a guide to understanding the enrollment verification ... · pdf fileenrollment verification...

A Guide

To Understanding the

Enrollment Verification Report (EVR) Included in this document:

What is an Enrollment Verification Report?

Section I: Record Counts

Section II: Division Counts

Section III: Transaction Summary

Section IIIa: Transactions Attempted Summary

Section IV: Current Enrollment Summary

Section V: Reject Detail

Reject Error Messages

Glossary

Frequently Asked Questions

Enrollment Verification Report Guide 2

What is an Enrollment Verification Report? The Enrollment Verification Report* (or EVR) is an automatically generated report created and sent out within 24 hours of a file load. It is considered confirmation that a file has been loaded and no other file confirmation is sent out. The EVR allows you to verify your membership counts and identify any errors or rejected records that occur as a result of your file load. The EVR can then be used as a guide to correcting these errors or rejected records on your file.

Please note: We can only send the EVR to a maximum of four emails or fax numbers per group.

*The EVR has also been called an error report, a discrepancy report, or a load report.


Sample Section I: Record Counts

Section I: Record Counts will provide the following for both members and dependents sent on the file: the total number of records

1, the number of eligible records

2, the number of ineligible records

3, the number of rejected records

4, and the number of

duplicate SSN/IDs5.

VISION SERVICE PLAN Enrollment Verification Report

Date Printed: 12/21/2000 Time Printed: 7:04:49AM Job Name: PMBRJ7U8 Page 2

File ID: 2344321 Group: SAMPLE EVR

Memb Coord: EDI ENROLLMENT Phone: (877) 396-8940 Fax: (___) ___-____ Email: [email protected]

Section I: Record Counts

Records1 Type Eligible

2 Ineligible

3 Rejects

4 Dup SSN/ID

5

23,562 MBR 11,291 0 1 0

DEP 12,269 0 1 0

Totals 23,560 0 2 0


Sample Section II: Division Counts

Section II: Division Counts provides the total number of member and dependent records sent per division on the current file load1

as well as the number of errors per division2. Each division is identified by its VSP group-division-class number

3, VSP division

name4, and the corresponding division code

5 that is sent on the file and identifies which VSP division each member and

dependent belongs in.

Section II: Division Counts

VSP Group-Div-Class3 VSP Division Name4 Group’s Division Code5 Errors

2

Reject Dup

SSN/ID

Current Load1

12/15/2000

Mbr Dep 12344321-0008-0002 SAMPLE EVR 1000 1 0 5,558

Division Total 0 5,558

12344321-0008-0003 SAMPLE EVR 1100 0 0 1,865


12344321-0008-0004 SAMPLE EVR 1010 0 0 445

Division Total 0 445

12344321-0008-0005 SAMPLE EVR 1110 0 0 1,132


12344321-0008-0006 SAMPLE EVR 1020 0 0 443

Division Total 0 443

12344321-0008-0007 SAMPLE EVR 1120 0 0 1,849


Group’s Div Code Unknown 1 0 0

Totals 2 0 11,292


Sample Section III: Transaction Summary

Section III: Transaction Summary provides the number of member and dependent transactions that occurred in each division as a result of the current load. These transactions include future effective dates

1, adds

2, changes

3 (coverage level changes, name changes, and address updates),

terms4, and drops

5 (for a definition of a “drop”, see Glossary).





Section III: Transaction Summary

VSP Group-Div-Class VSP Division Name Group’s Division Code Future1

Mbr Dep

Adds2

Mbr Dep

Changes3

Mbr Dep

Terms4

Mbr Dep

Drops5

Mbr Dep 12344321-0008-0002 SAMPLE EVR 1000 0 0 20 0 42 0 0 0 0 0

Division Total 0 0 20 0 42 0 0 0 0 0

12344321-0008-0003 SAMPLE EVR 1100 0 0 8 11 16 0 0 0 0 0

Division Total 0 0 8 11 16 0 0 0 0 0

12344321-0008-0004 SAMPLE EVR 1010 0 0 1 1 3 0 0 0 0 0

Division Total 0 0 1 1 3 0 0 0 0 0

12344321-0008-0005 SAMPLE EVR 1110 0 0 3 8 9 0 0 0 0 0

Division Total 0 0 3 8 9 0 0 0 0 0

12344321-0008-0006 SAMPLE EVR 1020 0 0 0 0 0 0 0 0 0 0

Division Total 0 0 0 0 0 0 0 0 0 0

12344321-0008-0007 SAMPLE EVR 1120 0 0 2 13 21 3 0 0 0 0

Division Total 0 0 2 13 21 3 0 0 0 0

Total 0 0 34 33 91 3 0 0 0 0


Sample Section IIIa: Transactional Attempted Summary

Section IIIa: Transactions Attempted Summary will appear on an EVR if one or more of a group’s divisions fail to load. It reflects the transaction activity that would have occurred, if the division(s) had loaded successfully. This happens if the number of errors or transactions in that division on the current file load hits the internal VSP tolerance levels. Like Section III, these attempted member and dependent transactions include future effective dates

1, adds

2, changes

3 (coverage level changes, name changes, and address updates), terms

4, and drops

5 (for a definition of a “drop”,

see Glossary).





Section IIIa: Transactions Attempted Summary

VSP Group-Div-Class VSP Division Name Group’s Division Code Future1

Mbr Dep

Adds2

Mbr Dep

Changes3

Mbr Dep

Terms4

Mbr Dep

Drops5

Mbr Dep

12344321-0008-0006 SAMPLE EVR 1020 0 0 0 0 3 0 0 0 0 0

Division Total 0 0 0 0 3 0 0 0 0 0

Total 0 0 0 0 3 0 0 0 0 0


Sample Section IV: Current Enrollment Summary

Section IV: Current Enrollment Summary provides the total number of members within each division, sorted by family indicator (also known as a coverage code). The counts in this section over the course of each billing period are the basis for your administrative billing; however, you may see minor fluctuations as a result of membership activity that occurs outside of the file loads. For real-time membership numbers, you may go to www.vsp.com.

Please note: The counts listed in this section may differ from the counts listed in Section I. For more details, please refer to the Frequently Asked Questions.





Section IV: Current Enrollment Summary

VSP Group-Div-Class VSP Division Name Group’s Division Code A B C D Total

12344321-0008-0002 SAMPLE EVR 1000 0 0 5,558 0 5,558

Division Total 0 0 5,558 0 5,558

12344321-0008-0003 SAMPLE EVR 1100 0 1,865 0 0 1,865

Division Total 0 1,865 0 0 1,865

12344321-0008-0004 SAMPLE EVR 1010 0 445 0 0 445

Division Total 0 445 0 0 445

12344321-0008-0005 SAMPLE EVR 1110 1,132 0 0 0 1,132

Division Total 1,132 0 0 0 1,132

12344321-0008-0006 SAMPLE EVR 1020 0 0 0 443 443

Division Total 0 0 0 443 443

12344321-0008-0007 SAMPLE EVR 1120 1,849 0 0 0 1,849

Division Total 1,849 0 0 0 1,849

Total 2,981 2,310 5,558 443 11,292

Family Indicators: A = Family, B = Member + 1, C = Member Only, D = Member + Children

* NOTE ITEMS MARKED WITH AN ASTERISK "*". ZERO RECORDS WERE INCLUDED OR ACCEPTED FOR THIS DIVISION

ON THIS LOAD. PLEASE CONTACT YOUR ANALYST IF THIS IS NOT CORRECT.

http://www.vsp.com/


Sample Section V: Reject Detail

Section V: Reject Detail identifies any errors that occurred as a result of your file load. Each error is listed by a header that contains the error number

1, the name of the error

2, and how many records were affected

3 (at least 3 of the affected records will be listed for each error). Below the

header is an explanation of what caused the error4 and how the error may be resolved

5. A detailed explanation of each of the possible error

messages you may see can be found in Reject Error Messages.

Please note: As some rejects may have resulted from records that were not sent on the file but are in VSP’s system, the total number of rejected records listed in Section V may differ from the number of rejects listed in Section I.


Date Printed: 12/21/2000 Time Printed: 7:04:49AM Job Name: PMBRJ7E8 Page 5



Section V: Reject Detail

ERR#5971 - Group’s Division code not found

2 (Total Occurrences

3: 1)

Cause and Example4:

A code being sent on the input file that VSP is not

mapping to a specific Group-Div-Class.

Resolution5:

Notify your Membership Coordinator and discuss whether

this is a new VSP Group-Div-Class or should be pointing

to an existing VSP Group-Div-Class.

T1 M

2 R

3 F

4 Mbr-SSN/ID Name Group’s Div Code Birth Begin End Xref-A Xref-B

R D C XXXXXXXXX 0010 2152000T

ERR#999 – Total VSP internal errors for this load (Total Occurrences: 1)

Cause and Example:

The errors/rejects are considered internal to VSP.

Resolution:

These internal errors/rejects are a summary of:

errors the group chose not to view, and/or

errors to be researched and/or corrected by VSP.

T1 M

2 R

3 F

4 Mbr-SSN/ID Name Group’s Div Code Birth Begin End Xref-A Xref-B

1. Transaction Code: R = Full Replacement, A = Add record, C = Change record, E = End record, I = Member Reinstate

2. Mbr/Dep: M = member record, D = dependent record, E = encounter record

3. Relation: 1 = Member, S = Spouse, C = child, H = Handicap, T = Student, etc.

4. Family Indicator: A = Family, B = Member + 1, C = Member Only, D = Member + Dependent Children

9

Enrollment Verification Report Guide

Reject Error Messages

When records reject on the file load, error messages will appear on the EVR. It is considered the responsibility of the client or TPA to resolve these errors. The table below outlines each of the reject error messages that can appear on the EVR as well as possible causes and potential resolutions.

Error Number

Reject Error Message

Possible Cause and Example Potential Resolution(s)

#009 Invalid transaction ind (replacement or maintenance trans)

According to the format being used, an invalid transaction code is being sent or this field is empty. For ANSI 834 files, this code is found in INS03. For most VSP Proprietary files, this code is found in position 4.

Please update the file with the correct transaction code, according to the format being used. The correct codes for ANSI 834 are: 001-Change, 021-Add, 024-Term, 030-Full Replace. For VSP Proprietary files, the codes are: (R)eplace, (A)dd, (E) Term, (C)hange, (I) Reinstate.

#015/

#038

Invalid Termination Date on record

The record was sent with an invalid date (e.g. month = something other than 01-12, day = something other than 01-31), a future date was sent, or the field was left blank.

Please replace the invalid date with a correctly formatted date.

Example: 20130101

#019 Duplicate Record on Enrollment File

The file contains two or more identical records (with the same SSN or ID number, full name, gender and DOB under the same VSP Group-Division-Class).

Please ensure that only one record per member or dependent is being sent within a VSP Group-Division-Class.

#026 Dep with no mbr association

The dependent record does not correspond with a member record within the file. If there are multiple divisions, the member and dependent may have been sent with different division codes.

Please ensure that a corresponding member record is sent on the file for this dependent within the same division. If the associated member is termed, please remove the dependent from the file.

#030 Invalid transaction ind According to the file layout being used, an invalid transaction code is being sent or this field is empty.

Please update the file with the correct transaction code, according to the file layout being used. Please contact [email protected] for a list of valid codes.

#031 Invalid mbr-dep ind on enrollment record

According to the file layout being used, an invalid member or dependent code is being sent or this field is empty

Please update the file with the correct member or dependent code, according to the file layout being used. Please contact [email protected] for a list of valid codes.

#032/

#033

Invalid relationship code/ind on enrollment rec

According to the file layout being used, an invalid relationship code is being sent or this field is empty.

Please update the file with the correct relationship code, according to the file layout being used. Please contact [email protected] for a list of valid codes.

#034 Invalid family ind on enrollment rec

According to the file layout being used, an invalid family indicator (coverage level code) is being sent or this field is empty.

Please update the file with the family indicator (coverage level code), according to the file layout being used. Please contact [email protected] for a list of valid codes.

mailto:[email protected]




10


#035 Mbr SSN/ID not numeric on enrollment rec

The record was sent with an invalid SSN/ID such as dropped 0’s, all the digits used were identical, or there are too many or too few characters.

Correct the invalid character(s), according to the file format being used.

#037 Invalid DOB on enrollment rec

The record was sent with an invalid date (e.g. month = something other than 01-12, day = something other than 01-31), a future date was sent, or the field was left blank.


Example: 20130101

#097 Invalid dep eff date < mbr eff date on mbr file

The dependent’s effective date is prior to the corresponding member’s effective date.

Please correct the effective date for either the dependent or the member. A dependent’s effective date must be equal to or occur after a member’s effective date.

#098 Invalid dep eff date< DOB

The dependent’s effective date is prior to their date of birth. Please correct the applicable date (either the effective date or the birth date).

#241 WMX75:Term dt is < org eff dt

The term date is prior to the effective date sent on the file for this member or dependent.

Please correct the applicable date (effective date or term date). Term dates must be equal to or occur after a member or dependent’s effective date on the file.

#277 Mbr/dep records tran codes or div codes out of sync

The dependent maintenance record does not correspond with a member record within the file. If there are multiple divisions, the member and dependent may have been sent with different division codes.

Please ensure that a corresponding member record is sent on the file for this dependent within the same division. If the associated member is termed, please remove the dependent from the file.

#304 Invalid dependent name

The first and/or last name field for the dependent is blank. Please include both the first and last name for the dependent on the file.

#596 Control # invalid According to the format being used, a control number is being sent or this field is empty.

A control number is assigned by VSP when using VSP’s Proprietary file layout. Please contact [email protected] if you do not know your assigned control number.

#597 Group’s Division code not found

A code is being sent on the enrollment file that VSP does not have pointing to a specific VSP Group-Division-Class.

Please contact [email protected] and let us know if this is a new Division or if this code should be directed to an existing VSP Group-Division-Class.

#599 Cannot term before eff date

The term date is prior to the effective date sent on the file for this member or dependent.

Please correct the applicable date (effective date or term date). Term dates must be equal to or occur after a member or dependent’s effective date on the file.

#618 New enrollment eff date > 1yr into the future

The member’s enrollment record has an effective date greater than one year from the current date.

Please change the effective date to be less than one year from the current day.

#624 Invalid member name The member’s first and/or last name field is blank. Please include both the first and last name on the file.



11


#626 Invalid eff date on record

The record was sent with an invalid date (e.g. month = something other than 01-12, day = something other than 01-31), or the field was left blank.


Example: 20130101

#628 Change to FI is > than Retro Allowance

The enrollment record has a Family Indicator (coverage code) change effective date that exceeds VSP's business rule: Retroactive enrollment changes are allowed for the current month, plus two prior months.

Please change the effective date to be within VSP's business rule: Retroactive enrollment changes are allowed for the current month, plus two prior months.

#629 Change to FI is > than future allowance

The enrollment record has a Family Indicator (coverage code) change effective date that exceeds VSP's business rule: Future enrollment changes are allowed for the current month, plus five future months.

Please change the effective date to be within VSP's business rule: Future enrollment changes are allowed for the current month, plus five future months.

#635 FI Change Effective Date < Original Effective Date

Member is on the file with a Family Indicator (coverage code) Change Effective Date that is prior to the member’s original effective date.

Please change the Family Indicator (coverage code) Change Effective date to a date that is equal to or occurs after a member effective date on the file.

#637 FI Changed and no FI Change Effective Date on File

Member is on the file with a different Family Indicator (coverage code) than what is currently in our system and there is no Family Indicator (coverage code) Change Effective Date being reported.

Include a Family Indicator (coverage code) Change Effective Date on the file.

***For ANSI 834 files, a DTP*303 segment must be sent in Loop 2300.

***For VSP Proprietary files, please use positions 178-185.

#999 Total VSP internal errors for this load

These errors/rejects are considered internal to VSP. These internal errors/rejects are a summary of:

- errors the group chose not to view

- errors to be researched and/or corrected by VSP

VSP will resolve these errors internally, if needed. If there is anything the client or TPA needs to do, a Membership Coordinator will contact you.

12


Glossary

Some words or phrases within this document may be unfamiliar, so we’ve included the glossary below as a reference.

Column Headers/ Row Titles

Definition/Calculation

A, B, C, or D This character identifies a member’s coverage level. The characters are referred to as family indicators or coverage codes.

A = Family

B = Member plus One Dependent (in a 4-tier rate structure, this code is defined as Member plus Spouse/Domestic Partner)

C = Member Only

D = Member Plus Child(ren) (applicable only with a 4-tier rate structure)

Adds The number of Member/Dependent records being added or attempting to be added into VSP’s system.

Begin The date the Member/Dependent became eligible for vision coverage.

Birth The date the Member/Dependent was born.

Changes The number of Member/Dependent records being changed or attempting to be changed. If multiple changes are present in a Member/Dependent’s record, they will be included in the count.

Current Load This refers to the file that the EVR was based on. Current load counts (Section II) refer only to what was sent on this file and do not include previous files or system counts.

Dep An abbreviation for dependent. Dependents may be a Spouse, Child, Domestic Partner, Dependent Parent, Disabled Child, Student, or other.

Division Total The sum of activity for a specific VSP division in each column.

Division Code (a.k.a. Group’s Div Code)

An alpha-numeric code (1-30 characters), assigned by the group or VSP, to allow our system to load membership to a specific VSP Group-Div-Class. A division code can only point to one division but a division can have more than one division code mapped to it.

Drops* *Drops can also be

referred to as a “term by omission”.

These are member/dependent records that are currently active in our system but were not included on the file. This results in our system terminating or attempting to terminate these member/dependent records according to the group’s drop date logic. (This only applies to full-replacement files.)

- Please email [email protected] for a list of drop date logic options.


13


Dup SSN/ID Member or dependent records on the input file with the same SSN or ID number, full name, gender and DOB under the same VSP Group-Division-Class.

Eligible Member/Dependent records qualified for coverage.

End The date the Member/Dependent terminated eligibility for vision coverage.

Errors These are rejects and/or Duplicate SSN/Ids that occurred on the current load.

File ID A 7 digit number that is used as the file’s name and/or as a group’s username when sending files to VSP. This number is often derived from the 8 digit VSP group number.

Future Member/dependent records with a begin date that has not yet occurred.

Ineligible Member/Dependent records not qualified for coverage.

Mbr An abbreviation for Member.

Mbr-SSN/ID The member’s Social Security number or other unique identifier.

Records Data sent on the file for each member or dependent. Each file type formats this data differently.

Rejects Member or dependent records on the file that contain erroneous data and which could not load with the rest of the file.

Terms Member/dependent records terminated or attempting to terminate due to a termination date (including future termination dates) on the file, as well as drops.

Type The type of record (e.g. Member, Dependent).

VSP Division Number

A 4 digit number that identifies categories into which members and dependents are loaded, as indicated by the division codes sent on the file. Divisions often indicate different company locations, VSP plans/rates, or COBRA.

VSP Group Number An 8 digit number that identifies the overall structure created by a group’s requirements. This determines which division the membership is loaded into within the group’s structure. This number is assigned by VSP.

Xref-A Alpha-numeric cross reference codes (8 characters each) - Applicable only when additional data is needed to cross reference back to a group’s system via claims reporting

Xref-B They can be combined as one code, which would allow a 16-character code.


Frequently Asked Questions:

1. Q: What can cause the member count differences between Section I and Section IV to be different?

A: The three most common reasons for this are:

Member records with future effective dates.

Member records with past term dates.

A division with a future effective date.

2. Q: Why is a division in Section II/III/IV showing zero membership?

A: Records for this division may not have been included on the file, or we were unable to load membership for this division. Please confirm that the division is active and the membership for that division is being sent correctly on the file.

3. Q: Why would Section IV reflect membership when a division is terminated?

A: The division is still showing active in VSP’s system and membership has not yet been terminated. Please email [email protected] if the division should be terminated in VSP’s system.

4. Q: Why would the EVR reflect a partial load?

A: A partial load often occurs when the number of transactions (e.g. adds, updates, terminations) is greater than 30% of that division’s total membership. The system rejects the entire division for verification by VSP and only the divisions that do not hit this threshold will be loaded into VSP’s system. (Rejected divisions appear in Section IIIa)

5. Q: Why would the reject counts in Section V counts differ from the reject counts reported in Section I?

A: Internal rejects are only counted once for Section I, but can be counted more than once for Section V (the records may appear under more than one reject error message).

If you have any questions about the EVR that were not answered in this document, please contact us using the information below.

VSP EDI Membership Team Email: [email protected] Phone: 1.877.396.8940 Hours: 5:30am to 5:30pm, PST



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