLTC program plans
that have spend down consumers.
Filler
361
371
11
Spaces
Insurance
Code
372
377
6
Indicates any insurance for which the enrollee is eligible.
Begin Date
378
385
8
Date for which insurance was applicable. CCYYMMDD
End Date
386
393
8
Date for which insurance was terminated. CCYYMMDD
Insurance
Code
394
399
6
Indicates any insurance for which the enrollee is eligible.
Begin Date
400
407
8
Date for which insurance was applicable. CCYYMMDD
End Date
408
415
8
Date for which insurance was terminated. CCYYMMDD
Reason Code
416
417
2
Code indicating reason recipient enrolled/disenrolled.
Fee Flag
418
419
2
For future use.
Filler
420
427
8
Spaces.
New Indicator
428
428
1
Indicates this is first time recipient appears on roster.
Monthly Managed Care Recipient Roster File Layout
01 PCP-ROS-HEADER.
05
PCP-ROS-HDR-ID
PIC X(18).
05
FILLER
PIC X(44).
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05
PCP-ROS-HDR-UP-DN
PIC
X(2).
05
PCP-ROS-HDR-TYPE
PIC
X(2).
05
PCP-ROS-HDR-ELIG-BEG-DT
PIC
X(8).
05
PCP-ROS-HDR-ELIG-END-DT
PIC
X(8).
05
PCP-ROS-HDR-CREATION-DT.
10 PCP-ROS-HDR-CRT-CC
PIC
9(2).
10 PCP-ROS-HDR-CRT-YY
PIC
9(2).
10 PCP-ROS-HDR-CRT-MM
PIC
9(2).
10 PCP-ROS-HDR-CRT-DD
PIC
9(2).
05
PCP-ROS-HDR-EXP-DATE.
10 PCP-ROS-HDR-EXP-MM
PIC
9(2).
10 PCP-ROS-HDR-EXP-DD
PIC
9(2).
10 PCP-ROS-HDR-EXP-CC
PIC
9(2).
10 PCP-ROS-HDR-EXP-YY
PIC
9(2).
BL0510
05
FILLER
PIC
X(366).
01 PCP-ROS-RECORD.
05
PCP-ROS-927-TRANS-DIST
PIC
X(02).
05
PCP-ROS-048-PROV-ID-NUM
PIC
X(08).
05
PCP-ROS-010-CIN
PIC
X(08).
05
PCP-ROS-031-SSN
PIC
X(09).
05
PCP-ROS-NAME.
10 PCP-ROS-005A-LAST-NAME
PIC
X(16).
10 PCP-ROS-005B-FIRST-NAME
PIC
X(10).
10 PCP-ROS-005C-MI
PIC
X(01).
05
PCP-ROS-012-SEX
PIC
X(01).
05
PCP-ROS-010-DOB.
15 PCP-ROS-DOB-MM
PIC
X(02).
15 PCP-ROS-DOB-DD
PIC
X(02).
15 PCP-ROS-DOB-CC
PIC
X(02).
15 PCP-ROS-DOB-YY PIC X(02).
05
PCP-ROS-DOB-NUM
REDEFINES PCP-ROS-010-DOB
PIC
9(08).
BL1208
05
PCP-ROS-070-CASE-NAME
PIC
X(28).
BL0510
05
PCP-ROS-008-STREET
PIC
X(35).
05
PCP-ROS-883-CITY
PIC
X(15).
05
PCP-ROS-884-STATE
PIC
X(02).
05
PCP-ROS-009-ZIP
PIC
X(05).
BL0510
05
PCP-ROS-110-CO-NAME
PIC
X(28).
BL0510
05
PCP-ROS-120-STREET
PIC
X(35).
BL0510
05
PCP-ROS-130-CITY
PIC
X(15).
BL0510
05
PCP-ROS-140-STATE
PIC
X(02).
BL0510
05
PCP-ROS-150-ZIP
PIC
X(05).
BL0510
05
PCP-ROS-PHONE
PIC
X(10).
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05
PCP-ROS-928-CASE-NUM
PIC
X(10).
05
PCP-ROS-014-LOC-OFF
PIC
X(03).
05
PCP-ROS-EXPIR-DATE.
10
PCP-ROS-EXPIR-MM
PIC
X(02).
10
PCP-ROS-EXPIR-DD
PIC
X(02).
10
PCP-ROS-EXPIR-CC
PIC
X(02).
10
PCP-ROS-EXPIR-YY
PIC
X(02).
05
PCP-ROS-EXPIR-NUM REDEFINES PCP-ROS-EXPIR-DATE
PIC 9(08).
05
PCP-ROS-027-MAID-COV PIC X(01).
05
PCP-ROS-015-AID-CAT PIC X(02).
BL1208
05
PCP-ROS-110-CAT-CD PIC X(02).
BM0203
05
PCP-ROS-120-INDIV-STATUS PIC X(02).
05
PCP-ROS-022-MAID-EXC-CD OCCURS 2 TIMES
PIC X(02).
05
PCP-ROS-023-MARE-CD PIC X(01).
05
PCP-ROS-004-MCR NUMBER PIC X(12).
05
PCP-ROS-BNFT-PKG PIC X(02).
05
PCP-ROS-CAP-CODE PIC X(01).
BM1099
05
PCP-ROS-FROM-DATE PIC X(08).
05
PCP-ROS-RATE-CODE PIC X(04).
05
PCP-ROS-GUAR-DATE PIC X(08).
05
PCP-ROS-GUAR-NUM REDEFINES PCP-ROS-GUAR-DATE
PIC 9(08).
05
PCP-ROS-AUTH-DATE PIC X(08).
05
PCP-ROS-AUTH-NUM REDEFINES PCP-ROS-AUTH-DATE
PIC 9(08).
BM0203
05
PCP-ROS-RECERT-DATE PIC X(08).
BM0203
05
PCP-ROS-RECERT-NUM REDEFINES PCP-ROS-RECERT-DATE
BM0203
PIC 9(08).
BM1099
05
PCP-ROS-LAST-TRANS-DT PIC X(08).
05
PCP-ROS-RESP-WORKER PIC X(05).
05
PCP-ROS-ASSOC-PROV PIC X(08).
05
PCP-ROS-146-IND
PIC X(01).
05 PCP-ROS-147-CLM-GEN PIC X(01).
05
PCP-ROS-549-PLAN-CD PIC X(02).
BL1211
05
PCP-ROS-COPAY-EXEMPT PIC X(01).
BL0512
05
PCP-ROS-EXCESS-INCOME PIC X(10).
BL0512
05
PCP-ROS-FAMILY-IND PIC X(01).
BL0512
05
FILLER PIC X(15).
***
TPHI
INSURANCE INFORMATION ***
05
PCP-INSUR-INFO OCCURS 2 TIMES.
BM0705
10 PCP-ROS-018-INS-CD PIC X(06).
10 PCP-ROS-INS-DATES.
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15 PCP-ROS-019A-BGN-DATE
PIC
X(08).
15 PCP-ROS-019B-END-DATE
PIC
X(08).
05
PCP-ROS-NYC-RID
PIC
X(11).
05
PCP-ROS-NEW-IND
PIC
X(01).
05
PCP-ROS-RECERT
PIC
X.
05
PCP-ROS-REASON
PIC
X(02).
05
PCP-ROS-FEE-FLAG
PIC
X(02).
BL0110
05
PCP-ROS-LANGUAGE
PIC
X(02).
BL0807
05
PCP-ROS-ETHNIC-AFL
PIC
X(06).
BL0407
05
PCP-ROS-150-CHRG-IND
PIC
X(02).
BL0308
05
PCP-ROS-EPI-IND
PIC
X(01).
BL0110
05
FILLER
PIC
X(13).
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Monthly Disenrollment Report
The Disenrollment Report provides managed care plans with a list of those enrollees on
the previous month’s roster who were disenrolled from the MCO, transferred to another
MCO, or whose enrollments were removed from the file. The Disenrollment Report does
not include enrollees who were dropped from the roster due to loss of Medicaid coverage
(unless the local district also ends the enrollment on file). Enrollees who have lost
eligibility, but remain enrolled, are listed on the Error Report. They will not be reflected on
the Disenrollment Report, even when they are removed from the Error Report (coverage
lapsed greater than 90 days).
Data Elements:
CIN – Client Identification Number or Medicaid Identification Number of disenrolled
individual.
Social Security Number
Name
Sex
Date of Birth (DOB)
Address Local Office Code Disenrollment Reason Code – see (1) below
Case Number – Individual’s case number, assigned by local district
Disenrollment From Date – Effective date of disenrollment/transfer
Disenrollment Reason – see (2) below
Aid Category – Defines the type of medical assistance for which the disenrolled member
is eligible.
Those recipients whose Disenrollment Reason is indicated as “Disenrolled” are clarified by
use of a Disenrollment Reason Code. These codes are:
59
Lost Eligibility – No Automated Re-Enrollment within 90 Days
63
Medicare Recipient
65
Plan Termination
66
Recipient retroactively disenrolled (plan must void claims subsequent to the
disenrollment date
85
Death
86
Enrollee request
93
Enrollee exempt/excluded from managed care enrollment
95
Lost MA eligibility
97
Moved out of plan’s service area
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Note: A general disenrollment reason is indicated for all enrollees on this report. Reasons
indicated are:
Disenrolled (see reason codes listed above)
Enrolled in Another Plan – Enrollee transferred to another plan
Enrollment Deleted – Enrollment removed from file (i.e., Enrolled in error)
Undeterminable - Enrollment/disenrollment transactions need to be manually
reviewed to determine reason
Monthly Disenrollment Report, PIC Format
LABEL RECORDS ARE STANDARD BLOCK
CONTAINS 25 RECORDS RECORD
CONTAINS 180 CHARACTER DATA RECORD
IS PCP-DIS-RECORD.
01 PCP-DIS-RECORD.
05 PCP-DIS-TRANS-DIST
PIC X(02).
05 PCP-DIS-PROV-ID-NUM
PIC X(08).
05 PCP-DIS-CIN
PIC X(08).
05 PCP-DIS-SSN
05 PCP-DIS-NAME.
PIC X(09).
10 PCP-DIS-LAST-NAME
PIC X(16).
10 PCP-DIS-FIRST-NAME
PIC X(10).
10 PCP-DIS-MI
PIC X(01).
05 PCP-DIS-SEX
05 PCP-DIS-DOB.
PIC X(01).
10 PCP-DIS-DOB-MM
PIC X(02).
10 PCP-DIS-DOB-DD
PIC X(02).
10 PCP-DIS-DOB-YR
PIC X(04).
05 PCP-DIS-C-O-NAME
PIC X(16).
05 PCP-DIS-STREET
PIC X(28).
05 PCP-DIS-CITY
PIC X(15).
05 PCP-DIS-STATE
PIC X(02).
05 PCP-DIS-ZIP
PIC X(05).
05 PCP-DIS-CASE-NUM
PIC X(10).
05 PCP-DIS-LOC-OFF
05 PCP-DIS-FROM-DT.
PIC X(03).
10 PCP-DIS-FROM-YR
PIC X(04).
10 PCP-DIS-FROM-MM
PIC X(02).
10 PCP-DIS-FROM-DD
PIC X(02).
05 PCP-DIS-REASON-CD
PIC X(02).
05 PCP-DIS-REASON
PIC X(25).
05 PCP-DIS-AID-CAT
PIC X(02).
05 FILLER
PIC X(01).
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Monthly Error Report
The purpose of the error report is to track on an interim basis those enrollees who lost
Medicaid eligibility because their case was closed, or because their Medicaid coverage
“expired” (no action was taken by the local department of social services to either end or
reauthorize the enrollee’s eligibility), but who remain enrolled in the plan.
The enrollees are indicated on the Error Report with the following messages:
No PCP Cov or Eligibility Expired – Indicates recipients whose Medicaid eligibility has
either lapsed or was terminated prior to the last day of the previous month.
Eligibility Ended (last day of previous month) – Indicates recipients whose Medicaid
eligibility expired the last day of the month before the roster month. If the recipient
remains on the Error Report (that is, no action taken to end or reauthorize eligibility), the
message will change to (1) above, in subsequent months.
Eligibility Ended (last day of previous month) (Closed) – Indicates recipients whose
Medicaid eligibility was terminated effective the last day of the month before the roster
month. If the recipient remains on the Error Report for subsequent months, the message
will change to (1) above.
County Codes Do Not Match
Indicates recipients who are receiving Medicaid in one fiscal district, but enrollment is in
another fiscal district (usually due to a change of address). These discrepancies must be
reconciled between the two districts, and until that is done, the case is reflected on the
Error Report.
Generally, recipients who have lost Medicaid eligibility will appear on the Error Report for
the first time for reasons (2) and (3) indicated above. However, recipients who were on
the previous month’s roster and whose eligibility ends effective prior to the last day of the
previous month, will appear on the Error Report for the first time with reason (1) indicated
above. Also included in (1) will be the carryovers from (2) and (3). Thus, these reason
codes alone cannot be used to identify all of the recipients who were on the previous
month’s roster and are now on the Error Report.
All of the above enrollees are removed from the monthly roster, but their Medicaid records
continue to reflect managed care enrollment for 90 days, even though the recipient is not
actively enrolled in Medicaid. The Error Report provides a means of tracking these
recipients for a 90-day period. If the recipient is recertified or reopened as Medicaid
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eligible within that period, this allows the recipient to be automatically reinstated on the
roster, without the need to actively re-enroll in the plan.
Note:
In New York City, the expired cases are automatically closed after 90 days, and their
PCP enrollment terminated. These expired cases drop from the Error Report (no
Medicaid coverage or PCP enrollment). Prepaid Capitation Plan (PCP) enrollment for
closed cases is terminated after 90 days as well.
Upstate, expired cases are not automatically closed. However, their PCP enrollment
is automatically terminated after 90 days. PCP enrollment for closed cases is terminated
after 90 days as well, and they too, are dropped from the Error Report.
Recipient ID: Enrollee’s Medicaid Identification Number
County: Enrollee’s district of financial responsibility for Medicaid eligibility
Aid Category: Defines the type of medical assistance the enrollee is eligible for with the
Medicaid program.
Case Number: Enrollee’s case number assigned by the local district
Error Message – see (1)– (6) above.
Monthly Error Report – PIC Format
01 PROV-ERR-RECORD.
05 PROV-IREF-NAME PIC X(25)
05 PROV-IREF-CIN PIC X(08)
05 PROV-IREF-CNTY PIC X(02)
05 PROV-IREF-AID-CAT PIC X(02)
05 PROV-IREF-CASE PIC X(10)
05 PROV-PCP-CIN PIC X(08)
05 PROV-PCP-CNTY PIC X(02)
05 PROV-PCP-CASE PIC X(10)
05 PROV-PROV-ID PIC X(08)
05 PROV-ERR-MSG PIC X(28)
05 PROV-RESP-WRKR PIC X(05)
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Medicaid Eligibility Verification System (MEVS)
New York State has implemented the Medicaid Eligibility Verification System (MEVS) as a
method for providers to verify recipient eligibility prior to provision of Medicaid services.
Plans may use MEVS, if necessary, to verify information about Medicaid eligibility.
The Identification Card (Common Benefit or Connect) no longer constitutes full
authorization for provision of medical services and supplies. A recipient must present an
official Common Benefit Identification Card or Connect Card to the provider when
requesting services. The verification process through MEVS can be completed to
determine the recipient’s eligibility for Medicaid services and supplies.
The verification process through MEVS can be completed using any one of the following
methods:
• the MEVS Terminal (OMNI 3750)
• a telephone verification process
• direct CPU link or batch transmissions
Verifications can be completed within seconds with a touchtone telephone or an MEVS
terminal. Information available through MEVS will provide you with:
• The eligibility status for a Medicaid recipient for a specific date;
• The county having financial responsibility for the recipient (used to determine the
contact office for prior approval and prior authorization); and
• Any Medicare or third-party insurance coverage that a recipient may have for the date
of inquiry, including managed care coverage.
MEVS is convenient and easy to use – it is available 24 hours a day, seven days a week.
MEVS provides current eligibility status information for all Medicaid recipients and is
updated on a daily basis.
The MEVS manual is available at and can be downloaded from www.emedny.org. The
manual contains different sections discussing the Common Benefit Identification Card, the
verification equipment, procedures for verification, a description of eligibility responses,
and test transactions.
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Section III – Appendices
Appendix A – County / District Codes
An alphabetical listing of all counties and their corresponding district codes is listed below.
These codes are also available at www.emedny.org. Select Provider Manuals under
“Information for All Providers.”
County Code
County
County Code
County
01 Albany 32 Ontario
02
Allegany
33
Orange
03
Broome
34
Orleans
04
Cattaraugus
35
Oswego
05
Cayuga
36
Otsego
06
Chautauqua
37
Putnam
07
Chemung
38
Rensselaer
08
Chenango
39
Rockland
09
Clinton
40
St. Lawrence
10
Columbia
41
Saratoga
11
Cortland
42
Schenectady
12
Delaware
43
Schoharie
13
Dutchess
44
Schuyler
14
Erie
45
Seneca
15
Essex
46
Steuben
16
Franklin
47
Suffolk
17
Fulton
48
Sullivan
18
Genesee
49
Tioga
19
Greene
50
Tompkins
20
Hamilton
51
Ulster
21
Herkimer
52
Warren
22
Jefferson
53
Washington
23
Lewis
54
Wayne
24
Livingston
55
Westchester
25
Madison
56
Wyoming
26
Monroe
57
Yates
27
Montgomery
66
New York City
28
Nassau
77
Other State Territory
29
Niagara
97
OMH
30
Oneida
98
OPWDD
31
Onondaga
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Appendix B – Insurance Coverage Codes
Third Party Health Resources
Insurance codes are used to identify Third Party Resources (TPR) other than Medicaid and
Medicare, under which a client has insurance coverage, including managed care. Such
coverage must be utilized for payment of medical services prior to submitting claims to
Medicaid. Insurance and coverage codes are also available at: www.emedny.org.
Select Provider Manuals under “Information for All Providers.”
Under MEVS, information specific to managed care will be reported to you when you request
an eligibility verification for a Medicaid recipient.
Please refer to the MEVS Provider Manual for more detailed information on eligibility
verifications, which can be found on the eMedNY website at:
https://www.emedny.org/ProviderManuals/AllProviders/supplemental.aspx
The MEVS response will include information on a maximum of two third party insurance carriers.
If a Medicaid recipient is covered by more than two carriers you will receive a response of ZZ as
an insurance code which indicates additional insurance. To obtain coverage information when
there are more than two carriers, call 1-800-343-9000.
Other insurance codes are available at www.emedny.org.
Select Provider Manuals
The codes are listed in the Information for All Providers section, under Third Party
Information
Insurance Coverage Codes
MEVS will only return coverage codes for Medicaid Managed Care Plans. These codes
identify which services are covered by the client's managed care plan.
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Code
Description
Explanation
A
Inpatient Hospital
All inpatient services are covered, except psychiatric care.
B
Physician In-Office
Services provided in the physician’s office are generally covered.
C
Emergency Room
Self-Explanatory
D
Clinic
Both hospital based and free-standing clinic services are covered.
E
Psychiatric Inpatient
Self-Explanatory
F
Psychiatric Outpatient
Self-Explanatory
G
Physician In-Hospital
Physician services provided in a hospital or nursing home are covered.
H
Drugs No Card
Drug coverage is available, but a drug card is not needed.
I
Lab/X-Ray
Laboratory and x-ray services are covered.
J
Dental
Self-Explanatory
K
Drugs Co-pay
Although the insurance carrier expects a co-payment, you may not
request it from the recipient. If the insurance payment is less than the
Medicaid fee, you can bill Medicaid for the balance, which may cover the
co-payment.
L
Nursing Home
Some nursing home coverage is available. You must bill until benefits are
exhausted.
M
Drugs Major Medical
Drug coverage is provided as part of a Major medical policy
N
All Physician Services
Physician services, without regard to where they were provided, are
covered.
O
Drugs
Self-Explanatory
P
Home Health
Some home health benefits are provided. Continue to bill until benefits
are exhausted.
Q
Psychiatric Services
All psychiatric services, inpatient and outpatient, are covered.
R
ER and Clinic
Self-Explanatory
S
Major Medical
The following services are covered: physician, clinic, emergency room,
inpatient, laboratory, referred ambulatory, transportation and durable
medical equipment.
T
Transportation
Medically necessary transportation is covered.
U
Coverage to
Complement Medicare
All services paid by Medicare, which require a coinsurance or deductible
payment, should be billed to the insurance carrier prior to billing
Medicaid.
V
Substance Abuse
Services
All substance abuse services, regardless of where they are provided, are
covered.
W
Substance Abuse
Outpatient
Self-Explanatory
X
Substance Abuse
Inpatient
Self-Explanatory
Y
Durable Medical
Equipment
Self-Explanatory
Z
Optical
Self-Explanatory
All
All of the above
All services are covered.