File Types

File Content

File* GroupCustomerId

Every File that is received by an insurance carrier is comprised of a set of Family Records. The File contains an identifier for the Group Customer that submitted the file. Each Family Neutral Record contains the information that needs to be processed for a Member of the Group Customer. The Family Neutral Record contains an identifier that can be used to uniquely identify the employee/primary participant/sponsor for the Group Customer. It is comprised of a set of Member Records.

Records are grouped together by Primary Participant / Employee / Sponsor to form what is called a "Family Neutral Record" (FNR) identified by the Sponsor ID, which could be the Sponsor Tax ID or Employee ID. Each FNR is comprised of a set containing one or more records containing information about the Employee or one of the Employee's dependents. It is possible that more than one record exists in the same FNR for the same member (employee or dependent), on the same file. In order for OIPA to be able to process multiple records pertaining to the same individual member, a process order must be specified that dictates the order of processing for the records within the FNR. For any given file definition, each record contains the same fields; however, it is possible that some fields will not be populated. For example, the "Salary" field would be populated for an employee of the group customer, but would not be populated for the spouse or child of the employee.

An example of an FNR follows. In this example, a single FNR pertains to a sponsor with an id of ABC1000 whose name is Frank Smith. He has a wife, Donna, and a child, Bobby.

In the FNR, there are multiple records pertaining to the employee or one of his dependents. This information comes in on the same file for the sponsor Frank Smith.

MemberID Seq Last First Gender RelCd AddrTyp Line1 JobStat
ABC1000 1 Smith

Frank

M E H

1 Main

A
ABC1000 2 Smith Frank M E H 2 Tree A
ABC2000 3 Smith Donna F W H 1 Main  
ABC2000 4 Smith Donna F W H 2 Tree  
ABC3000 5 Smith Bobby M C H 1 Main  
ABC3000 6 Smith Bobby M C H 2 Tree  

In the example above, it is possible that each record for Frank Smith contains changes. OIPA must be able to process changes for both records pertaining to Frank Smith, in the process order specified. If the First record for Frank Smith had an address change, and the second record had a coverage change, both changes would have to be processed in the system; the address change would be executed first before the coverage change.

File Types

There are different types of files that can be received by an insurance carrier for processing. In addition, each type of file may contain different Record Types and result in different processing. The files may also vary between Group Customers.

Participation File

In a Participation File, only eligible members who have elected to participate in coverage are included in the file. The insurance carrier is instructed as to the end state by the Group Customer. The Participation File will contain data for both Eligibility and Enrollment. The Group Customer does all of the record keeping, and OIPA can simply assign an employee to eligibility classes and enroll them without a requirement to validate. The net result of processing a Participation File is that Eligibility and Enrollment updates will be applied. For example, for a new member:

Eligibility File

In an Eligibility File, only eligible members from a Group customer are included in the file. Other members who are not eligible for coverage are not included. OIPA will calculate the eligibility classes based on the member information provided. If the file specifies classes then OIPA validates the classes provided. If the file does not specify classes, then OIPA determines the eligibility classes. The net result of processing an Eligibility File is the placement of the member into one or more eligibility classes in OIPA. An Eligibility File falls into one of two sub-types:

For example, for a new member:

Note: When receiving an Eligibility file, OIPA will not automatically enroll the members in the file.

Population Files

Population files contain all or any subset of a Group Customer's members irrespective of whether or not they are eligible for coverage. No Eligibility determination is made by the Group Customer. Population Files are sometimes referred to as Universe files. Since the Group Customer does not send any eligibility information on a Population file, OIPA will always need to calculate eligibility. The net result of a Population File is the same as an Eligibility File; the member will be placed into one or more eligibility classes in the system.

For example, for a new member:

Note: Enrollment will not be processed for a Population File.

 

 

 

 

 

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