Dominion Dental Electronic Eligibility File Layout for Employer Groups

Dominion Dental Electronic Eligibility File Layout for Employer Groups

Table of Contents

Overview

Method of Data Transfer

Frequency and Thresholds

Next steps

Format

Rules and Notes

Required information

Overview

The purpose of this document is to provide a step-by-step guide to a successful implementation of an electronic eligibility feed. Below you will find the needed actions to implement the process. Questions regarding the process or requests for added fields and/or unique logic should be directed to: .

Method of Data Transfer

Dominion utilizes Secure File Transfer Protocol (SFTP) for all electronic eligibility. Dominion can accommodate either push (Dominion-hosted SFTP) or pull (Client-hosted SFTP). If Dominion hosts the SFTP, client will be provided login credentials within one week.

By default, all data is encrypted when uploaded to the server, and decrypted when downloaded from the server.

Exceptions can be made for urgent requests and notification should be sent to for assistance in accommodating the requests.

Steps for using the SFTP:

1)Client provides list of the IP addresses that will be required to connect to Dominion SFTP servers.

2)Dominion will create SFTP site using client-preferred naming for directories.

3)Dominion will provide the client-certified user with login credentials.

4)Client user will connect to SFTP using provided credentials.

5)Client user will then be able to upload or download files to/from local or secure network location.

Sending data:

• File naming convention: Standard naming convention is: {clientname}_{process}_datetime.dat (ex. Archies_elig_20151001164537.dat)
• Dominion can also use custom naming conventions at the client’s request.
• Dominion sweeps client SFTP location for new files, triggering process kickoff. Dominion can configure email notification once this has occurred.

Frequency and Thresholds

Electronic eligibility is generally available for Clients with 200+ subscribers. Dominion will accept electronic eligibility files at the Client-preferred frequency. The files can either be full, or delta (change) files. If change files are preferred, Dominion will require a full eligibility file at month-end for reconciliation purposes. Frequency of feeds is determined by the Client and the group size:

Daily: 1000+ subscribers; Weekly and bi-weekly: 200+ subscribers; Monthly 50+

Next steps

Once the Format and Rules section have been reviewed by the Client and/or Vendor, please complete Required Information section and email the completed document to and a Dominion EDI team member will respond within two business days to discuss timing and readiness.

The Client configuration process normally takes two weeks, with an additional two weeks of testing to ensure production readiness.

Format

Dominion uses a fixed width format for electronic eligibility. Dominion has the capability to implement other proprietary formats on a case-by-case basis (please note this in #6 of Required Information). Additional layout rules and notes are provided at the end of this document.

Field / Type / Length / Subscriber / Spouse or Child / Description / Values, Format or Comments
1 / sub_alt_id / Char / 20 / Preferred (include if available) / Preferred (include if available) / Subscriber ID / An identifier, other than the SSN, which uniquely identifies a subscriber. SSN can be substituted if needed.
2 / alt_id / Char / 20 / Preferred (include if available) / Preferred (include if available) / Member ID / An identifier, other than the SSN, which uniquely identifies a member.
For the subscriber, the “alt_id” value should be the same as “sub_alt_id” value.
3 / sub_ssn / Char / 11 / Required / Required / Subscriber SSN / Format: 000-00-0000.
4 / ssn / Char / 11 / Required / Required / Member SSN / Format: 000-00-0000.
For the subscriber, the “ssn” value should be the same as “sub_ssn” value.
5 / member_code / Char / 3 / Required or Optional* / Required or Optional* / Member Code in Dominion’s system.
* If Dominion’s member code is not provided in this field, data is required in both the “gender” and “relationship” fields so that Dominion can calculate the member code. / 10 = Male Subscriber
20 = Female Subscriber
30 = Male Spouse or Male Domestic Partner (if covered by plan)
40 = Female Spouse / Female Domestic Partner (if covered by plan)
50 = Male Child
70 = Female Child
6 / last_name / Char / 15 / Required / Required / Member Last Name / Case-insensitive (any case).
7 / first_name / Char / 15 / Required / Required / Member First Name / Case-insensitive (any case).
8 / middle_init / Char / 1 / Optional (include if available) / Optional (include if available) / Member Middle Initial / Case-insensitive (any case but usually uppercase).
9 / date_of_birth / Char / 10 / Required / Required / Member Date of Birth / YYYY-MM-DD
10 / student_flag / Char / 1 / Optional (include if available) / Optional (include if available) / Student Indicator / “Y” = Yes, this member is a student “N” = No, this member is not a student
blank = there is no student indicator in the Client’s system
11 / disabled_flag / Char / 1 / Optional (include if available) / Optional (include if available) / Disabled Indicator / “Y” = Yes, this member is disabled “N” = No, this member is not disabled
Single spaceif unavailable.
12 / cobra_flag / Char / 1 / Not Available / Not Available / COBRA Indicator / “Y” = Yes, this member is disabled “N” = No, this member is not disabled
Single space if unavailable.
13 / address1 / Char / 30 / Required / Ignored / Subscriber Mailing Address – Street Address Line 1 / Case-insensitive (any case).
14 / address2 / Char / 30 / Optional / Ignored / Subscriber Mailing Address – Street Address Line 2 / Case-insensitive (any case).
15 / city / Char / 25 / Required / Ignored / Subscriber Mailing Address – City / Case-insensitive (any case).
16 / state / Char / 2 / Required / Ignored / Subscriber Mailing Address – State Abbreviation / Uppercase. Standard 2 character USPS state abbreviation.
17 / zip_code / Char / 5 / Required / Ignored / Subscriber Mailing Address – Zip Code / 5-digit USPS zip code.
18 / zip4 / Char / 4 / Optional / Ignored / Subscriber Mailing Address – Zip + 4 / Last four digits of a zip code in the USPS zip+4 format. If present, it must be 4 digits. If unknown, leave blank or use “0000”.
19 / home_phone / Char / 10 / Optional (include if available) / Ignored / Subscriber Home Phone / If present, the home phone number must be 10 digits.
20 / home_ext / Char / 5 / Optional (include if available) / Ignored / Subscriber Home Phone Extension / If present, the home phone extension must be all digits. Front-pad with spaces, if needed.
21 / work_phone / Char / 10 / Optional (include if available) / Ignored / Subscriber Work Phone / If present, the work phone number must be 10 digits.
22 / work_ext / Char / 5 / Optional (include if available) / Ignored / Subscriber Work Phone Extension / If present, the work phone extension must be all digits. Front-pad with zeroes, if needed.
23 / gender / Char / 1 / Required or Optional * / Required or Optional * / Member Gender
* Required if Dominion’s “member code” is not provided. / M | F
24 / relationship / Char / 10 / Required or Optional * / Required or Optional * / Member’s Relationship to Subscriber.
* Required if Dominion’s “member code” is not provided. / Value used should help Dominion determine if the person is a subscriber, spouse, or child.
Please provide coding crosswalk.
25 / parent_id / Char / 10 / Ignored for incoming data / Ignored for incoming data / Parent Group of Group Identifier
FOR DOMINION USE ONLY / Dominion use only. Leave blank for incoming data.
26 / group_id / Char / 10 / Required / Optional / Subscriber Group Identifier / Can either be Dominion’s group identifier or a group identifier provided by the client. The Client’s value can be alpha, numeric, or alphanumeric.
27 / group_eff_date / Date / 10 / Ignored for incoming data / Ignored for incoming data / Member Group Effective Date
FOR DOMINION USE ONLY / Dominion use only. Leave blank for incoming data.
28 / group_term_date / Date / 10 / Ignored for incoming data / Ignored for incoming data / Member Group Termination Date
FOR DOMINION USE ONLY / Dominion use only. Leave blank for incoming data.
29 / plan_id / Char / 10 / Required / Optional / Subscriber Plan, Benefit, or Coverage Identifier / Can either be Dominion’s plan identifier or a plan identifier provided by the Client. Dominion’s value is an integer. The Client’s value can be alpha, numeric, or alphanumeric.
30 / plan_eff_date / Date / 10 / Required / Required / Member Plan Effective Date
This is the effective date used for member enrollment. / YYYY-MM-DD
Spouse or child’s effective date can’t be earlier than the subscriber’s effective date.
31 / plan_term_date / Date / 10 / Required if terminated / Required if terminated / Member Plan Termination Date
This is the termination date used for member enrollment. / YYYY-MM-DD
Values for active (not terminated) members should either be:

1. Blank
2. “2099-12-31”
3. Any other consistent Client value

32 / facility_id / Integer / 6 / Optional / Optional / Dominion’s Facility ID selected by a member enrolled in a DHMO plan / Used for initial enrollment in Dental HMO plans only.
Use “0” for an undesignated DHMO facility.
Leave blank or use “0” for PPO or Fee-for-service plans.
33 / facility_eff_date / Date / 10 / Do not include for incoming data / Do not include for incoming data / Member Facility Effective Date In Dominion’s Dental Facility
FOR DOMINION USE ONLY / Dominion use only. Do not include for incoming data.
34 / facility_term_date / Date / 10 / Only used when Client will terminations from dental facility.

Rules and Notes

1. It is highly recommended that sub_alt_id and alt_id fields are used to uniquely identify a subscriber and dependents.

1. All fields should be padded with leading spaces, unless otherwise noted.

1. Termination records should appear on only one file.

1. “Drop” records: when performing reconciliation activities, Dominion will terminate any records that are active in the eligibility system, which are not on the Client full-file. The general rule is for the beginning of the month in which the file is received, though Dominion can administer Client logic. Please provide comments in #6 of the Required Information section.

1. The Client should collapse different eligibility segments. This means if Client system maintains eligibility segments with effective and end dates, but there is no break in coverage on a given product, one continuous segment spanning the original effective date to present should be sent. Please provide comments in #6 of the Required Information section if the Client will be sending the data in a manner different from this.

1. “plan_eff_date”, the plan effective date, and “plan_term_date”, the plan termination date, are the dates used for enrollment purposes.

1. The term “member” in this documentation refers to a subscriber, spouse, or child.

1. The term “dependent” in this documentation refers to a spouse or child.

1. Fields that are shaded gray and have the note “FOR DOMINION USE ONLY” should be left blank for incoming records. Any values appearing in these fields will be ignored for incoming data. For incoming data, the last field should be field number 32, “facility_id”.

1. The subscriber’s value will be used when no value is provided for optional dependent fields. Examples include the group id, plan id, plan effective date and plan termination date.

1. Dominion will assume the task of mapping the Client’s group and plan identifiers to Dominion’s group and plan identifiers if the Client wishes to use proprietary identifiers, rather than Dominion identifiers.

Required information

Please email the below form to Dominion’s eligibility team at nd you will received a response within 48 hours to obtain/provide SFTP details, discuss plan-mapping, and address any questions or potential operational hurdles.

1) Client (group) name:

Eligibility contact information

First name:

Last name:

Phone:

Email:

2) EDI vendor company name (if applicable):

EDI contact information

First name:

Last name:

Phone:

Email:

3) Desired “go-live” date:

4) Desired file frequency and type.

Select one: DailyWeeklyBi-weeklyMonthly

Select one: Change, with monthly full fileFull file

5) SFTP hosting, select one: Client-hosted Dominion-hosted

Dominion eligibility team will reach out to Client to provide or obtain credentials/IP addresses depending on the above selection.

6) Will Client use Dominion Plan Identifiers, or Client-proprietary Identifiers?

Client Dominion

7) Please describe any additional information or obstacles as it relates to any part of the above process, with special attention to the Format and Rules sections.

Dominion Dental Electronic Eligibility File Layout_Standard

Page 1 of 10

October 27, 2015

By Dean Rogers, Dominion Dental Services, Inc, (703) 518-5000 x 3046

;