Brief Issue Description
This best practice document outlines the challenges states have faced with managed care plan identifiers for beneficiaries enrolled in a managed care plan in their T-MSIS ELIGIBLE file submissions and recommends best practices for states' reporting.
The managed care identification number enables states to report managed care plans in which beneficiaries are enrolled. This identification number is reported on the eligibility file under the data element MANAGED-CARE-PLAN-ID. This managed care plan ID is used to link beneficiary enrollment information to information in the other T-MSIS files: capitation payments reported on the CLAIM OT file; encounters reported on the CLAIM IP, CLAIM LT, CLAIM OT, and CLAIM RX files; and information regarding the managed care plan on the managed care plan file. The format of the managed care ID can vary by state, in length, and composition of the ID number.
One challenge identified is that the states report managed care plan ID numbers inconsistently across claim files. This leads to challenges linking the beneficiary's encounters to enrollment in the managed care plan. Because beneficiaries can be enrolled in multiple managed care plans at once, matching ID numbers are essential for end users analyzing managed care data. For example, if a state reports a managed care plan ID that has leading zeroes on the eligibility file, but the leading zeroes are truncated on the claims files, this prevents linking across the files. In another example, states will append a character to the end of the managed care plan ID numbers reported on the claims files, but not the eligibility file. In both of the examples, the issue is the same: unless the plan ID numbers match perfectly, they will not link in the analysis of the files. In the second example, the appended character might hold meaning in the state's internal system and is necessary. However, this causes problems downstream, and the state will need to identify processes to drop the appended character.
An additional challenge is that managed care plans are not reported at the highest level possible. Instead of reporting all enrollees under one managed care plan, the beneficiaries are reported as being enrolled in different plan ID numbers based on a criteria established by the plan, typically geographic location. However, all of the subdivided plans share the same enrollment and benefit requirements under the managed care organizations. One example of this is that a state will report a managed care plan ID number based on the county in which the beneficiary is enrolled. The root managed care plan ID numbers are identical, with a final character value added to the end of the claim to identify the county in which the beneficiary lives.
A managed care plan ID number should be reported on the eligibility file for any beneficiary who is enrolled in some type of managed care plan. A managed care plan ID reported on the eligibility file should match managed care plan ID numbers reported on the other file types including the managed care file, the inpatient claims file, the long-term care claims file, the prescription claims file, and the other type claims file. The managed care plan ID reported across all files needs to have both the same string length and matching values in each string field.
In the example noted above, an additional character might be appended to the managed care plan ID reported in the claims files for internal processing requirements. States should modify this plan ID for T-MSIS reporting by removing the added character to ensure the plan IDs on the claims and eligibility files link. This recommendation is consistent with guidance the operational readiness testing (ORT) team is currently providing states.
Please also refer to CMS Guidance: Primary Care Case Management Reporting, Updated and Reporting Non‐Emergency Medical Transportation (NEMT) Prepaid Ambulatory Health Plans (PAHPs) in the T‐MSIS Managed Care File.