Appendix B - Data-Map Process Documents

 

Eligibility Data – Mapping into Database

 

The standard process for mapping Eligibility data into the Healthx database uses the GroupNumber, MemberID and ProdID fields to determine if a record is added or replaced.

 

If there is an exact match of the values in the GroupNumber, MemberID and ProdID fields between the record in the file and the record in the database, then the file record replaces the database record.

 

If there is no match of the values in the MemberID field, then process will then compare the SSN in the file to the MemberID in the database for a possible match. If there is match with the SSN to the MemberID as well as the GroupNumber and ProdID, then the file record replaces the database record.

 

If there is no match of the values in the GroupNumber, MemberID, SSN and ProdID fields between the record in the file and the record in the database, then the file record is added as a new database record.

 

If there is more than one record in the same eligibility file with the same GroupNumber, SSN (or MemberID if there is no SSN in the record) and ProdID, then the last record in the file will replace the prior record as records are updated/added in the same order as in the file.

 

When an existing member record is replaced by a record in the file, the eligibility process will first delete any associated dependent records for that member, then delete all coverage records for both the member and dependents and, finally, delete all accumulator records for the dependents.

 

After these records have been deleted, the member’s database record is replaced with the file record. Once all member records are updated or added, the eligibility process will then add the dependent records to the associated member eligibility record.

 

 

 

Eligibility Coverage Data – Mapping into Database

 

The standard process for mapping Eligibility Coverage data into the Healthx database uses the GroupNumber, MemberID and DependentNumber (used for dependent records only) fields to identify the associated eligibility record.


If there is an exact match of the values in the GroupNumber, MemberID and DependentNumber fields between the record in the file and the record in the eligibility database, then the file record is added to the database.

 

If there is no match of the values in the GroupNumber, MemberID and DependentNumber fields between the record in the file and the record in the eligibility database, then the file record is bypassed and is not added to the database.

 

If there is more than one record in the eligibility database with the same GroupNumber, MemberID and DependentNumber, the process cannot continue and will stop. Any remaining records in the file will not be added.

 

If there is a record in the coverage file for a member currently in the eligibility database but not included in the corresponding eligibility file with the same extract date, the coverage will be added to the existing coverage records. Potentially this could result in duplicate coverage records. See Eligibility Data-Map Process document for details on how the eligibility process affects the coverage process.

 

 

Eligibility Accumulator Data – Mapping into Database

 

The standard process for mapping Eligibility Accumulator data into the Healthx database uses the GroupNumber, MemberID and DependentNumber (used for dependent records only) fields to identify the associated eligibility record.

 

If there is an exact match of the values in the GroupNumber, MemberID and DependentNumber fields between the record in the file and the record in the eligibility database, data values in specific fields from the file record are compared to the database record to verify if there is an existing accumulator record. The specific fields include:

 

Field #

Field Name

6

Name

7

Coverage Type

8

Specific Type

11

In Network

12

Individual Accum

16

Date Range

 

If exact matches are found for all these specific fields, the remaining fields from the records are updated in the existing database record.  If there is no match for all these fields, then the file record is added as a new database record.

 

If there is no match of the values in the GroupNumber, MemberID and DependentNumber fields between the record in the file and the record in the eligibility database, then the file record is bypassed and is not added to the database.

 

If there is more than one record in the eligibility database with the same GroupNumber, MemberID and DependentNumber, the process cannot continue and will stop. Any remaining records in the file will not be added.

 

See Eligibility Data-Map Process document for more details on how the eligibility process affects the accumulator process.



Claims Data – Mapping into Database

 

The standard process for mapping Claims data into the Healthx database uses the ClaimNumber, GroupNumber and ProdID fields to determine if a record is added or replaced. To facilitate members being able to view their records a MemberID is required and it must match the MemberID sent in Eligibility.  Please refer to Member ID Rules section for more information.

If there is an exact match of the values in the ClaimNumber, GroupNumber and ProdID fields between the record in the file and the record in the database, then the file record replaces the database record.

 

If there is no match of the values in the ClaimNumber, GroupNumber and ProdID fields between the record in the file and the record in the database, then the file record is added as a new database record.

 

If there is more than one record in the same claim file with the same ClaimNumber, GroupNumber and ProdID, then the last record in the file will replace the prior record as records are updated or added in the same order as in the file.

 

When an existing record is replaced by a record in the file, the claim process will first update the claim header record and delete any associated claim lines. Once all the header records are updated or added, the claim process will then add the claim line records to the associated header record.

 

 

 

Provider Data – Mapping into Database

 

The standard process for mapping Provider data into the Healthx database uses the OrgProviderID and RecordType fields to determine if a record is added or replaced.

 

If there is an exact match of the values in the OrgProviderID and RecordType fields between the record in the file and the record in the database, then the file record replaces the database record.  

 

When the record is added, all associated records in the Provider Language, Provider Degree, Provider Board Certification and Provider Relationship tables will be deleted. Once all the provider records are updated or added, the Provider Language, Provider Degree, Provider Board Certification and Provider Master Relationship files will be processed to add the associated records.

 

If there is no match of the values in the OrgProviderID and RecordType fields between the record in the file and the record in the database, then the file record is added as a new database record.

 

If there is more than one record in file with the same OrgProviderID and RecordType, then the last record in the file will replace the prior record as records are updated or added in the same order as in the file.


 

 

Provider Cross Reference Data – Mapping into Database

 

The standard process for mapping Provider Cross Reference data into the Healthx database uses the Code and CrossRefType fields to determine if a record is added or replaced.

 

If there is an exact match of the values in the Code and CrossRefType fields between the record in the file and the record in the database, then the file record replaces the database record.  

 

If there is no match of the values in the Code and CrossRefType fields between the record in the file and the record in the database, then the file record is added as a new database record.

 

If there is more than one record in the file with the same Code and CrossRefType, then the last record in the file will replace the prior record as records are updated or added in the same order as in the file.

 

The records in this file are used to populate the drop-down search selection fields of the Provider Directory service.  Unless there are changes to the records, this file does not need to be transferred for processing on a daily basis, only as needed.

 

 

 

Provider Specialty Category Data – Mapping into Database

 

The standard process for mapping Provider Specialty Category data into the Healthx database uses the SpecCategoryName and SpecCode fields to determine if a record is added or replaced.

 

If there is an exact match of the values in the SpecCategoryName and SpecCode fields between the record in the file and the record in the database, then the file record replaces the database record.

  

If there is no match of the values in the SpecCategoryName and SpecCode fields between the record in the file and the record in the database, then the file record is added as a new database record.

 

If there is more than one record in file with the same SpecCategoryName and SpecCode, then the last record in the file will replace the prior record as records are updated/added in the same order as in the file.

 

The records in this file are used to populate the drop-down lists on the provider search screens.  Therefore, if there are no daily changes in these values, the file does not need to be sent daily, but only as changes to the values warrants.


Provider Hospital Affiliation Data – Mapping into Database

 

The standard process for mapping Provider Hospital Affiliation data into the Healthx database uses the OrgProviderID field to determine if a record is added or replaced.

 

If there is an exact match of the values in the OrgProviderID field between the record in the file and the record in the database, then the file record replaces the database record.  

 

If there is no match of the values in the OrgProviderID field between the record in the file and the record in the database, then the file record is added as a new database record.

 

If there is more than one record in the file with the same OrgProviderID, then the last record in the file will replace the prior record as records are updated or added in the same order as in the file.

 

The records in this file are used to populate the drop-down search selection fields of the Provider Directory service.  Unless there are changes to the records, this file does not need to be transferred for processing on a daily basis, only as needed.

 

 

Provider Board Certification Data – Mapping into Database

 

The standard process for mapping Provider Board Certification data into the Healthx database uses the OrgProviderID and RecordType fields to identify the associated provider record.

 

If there is an exact match of the values in the OrgProviderID and RecordType fields between the record in the file and the record in the provider database, then the file record is added into the database.  

 

If there is no match of the values in the OrgProviderID and RecordType fields between the record in the file and the record in the provider database, then the file record is bypassed and is not added to the database.

 

If there is a record in the board certification file for a provider currently in the provider database but not included in the corresponding provider file with the same extract date, the board certification record will be added to the existing records. Potentially this could result in duplicate board certification records. See Provider Data Map-Process document for details on how the provider process affects the board certification process.


Provider Degree Data – Mapping into Database

 

The standard process for mapping Provider Degree data into the Healthx database uses the OrgProviderID field to determine which provider record to tie the data to.

 

If there is an exact match of the values in the OrgProviderID field between the record in the file and the record in the provider database, then the file record is added into the database.  

 

If there is no match of the values in the OrgProviderID field between the record in the file and the record in the provider database, then the file record is bypassed and is not added to the database.

 

If a degree record is sent and there is an exact match to a provider record, but that provider record was not sent in the same day’s files, the degree records will be duplicated.

 

If there is record in the degree file for a provider currently in the provider database but not included in the corresponding provider file with the same extract date, the degree record will be added to the existing records. Potentially this could result in duplicate degree records. See Provider Data Map-Process document for details on how the provider process affects the degree process.



Provider Language Data – Mapping into Database

 

The standard process for mapping Provider Language data into the Healthx database uses the OrgProviderID field to determine which provider record to tie the data to.

 

If there is an exact match of the values in the OrgProviderID field between the record in the file and the record in the provider database, then the file record is inserted into the database.  

 

If there is no match of the values in the OrgProviderID field between the record in the file and the record in the provider database, then the file record is discarded.

 

If a language record is sent and there is an exact match to a provider record, but that provider record was not sent in the same day’s files, the language records will be duplicated.


Provider Master Relationship Data – Mapping into Database

 

The standard process for mapping Provider Master Relationship data into the Healthx database uses the OrgPractitionerID, OrgFacilityID, OrgHospitalID and RecordType fields to identify the associated provider record.

 

If there is an exact match of the values in the OrgPractitionerID, OrgFacilityID, OrgHospitalID and RecordType fields between the record in the file and the record in the provider database, then the file record is added into the database.  

 

If there is no match of the values in the OrgPractitionerID, OrgFacilityID, OrgHospitalID and RecordType fields between the record in the file and the record in the provider database, then the file record is bypassed and is not added to the database

 

If there is a record in the master relationship file for a provider currently in the provider database but not included in the corresponding provider file with the same extract date, the master relationship record will be added to the existing records. Potentially, this could result in duplicate master relationship records. See Provider Data Map-Process document for details on how the provider process affects the master relationship process.

 

 

 

Flex Election Data – Mapping into Database

 

The standard process for mapping Flex Election data into the Healthx database uses the MemberID, GroupNumber, FlexType and PlanYear fields to determine if a record is added or replaced.

 

If there is an exact match of the values in the MemberID, GroupNumber, FlexType and PlanYear fields between the record in the file and the record in the database, then the file record replaces the database record.

 

If there is no match of the values in the MemberID, GroupNumber, FlexType and PlanYear fields between the record in the file and the record in the database, then the file record is added as a new database record.

 

If there is more than one record in the same file with the same MemberID, GroupNumber, FlexType and PlanYear, then the last record in the file will replace the prior record as records are updated or added in the same order as in the file.

 

When an existing record is replaced by a record in the file, the flex process will first update the election record and delete any associated transaction records. Once all of the election records are updated or added, the process will then add the flex transaction/payment record to the associated election record.


Flex Transaction Data – Mapping into Database

 

The standard process for mapping Flex Transaction (payment) data into the Healthx database uses the MemberID, GroupNumber, FlexType and PlanYear fields to identify the associated election record.

 

If there is an exact match of the values in the MemberID, GroupNumber, FlexType and PlanYear fields between the record in the file and the record in the database, then the transaction/payment record is added to the database. 

 

If there is no match of the values in the MemberID, GroupNumber, FlexType and PlanYear fields between the record in the file and the record in the database, then the file record is bypassed and is not added to the database.

 

If there is a record in the transaction file for an election record currently in the flex database but not included in the corresponding election file with the same extract date, the transaction record will be added to the existing records. Potentially this could result in duplicate transaction records.  See Flex Election Data Map-Process document for details on how the flex process affects the transaction records.

 

 

Authorization Data – Mapping into Database

 

The standard process for mapping Authorization data into the Healthx database uses the AuthNumber and ProviderTIN fields to determine if a record is added or replaced.

 

If there is an exact match of the values in the AuthNumber and ProviderTIN fields between the record in the file and the record in the database, then the file record replaces the database record.

 

If there is no match of the values in the AuthNumber and ProviderTIN fields between the record in the file and the record in the database, then the file record is added as a new database record.

 

If there is more than one record in the same authorizations file with the same AuthNumber and ProviderTIN, then the last record in the file will replace the prior record as records are updated or added in the same order as in the file.


HRA Data – Mapping into Database

 

The standard process for mapping HRA data into the Healthx database is to use the Flex Election and Flex Transaction data files.  To send the following fields RolloverBalance and StartingRollover, use the TextQualifier and UserDefinedText fields.

 

 

 

Prescription Claims Data – Mapping into Database

 

The standard process for mapping Prescription Claims data into the Healthx database uses the RxNumber and ProdID fields to determine if a record is added or replaced. To facilitate members being able to view their records a MemberID is required and it must match the MemberID sent in Eligibility.  Please refer to Member ID Rules section for more information.

 

If there is an exact match of the values in the RxNumber and ProdID fields between the record in the file and the record in the database, then the file record replaces the database record.

 

If there is no match of the values in the RxNumber and ProdID fields between the record in the file and the record in the database, then the file record is added as a new database record.

 

If there is more than one record in the same prescription claims file with the same RxNumber and ProdID, then the last record in the file will replace the prior record as records are updated or added in the same order as in the file.

 

 


 



 

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