ProviderOne

Created on: 
Oct 21 2015

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

What is the ProviderOne interface?

The ProviderOne interface is an exchange of information between ACES and the Health Care Authority (HCA) ProviderOne system. ProviderOne uses this information to authorize payment for medical bills from medical providers, generate reports, and obtain federal funding. 

ACES uses the data received from ProviderOne to automatically update the appropriate screens with the new or updated medical information data, Third Party Liability (TPL) data, provider data, and rate information.

How often does the ProviderOne interface take place?

The ProviderOne interface takes place on a daily, weekly, and monthly basis depending on what client or provider information is being exchanged.

Online Processing​

What information is sent from ACES to ProviderOne?

The Eligibility Interface file contains client demographic, medical eligibility, spenddown, and TPL information. ACES sends this file to ProviderOne in the overnight batch process. The real-time version of this interface is sent throughout the day at approximately 15 minute intervals for clients who need medical services the same day their medical application is approved.

What information is received from ProviderOne to ACES?

The following files are received from ProviderOne and sent to ACES:

  • The Daily Facility Update file provides demographic and rate information for the various Long Term Care and Take Charge medical providers. When new providers are added or changes are made to the information of existing providers, ACES updates the Provider Details with the new information on a daily basis. You can access the Provider Details pop up from the Facilities section on the Institutional Care/Expenses page, by clicking the Details link for the selected provider.
  • The Client TPL Insurance file identifies clients who have medical coverage through a third party provider. The file provides information about the insurance organization and other pertinent information related to the client’s coverage. ACES updates the client’s Third Party Liability page with the current TPL information that is sent. Included in this TPL file is Medicare data for Part A and Part B, which is used to ensure clients are added or deleted from the State’s Medicare Buy-In program.
  • The Medicare Buy-in data received from ProviderOne automatically updates changes of Medicare Part A and Part B premium payment data on the Third Party Liability page in the Paid By field. ACES also uses the transaction data to update clients’ Medicare (Title XVIII) data and this interface file is received weekly.
  • The Insurance Organization file identifies all the Insurance Organizations and all their pertinent information. ACES updates the TPL Organization Search page with the names, addresses, and carrier codes of all TPL carriers known to the state and this file is received monthly.

What information displays in the ProviderOne Web Service?

The ProviderOne Web Service provides real-time information and the file populates the Medical Information page in aces.online.

The data elements displayed on this page are:

  • Client Medical Information:      
    • ProviderOne ID number
    • Medicare
    • TPL Insurance
    • Relative Care Placement Indicator
    • Hospice Indicator
    • Restriction Indicator
    • DDA Client Indicator
  • Managed Care Information:
    • Health Plan
    • Program
    • Start and End Dates

For more information see Medical Information.

Mainframe Processing

What information is sent from ACES to ProviderOne?

The Eligibility Interface file contains client demographic, medical eligibility, spenddown, and TPL information. ACES sends this file to ProviderOne in the overnight batch process. The real-time version of this interface is sent throughout the day at approximately 15 minute intervals for clients who need medical services the same day their medical application is approved.

What information is received from ProviderOne to ACES?

The following files are received from ProviderOne and sent to ACES:

  • The Daily Facility Update file provides demographic and rate information for the various Long Term Care and Take Charge medical providers. When new providers are added or changes are made to the information of existing providers, ACES updates the PROV screen with the new information on a daily basis.
  • The Client TPL Insurance file identifies clients who have medical coverage through a third party provider. The file provides information about the insurance organization and other pertinent information related to the client’s coverage. ACES updates the client’s TPL1 screen with the current TPL information that is sent. Included in this TPL file is Medicare data for Part A and Part B, which is used to ensure clients are added or deleted from the State’s Medicare Buy-In program.
  • The Medicare Buy-in data received from ProviderOne automatically updates changes of Medicare Part A and Part B premium payment data on the TPL1 screen in the Paid By field. ACES also uses the transaction data to update clients’ Medicare (Title XVIII) data and this interface file is received weekly.
  • The Insurance Organization file identifies all the Insurance Organizations and all their pertinent information. ACES updates the TPLC screen with the names, addresses, and carrier codes of all TPL carriers known to the state and this file is received monthly.

What information displays in the ProviderOne Web Service? 

This function does not currently exist in ACES Mainframe, see Online Processing-What information displays in the ProviderOne Web Service?

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.