Employer Bulletin

State Agencies & Local Health Employers
Vol. 19, No. 12
June 26, 2002

Health Insurance Enrollment Data Compare

The Department of Employee Trust Funds (ETF) is beginning an effort to perform a full file compare with the health plans in an attempt to find and resolve any discrepancies in health insurance enrollment data. Currently the maintenance of health insurance enrollment data is a manual process, with entry occurring by both ETF and the health plan. To ensure that the Health Insurance & Complaint System (HICS) data at ETF and coverage data at the health plan is accurate, we are implementing a method to verify the data between the health plans and HICS. The benefits of this comparative process go beyond just the accuracy of the HICS data: ETF will also be able to reconcile premium payments with eligibility information from HICS. In addition, the new Benefits Payment System (BPS) will use HICS data to calculate premiums for annuitants (annuity deducts and sick leave).

The full file compare project will compare selected subscriber and dependent data between the health plan and ETF.

Following is a list of the subscriber data being compared:

• Social Security Number
• Last Name, First Name, Middle Initial, Suffix
• Address
• Home phone number
• Work phone number
• Date of birth
• Gender
• Coverage effective date
• Coverage termination date
• Coverage type code
• Participant county code
• Physician county code
• Employer number
• Group number
• Employee type
• Carrier code

Below is a list of the Dependent data being compared:

• Social Security Number
• Last Name, First Name, Middle Initial, Suffix
• Gender
• Date of birth
• Relationship to the subscriber
• Student Status
• Handicap Indicator

The health plans will be required to send a file to ETF containing their enrollment data on a quarterly basis. This data will be compared to the HICS data, and discrepancies identified via exception reports. ETF will control the resolution process in order to ensure the accuracy of the HICS data and that all changes get completed properly. Most of the resolution effort will occur between ETF and the health plans (where keying errors are possible). Employers may need to assist in the process when additional information is required from the employer or the employee.

The roles and responsibilities for the resolution process are defined below:

ETF

• Review the exception reports
• Make corrections as necessary for problems within ETF's control
• Notify employers of required changes
• Assist an employer with changes by informing them of what is required to correct a problem (i.e. amended application, adjustment to monthly report)
• Notify health plan of required changes
• Ensure the HICS database is updated with correct information after final resolution

Employer

• Assist with research as requested (i.e. check for missing application, check for termination date)
• Perform corrections as required (i.e. amended application, adjustment to monthly report)

Health Plan

• Assist with research as requested
• Perform corrections as required.

Changes that require additional information from the employer (i.e. amended application) will be returned to Employer Services with a special designation to allow us to verify that the information has been received and close the problem. ETF will also be asking that the employers and health plans notify us when they have completed the corrections as requested by returning the exception reports to our Division of Employer Services.

The first compare date will be September 3, 2002 using active participants as of August 1, 2002. Since the problem resolution will take some time to complete, we cannot predict an exact timeframe for your agency.

Please direct questions about this process to the Employer Communication Center at (608) 264-7900.