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Member and Medicaid Eligibility FAQ

Q. We have a client that we know is Medicaid eligible but Diamond doesn’t show them as Medicaid. Why not and how do we get the record to be Medicaid?

A. The first thing to check is whether the UCI in Diamond has a Medicaid ID entered on the Diamond record. If not, then use EEI to find the Medicaid ID and put the Medicaid ID on the record in Diamond. (3-2000)

The second thing to check is to see if the date of birth in Diamond is the same as it is on the Medicaid eligibility file (MEDELIG). If not, Medicaid eligibility will not post until the two dates are the same.

The third thing to check is to use the EEI process to look up the Medicaid ID and see if the EEI returns a span covering today’s date. If there is a span covering today’s date, the nightly membership maintenance process should automatically change the line of business portion of the plan. If there are spans but they do not include today’s date, the person is NOT MEDICAID ELIGIBLE TODAY.

NOTE 1: Client records that don’t have a Medicaid ID in Diamond are used to check for exact matches on last name, date of birth, gender and social security number. Due to data entry mistakes made by clerks in county human services offices and mistakes in spelling and data entry into Diamond, a board should not rely on this process to automatically find a Medicaid ID for a client’s record.

NOTE 2: Any changes to spans other than the current span must be changed manually. When changing a span from NON to MCD, be sure to place the Medicaid ID in the Userdef1 field on the eligibility span. Failure to do this will prevent the claim from being extracted and billed to ODHS. (3-2000)

Q. Can you explain why a member was enrolled yesterday as non-Medicaid and after it went through nightly membership maintenance it now has a Medicaid number entered but did not change the plan from non-Medicaid to Medicaid?

A. The record was entered without a Medicaid ID and the nightly membership maintenance process found a single record on the eligibility file with the same last name, date of birth, gender, and social security number. The Medicaid ID was placed on the Diamond record. However, the Medicaid ID was NOT eligible on that day and therefore the plan was not changed. (3-2000)

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Q. We have a member that after checking the EEI shows that they are eligible for Medicaid but Diamond doesn’t have the same information. Why and how do we fix this?

A. Review carefully the difference between the answer for this question and the answer to the next question, which may appear to be the same but is not the same question. The difference is that this question says they are Medicaid eligible today. The problem, if they are eligible today and not in a Medicaid plan, is that the date of birth on Diamond does not agree with the date of birth on the Medicaid eligibility file. This is only true for the current span! (3-2000)

Q. We have a member that after checking the EEI shows that they were eligible for Medicaid but Diamond doesn’t have the same information. Why and how do we fix this?

A. In this case the client has an old span that doesn’t have the correct Medicaid status. Only the current span can be modified electronically. Therefore, all prior spans must be fixed manually. There are a wide variety of reasons why historical information doesn’t agree with the most current Medicaid eligibility file. They include:

Medicaid eligibility has been changed for an old period of time. This is often referred to as retroactive eligibility changes. They can add eligibility or remove eligibility.

The member was enrolled in Diamond several days, weeks, or months after they should have been. During that time, if the Medicaid eligibility changes, only the most recent status will be reflected in Diamond. Old spans have to be added manually.

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A client was enrolled in Diamond. Either the Medicaid ID was not on the record, the date of birth on Diamond didn’t agree with the date of birth on the eligibility file, or the client has more than one Medicaid ID and the ID that wasn’t eligible was on the member record. (3-2000)

Q. Some clients come in to the provider and have a Medicaid card but the system says they are non-Medicaid (and vice versa) How can you tell if a person is eligible?

A. Use the EEI function to look the person up and check the latest dates of eligibility. If the Diamond record doesn’t agree with the EEI it is almost always because either the Medicaid ID on the Diamond record is not the same or the date of birth on Diamond isn’t the same as the date of birth on the Medicaid eligibility file. (3-2000)

Q. We have a client with UCI ______ that is not having the eligibility information updated and the EEI shows that they are eligible today. Why not and how do we fix it?

A. The UCI specified has an ETERM reason of ERR01 (or EDUP1, EDUP2, or EDUP3). These are records that the membership maintenance group has reported as having an error that prevents us from trying to update these records. They are eliminated from the nightly membership maintenance process and all updates must be made manually. If the term reason begins with ERR it is because the record contains a critical error. The critical errors are missing first name, missing last name, missing or zeroes for social security number, or an effective date of enrollment which is in the future (at the time the update program last tried to use this record). If the term reason begins with EDUP, then the record has been identified as a duplicate of another record for the same person. The other record is being automatically updated during the nightly membership maintenance process. Providers that use a UCI with a term reason of EDUP should be informed of the correct UCI to use. (3-2000)

Q. We have a member that has a term date and every time I try to remove it, it is put back in by the nightly membership maintenance process. Why?

A. This should never happen unless the person is Medicaid eligible. On a Medicaid eligible client, the term date from the Medicaid file is automatically placed on the record to notify the board that the client’s eligibility is scheduled to terminate. Often the date is extended but there is a need to inform boards and providers of pending ineligibility. (3-2000)

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Q. Information in Diamond and the Medicaid eligibility file don’t agree but we know for a fact that the information in Diamond is correct and don’t want it changed by the information in Medicaid. What do we do?

A. If the Medicaid ID in Diamond is for the same person, but either the last name, first name, date of birth, or social security number are wrong on the Medicaid eligibility file, we have the ability to set a Medicaid Override Flag to prevent these changes from being posted. However, the only people that have access to this flag are the member maintenance group and they must be convinced that the Medicaid ID does in fact belong to the person in question before they will set the flag on. (3-2000)

Q. I think the nightly membership maintenance function has changed dual funded plans into MH plans a couple times. What is causing this to happen?

A. The only part of the plan that is modified by the programs in the nightly membership maintenance process is the line of business (NON/MCD). However, if a board made a change to a span after we began the nightly extract, the change could be overwritten by the contents of the plan field on the extract record. This would, if effect, put the plan back where it was before the board had made the change. The nightly membership maintenance extract process is currently scheduled to begin at 4:00 p.m. each weekday evening. The extract is taken between 6:00 a.m. and 9:00 a.m. on Saturday, Sundays and state holidays. Members can be added during this time and won’t be affected (their records will be processed in the next run). Changes in plans, effective dates, riders, or panels should not be made during these time periods. (3-2000)