HR-XML 3.0 Standards, 2009 September 23.
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The messages follow the format below:
[ Match | Mismatch: ] [Qualifying Info: ]? [ Subscriber | Dependent ]?
The first part is 'Mismatch:' The second part of the message qualifies the type of mismatch. The third part of the message corresponds to a name of the element within the Enrollment schema within which the mismatch occurred.
Match
Explanation
No material difference found between information on the record keeper’s system and that on the health plan system.
Many trading partners may not require an affirmative confirmation of a match.
Action
No Action.
Mismatch: Coverage: Dependent
Explanation
Information showing coverage for a dependent on the record keeper’s system differs from that on the health plan system.
Action
Sender should review the coverage discrepancies reported on the acknowledgment and send the Carrier updated Dependent coverage information if the Carrier's system has incorrect values.
If the Carrier's system has the correct coverage information for the Dependent, then the Sender does not need to do anything.
Mismatch: Coverage: Subscriber
Explanation
Information showing coverage for subscriber on the record keeper’s system differs from that on the health plan system.
Action
Sender should review the coverage discrepancies reported on the acknowledgment and send the Carrier updated Subscriber coverage information if the Carrier's system has incorrect values.
If the Carrier's system has the correct coverage information for the Subscriber, then the Sender does not need to do anything.
Mismatch: Active on Carrier System:
Dependent
Explanation
A Dependent is active on the health plan system for which no record exists in the audit file sent by the record keeper.
Action
Sender should review the eligibility status of the Dependent and send a request to terminate the Dependent if the Dependent should really be terminated.
If the Carrier's system has the correct coverage information for the Dependent, then the Sender does not need to do anything..
Mismatch: Active on Carrier System:
Subscriber
Explanation
A Subscriber is active on the health plan system for which no record exists in the audit file sent by the record keeper.
Action
Sender should review the eligibility status of the Subscriber and send a request to the Carrier to terminate the Subscriber if the Subscriber should really be terminated.
If the Carrier's system information is correct and the Subscriber should be active, then the Sender does not need to do anything.
Mismatch: Identity Field:
Dependent
Explanation
An identity field (name, person id number, etc.) for a dependent on the health plan system differs from that reported by the record keeper.
Action
Sender should review the identity field that did not match and determine which system has the correct information.
If the Carrier's system information is correct, the Sender does not need to do anything.
Mismatch: Identity Field:
Subscriber
Explanation
An identity field (name, person id number, etc.) for a subscriber on the health plan system differs from that reported by the record keeper.
Action
Sender should review the identity field that did not match and determine which system has the correct information.
If the Carrier's system information is correct, the Sender does not need to do anything.
If the Sender's system information is correct, the Sender should send a request to the Carrier to update the identity field for the Subscriber.
If there is a business rule that prevents the identity field to be updated, the Sender needs to contact the Carrier to have this identity field manually corrected on the Carrier's system.
Mismatch: Demographic Field:
Dependent
Explanation
A demographic field (e.g., phone number, etc.) for a dependent on the health plan system differs from that reported by the record keeper.
Action
Sender should review the demographic field that did not match and determine which system has the correct information.
If the Carrier's system information is correct, the Sender does not need to do anything.
If the Sender's system information is correct, the Sender should send a request to the Carrier to update the demographic field for the Dependent.
If there is a business rule that prevents the demographic field to be updated, the Sender needs to contact the Carrier to have this identity field manually corrected on the Carrier's system.
Mismatch: Demographic Field:
Subscriber
Explanation
A demographic field (e.g., phone number, etc.) for a subscriber on the health plan system differs from that reported by the record keeper.
Action
Sender should review the demographic field that did not match and determine which system has the correct information.
If the Carrier's system information is correct, the Sender does not need to do anything.
If the Sender's system information is correct, the Sender should send a request to the Carrier to update the demographic field for the Subscriber.
If there is a business rule that prevents the demographic field to be updated, the Sender needs to contact the Carrier to have this identity field manually corrected on the Carrier's system.
Mismatch: Terminated on Carrier System:
Dependent
Explanation
The health plan system indicates that a Dependent reported as active by the record keeper has a terminated status on the health plan system.
Action
Sender should review the Dependent's eligibility status and send a request to the Carrier to reinstate the Dependent if the Dependent should really be active.
If the Carrier's system information is correct and the Dependent should be terminated, then the Sender does not need to do anything.
Mismatch: Terminated on Carrier System:
Subscriber
Explanation
The health plan system indicates that a Subscriber reported as active by the record keeper has a terminated status on the health plan system.
Action
Sender should review the Subscriber's eligibility status
Sender should review the Subscriber's eligibility status on the Sender's system and send a request to the Carrier to reinstate the Subscriber if the Subscriber should really be active.
If the Carrier's system information is correct and the Subscriber should remain terminated, then the Sender does not need to take any action.
Mismatch: Not Found on Carrier System:
Dependent
Explanation
The health plan system indicates that a Dependent reported as active by the record keeper is not found on the health plan system.
Action
Sender should review the Dependent's eligibility status and send a request to the Carrier to add the Dependent if the Dependent should have health coverage.
If the Carrier's system information is correct and the Dependent should NOT have health coverage, then the Sender does not need to do anything.
Mismatch: Not Found on Carrier System:
Subscriber
Explanation
The health plan system indicates that a Dependent reported as active by the record keeper is not found on the health plan system.
Action
Sender should review the Subscriber's eligibility status and send a request to the Carrier to add the Subscriber if the Subscriber should have health coverage.
If the Carrier's system information is correct and the Subscriber should NOT have health coverage, then the Sender does not need to do anything.