MANAGING EDI FILES DURING OPEN ENROLLMENT
The below steps are designed to manage a successful file creation to transmit Open Enrollment data to carriers either during or post open enrollment. Carriers may have different file options and preferences on how open enrollment information is sent to them and how they will process ongoing files once the open enrollment data has been transmitted. Before beginning the process contact should be made with each carrier to determine what data is expected on the file.
NOTE: Make sure to select save on each page to make sure any changes made have been saved!
The set up page will instruct the system on what data to export on the open enrollment file. Based on carrier requirements, the system will need to be setup using one of the following options:
- Option 1 - Include Open enrollments
- This option Includes open enrollment elections on the file prior to the closing out the open enrollment.
- Using this option does NOT transmit ended enrollments for the prior plan year
- Use this option when the carrier turns on logic to "Term by Omission"
- Option 2 - Include Ended Enrollments
- Includes enrollments that are being ended for the current plan year.
- This field should only be selected if the closeout process has been completed.
- For example, if employee is enrolled in coverage for current plan year and did not elect for the upcoming year, including ended enrollments will ensure that the employee’s current enrollment record is transmitted with a coverage end date. In the event that “include ended enrollments” is not selected, the employee who did not enroll in the future plan would drop from the file.
- NOTE: If the carrier does not or will not term by omission use this option to “include ended enrollments."
The plans tab controls which plans are to be included in the file and houses the setup of the HD03 (Insurance Line Code Value) for renewing plans.
- Select the plans that to be included in the file. If sending both ended and open enrollments on the file, be sure to select both the current and future plans. If sending only open enrollments, to be sure that only the future plans are selected.
- Set the HD03 value from the drop down menu for future plans to match that of the current plans.
The structure configured within the file varies by carrier. Refer to the carrier implementation documents to determine which loops and segments contain company specific structure data.
- Plan Based Structure: Update existing structure codes configuration to include the renewing plans. Please note, if sending a file with both ended enrollments and future enrollments, leave the existing structure configuration active until after transmission of the file.
- To update the existing structure to include the renewing plans, go to the structure location and use the copy feature to copy the values and edit the criteria to set the rule to apply to the renewing plan
- Subgroup Based Structure: Based on sub-groupings, divisions, office locations and other similar elements. If there are no changes to the existing subgroup no further action is necessary. If there are adjustments to the current subgroups is necessary, additional mapping may need to be set. The carrier will provide coding changes/additions/terminations.
File Settings (File Naming Convention)
If the carrier requires that a change the naming convention of the file for open enrollment to include an indicator that it is an Open Enrollment file, make this change via the File Settings/File Naming Section.
- Note: Make sure to copy down the name of the current filename as the setting will need to be put back to the prior name once the OE file has been transmitted.
Time to send the file!
- If sending the open enrollment file and the carrier will continue to accept the ongoing future enrollment date, no additional steps are needed.
- If sending the file outside of the normally scheduled transmission, select the Run function on the Generation page. An email will be sent to the administrator who initiated the file once the file has been generated and transmitted.
- Note: Once Open Enrollment is closed, the current plan year plans will be inactive. As a result the current plan year plans will no longer transmit on weekly files. Any updates (all adds, terms, and changes) that impact the prior plan year plans need to be handled manually via the carrier site.
- Example, if the OE file was transmitted for the August 1st renewal on June 22nd and the closeout was completed, and an employee that terminates on June 25th, which results in coverage ending as of June 30th, the plan administrator will need to communicate the change to the carrier manually.
Post File Transmission
If ended enrollments were included AND transmitted the file, once the closeout is complete take the following action:
- On the Setup page de-select include ended enrollments
- On the Plans page deselect the current plans,
- If structure is plan based, inactivate the structure codes that point to the prior plan year plans
- If file naming convention was changed for Open Enrollment file, change the naming convention back to what is was previously.