Electronic Eligibility Files

HealthLink and NCPPO use payor eligibility to determine the proper place to route claims. This allows NCPPO and HealthLink to receive claims from providers, reprice and route claims to payors by automated means. All payors submit eligibility electronically.

Electronic eligibility files can be transmitted via FTP (File Transfer Protocol), electronic mail, or CD (?tapes? are not used).

Eligibility files must meet the following criteria:

• Full files (all employees or ?subscribers? and their dependents).
• At least a monthly transmission (files with 3,000 ee lives or greater records should be submitted more frequently, such as bi-monthly or weekly).
• ASCII, fixed-width format.
• Three months of (recent) terminations. (In the event that termination data cannot be sent, accommodations can be made upon special request .)
• Include both the subscriber's SSN and payor's policy (or privacy number) in separate fields (and then, these numbers will be returned on claims).
• Contain only network data and network effective dates.
• Include network product (OAII or PPO) and/or network access (NCPPO and HealthLink) codes applicable to the claims repricing requirements.

Electronic eligibility is preferred for the following reasons:

• Membership data can be loaded immediately and automatically;
• Data entry errors are minimized;
• Data are transmitted quickly and securely.

The client identification number (specific to each payor) should be submitted on the files. To send electronic eligibility or change the format in which it is sent, please contact your Payor Relations Specialist at 877-284-0101, extension 6132 or email PayorRelations@HealthLink.com .

Please refer to the Electronic Eligibility Format Specifications for more details. The specifications document can be downloaded from www.healthlink.com or www.ncppo.com.

National Capital Preferred Provider Organization, Inc. ("NCPPO") is a Maryland corporation. HealthLink®, Inc., is an Illinois corporation. Both are organizers of independently contracted provider networks, which are made available by contract to a variety of payors of health benefits, including insurers, third party administrators or employers. Neither has control nor right of control over the professional, medical judgment of contracted providers, nor are they liable for any acts or failures to act, by contracted providers. Neither is an insurance company and neither has liability for benefits under benefit plans offered or administered by payors. HealthLink® is a registered trademark of HealthLink, Inc. Both companies are subsidiaries of WellPoint, Inc.