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Page Properties


Number

0023

Submitting Entities

99EBD1, 95448B

Add Date

Update Date

 

Update

Updated descriptionAdded information about NULL disenrollment dates (ME163A)

Description

Arkansas QualChoice (QC) (SE 95448B) serves served as the third party administrator (TPA) for the Arkansas Employee Benefits Division (EBD) (SE 99EBD1) between 2013 and 2018.  Periodically, the same claims will be found in both 95448B and 99EBD1.  It is important to understand that this can occur so data from one of the two submitters can be excluded  depending on the analytic requirements. These member data and claims data are also submitted through EBD. It is recommended that the data sourced from 95448B be omitted.

Action / Resolution

Find the SE 99EBD1 member records related to the SE 95448B member records by grouping on Hash 95448B no longer submits data for the Arkansas Employee Benefits Division (99EBD1). Several enrollment records contain NULL in ME163A making the enrollment record appear to be open and active for the submitter. For all data use, when ME001 = '95448B' and ME032 (Group Name) = 'ARBenefits' or ME001_CAT = ‘EBD_TPA’ and ME163A is NULL, substitute the value in ME163A with 2013-12-31.

To omit member and claims data where QC is the EBD TPA:

  1. Identify member records duplicated between 99EBD1 and 95448B. Do this by grouping member records on Study ID (created by concatenating APCD Unique ID (ME998) and member gender (ME013))

when

  1. where ME001 = 99EBD1 with member records where ME001 = '95448B' and ME032 (Group Name

(ME032

  1. ) =

ARBenefits.

  1. 'ARBenefits' or ME001_CAT = ‘EBD_TPA’

  2. Select EBD medical claims: Use the member

numbers

  1. number (ME001, ME107) from

this grouping to find claims. Include additional fields to satisfy the grouping:When MC001 = 95448B and

  1. the EBD records pulled in step 1 to select related medical claims: Join ME001 = 99EBD1 and ME107 = EBD member # to MC001 = 99EBD1 and MC137 = EBD member #

  2. Select 95448B medical claims: Use the member number (ME001, ME107) from the 95448B records pulled in step 1 to select related medical claims: Join ME001 = 95448B and ME107 = QC member # to MC001 = 95448B and MC137 = QC member #

  3. Identify QC medical claims to omit: Merge the output from steps 2 and 3 on MC004, MC005, MC012, MC059

match MC004, MC005, MC012, MC059 when MC001 = 99EBD1.Note, this TPA uses different masking routines for the carrier-specific unique member ID (MC137), therefore it is not possible to find these duplicate claims by member

  1. and omit the records where MC137 = 95448B.

Category 1

Merged SE & Overlap

Category 2

TPA

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