HomeMy WebLinkAboutContract 54095-A2CSC No. 54095-A2
SECOND AMENDMENT
TO THE BUSINE55 SERVICES AGREEMENT
BETWEEN ACCOLADE, INC. AND CITY OF FORT FORTH
This "Second Amendment" is to the BUSINESS SERVICES AGREEMENT (the ("BSA"), dated June 30, 2020,
City Secretary Contract No. 54095, by and between Accolade, Inc. ("Accolade") and City of Fort Worth
("Customer"). Accolade and Customer are each a"Party" and collectively referred to as the "Parties."
Capitalized terms used but not defined herein shall have the respective meanings ascribed thereto in the
BSA. Section references herein, if any, shall refer to Section references in the BSA.
WHEREAS, Customer wishes to add Expert Medical Opinion Services to the list of Extended Services in the
Services Commitment Form ("SCF) of the BSA.
NOW, THEREFORE, for good and valuable consideration, the receipt and sufficiency of which is hereby
acknowledged, the Parties hereby agree to amend the BSA as follows:
1. Effective July 1, 2021, Expert Medical Opinion ("EMO") Services provided by Accolade 2ndMD
LLC, a subsidiary of Accolade, Inc. ("2nd.MD") are added to the list of Extended Services in the
SCF and shall be governed by the terms set forth in the attached Statement of Work (Exhibit A).
2. 2nd.MD hereby agrees to be bound by the terms of the BSA. In the event of a conflict between the
terms of Exhibit A and the BSA, the terms of the BSA shall control.
This Second Amendment shall be deemed executed as of the last date of execution by the Parties
hereto. Except as amended hereby and by any prior amendments to the BSA, the original BSA
shall remain in full force and effect in accordance with the terms thereof. In the event of a conflict
between the terms of this Second Amendment and the BSA, the terms of this Second Amendment
will govern.
OFFICIAL RECORD
CITY SECRETARY
FT. W�RTH, TX
IN WITNESS WHEREOF, the Parties hereto, by their duly authorized representatives, have executed this
Second Amendment.
CITY:
City of Fort Worth
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By: Jesus Chapa (May 21, 2021 20:57 PDT)
Name: Jesus Chapa
Title: Assistant City Manager
�ate: May 21� 2021
Approval Recommended:
By: „ <��
Name: Mark Barta
Title: Assistant Human Resources Director
Attest:
By: `���U ��� 0
Name: Mary Kayser
Title: City Secretary
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VENDOR:
Accolade, Inc.
Contract Compliance Manager:
By signing I acknowledge that I am the person
responsible for the monitoring and
administration of this contract, including ensuring
all performance and reporting requirements.
� %Gi�/�?� �/�ItO�I
By: Joanne Hinton (May 19, 202114:03 CDT)
Name: Joanne Hinton
Title: _Benefits Manager
Approved as to Form and Legality:
��8 St��t
BV� JBStrong(May 1,20211622CDT)
Name: John 6. Strong
Title: Assistant City Attorney
Contract Authorization:
M &C: 20-0444
2ndMD, LLC
By: Raie �n�n im�y ia, zozi i4 c�TJ By: Raie �n�n im�y ia, zozi i4 c�Ti
Name: Rajeev Singh Name: Rajeev Singh
Title: CEO Title: President
�ate: M ay 19� 2021
�ate: M ay 19� 2021
�FFICIAL REC�RD
CITY SECRETARY
FT. W�RTH, TX
EXHIBIT A
Expert Medical Opinion ("EMO") Services
1. Definitions
1.01 "Consultation" or "Expert Medical Consultation" means the Service whereby 2nd.MD
provides an interactive video or telephonic session between Member and a Specialist (as defined below)
allowing Member to discuss health questions and to obtain general health information from such
Specialist. 2nd.MD provides the technology and support to facilitate the Consultation in addition to
establishing the Specialist network to provide the medical expertise for such service.
1.02 "Hi�h Impact Conditions" shall include, but not be limited to: Transplants, Transcatheter
Heart Valve Procedures, Hysterectomy, Musculoskeletal procedures, Bariatric Surgery, Cardiac and
Vascular procedures, Prostatectomy, Gastrointestinal procedures, Vein procedures, Oncology procedures,
and Nervous System procedures.
1.03 "Inbound Call" means a communication received by 2nd.MD from Member through
which the Member initiates a request to use the Services. During the Inbound Call, 2nd.MD discusses
Member's specific needs and makes a determination as to whether to initiate a Consultation or other
appropriate next steps.
1.04 "Services" means the Expert Medical Consultation, Specialty Care Navigation, and related
services as further described in Section 2, below.
1.05 "Specialist" means a board-certified medical doctor who has completed a multiple year
residency in a specific subspecialty of inedicine. 2nd.MD Specialists are selected based upon their
credentials, having either studied, trained or currently working at a leading hospital or teaching institution
and/or have led multiple peer reviewed studies in their field of specialty.
1.06 "Specialty Care Navi�ation" or "SCN" means guidance on the Member's healthcare
journey by 2nd.MD condition-specific Care Team nurses. This clinical guidance includes condition-specific
education, high-touch coaching, scheduling Expert Medical Consultations, and other services that help
Members navigate the complexities of managing their health and achieving better health outcomes.
1.07 "Utilization" means the number of Expert Medical Consultations divided by the number
of employees per year.
2. Services
2.01 Service Overview: 2nd.MD shall provide Services to Members. Once a month, Customer
or Customer's representative will electronically transmit an eligibility file containing the covered
population of Members to 2nd.MD. Upon receipt of an authorized medical consent form, 2nd.MD will
collect the relevant Member medical records and provide the Member with written notes and
recommendations from the Specialist.
2.02 Medical Conditions Included: Consultations available on the 2nd.MD platform include a
range of inedical conditions, currently covering over one hundred and twenty (120) of the American Board
of Medical Specialties and over 3,000 diseases and conditions.
2.03 Obtainin� Service: Members shall access 2nd.MD's Services, as defined in Section 2.04
below, by calling a toll-free number or logging into 2nd.MD's secure website or secure mobile application.
The secure website and secure mobile application shall be available 24 hours a day, seven (7) days a week,
excluding limited periods of maintenance, or periods of emergency maintenance, internet-wide
disruptions, force majeure events, or attributable to Member's software or hardware used to attempt
access. Live support is provided from 7:00 am - 7:00 pm CST on Monday through Friday. 2nd.MD will
return calls within one (1) hour from 7:00 pm — 10:00 pm CST on Monday through Friday, and from 7:00
am — 7:00 pm on Saturdays. 2nd.MD's office will be closed on the following holidays: New Years' Day;
Good Friday; Independence Day; Thanksgiving Day; Christmas Eve; and Christmas Day.
2.04 Service Specifics: 2nd.MD's Services may include the following. Only Expert Medical
Consultations shall count toward Utilization.
2.04(a) Expert Medical Consultation: Members select a Specialist with the assistance of
the Care Team from 2nd.MD's list of inedical Specialists that are located in the United
States. Members share their medical background with 2nd.MD's Care Team. At
Member's request, the Care Team schedules a Consultation with the selected Specialist.
The Member may speak with a Specialist by secure video or phone. Following the
Consultation, written notes and recommendations from the Specialist will be available to
Members via the 2nd.MD secure portal or postmarked in the mail to the Member's
provided address.
2.04(b) SpecialtV Care Navigation: Members receive guidance via various 2nd.MD
communication channels on the Member's healthcare journey by 2nd.MD condition-
specific Care Team nurses. This clinical guidance includes condition-specific education,
high-touch coaching, scheduling Expert Medical Consultations, and other services that
helps Members navigate the complexities of managing their health and achieving better
health outcomes.
2.04(c) Personalized Local Support: 2nd.MD shall provide the Member with support and
education, which may include recommendations of a local, in-network physician, if
requested by the Member. 2nd.MD will use Member's location and specific case needs
to locate a physician for the Member's needs.
2.04(d) Records Retrieval Requests: 2nd.MD will retrieve, digitize, index, and securely
store in the member portal, medical records from facility and provider locations as
identified by the Member.
2.05 Care Team Roles and Responsibilities: A member of the 2nd.MD Care Team shall be
assigned to each Member's case. The "Care Team" shall be comprised of doctors, nurses and other
medical professionals hired by 2nd.MD, who will listen to the Members' medical concerns and assist them
through the Consultation process, including the creation of a Member profile, the selection and
scheduling of an appropriate medical Specialist and the retrieval and secure digitization of the Member's
medical records. 2nd.MD's post-session follow-up with Members will include Consultation satisfaction
ratings and effectiveness surveys to evaluate the impact of the Consultation service.
2.06 Response Time: 2nd.MD will respond to a Member's request within 48 hours. 2nd.MD
will endeavor to provide Member available times for a Consultation with a Specialist within three (3)
business days on average from the Member's selection of a Specialist and the receipt of all information
and approvals required to obtain Member's medical records.
2.07 Member's Relationship with Specialist: Customer acknowledges that the Services
provided by Specialists that participate in the 2nd.MD platform and/or Care Team (1) do not replace a
Member's relationship with his/her doctor and that the Services do not create or constitute a physician-
patient relationship; (2) do not constitute medical advice, diagnosis, ortreatment by orfrom the Specialist
and/or Care Team; (3) that all medical and clinical information provided by the Specialist and/or Care
Team (whether via telephone, video, the secure application, the secure website, electronic mail, or in
connection with any communications supported by 2nd.MD) is intended for general informational
purposes only; and (4) that Specialist and/or Care Team does not give prescriptions, perform physical
evaluations, or treat any disease or condition.
2.08 Communications: 2nd.MD will work with Customer to agree on appropriate
com m�.nication tactics to Customer's specific membership. 2nd.MD will coordinate and bear the cost of
design, printing, mailing, and email distribution services on behalf of Customer for 2nd.MD marketing
materials. Light customization of 2nd.MD materials is available at no additional cost to Customer. 2nd.MD
also provides key member communication translated into Spanish at no cost and additional language
translation services of materials for a fee. 2nd.MD shall obtain Customer's approval to proposed uses of
Customer's name and logo prior to 2nd.MD's use of Customer's name or logo.
Customer shall agree to, and collaborate on, best practice communication activities as part of the
Services:
1. Member Rollout of 2nd.MD program:
A. 2nd.MD shall facilitate an internal kick-off ineeting with Customer to approve
the Member roll-out strategy for Customer. This kick-off ineeting shall include
project background, communication objectives, understanding of existing
com m�.nication channels, stakeholder analysis, key messages, look and feel of
communication, media elements, and com m �.nication campaign timing.
B. Customer and 2nd.MD will collaborate on the execution of the Member roll-
out campaign. Within the first thirty (30) days of Services Start Date the
following roll-out activities must occur:
i. Training of appropriate Customer stakeholders on the 2nd.MD program.
ii. Announcement of 2nd.MD benefit from ustomer's internal
com m �.nication materials.
iii. Addition of 2nd.MD link and program information on Customer's website
/ intranet.
iv. Addition of 2nd.MD information to relevant benefits and enrollment
material distributed by Customer.
v. Printing and Distribution of welcome kit materials to all eligible Members
(all printing, distribution, and mailing costs are paid by 2nd.MD).
vi. Welcome email to Members encouraging account activation.
2. Customer or its representative will deliver the Member eligibility file to 2nd.MD on a
monthly basis. Go-live file will be delivered three (3) weeks before Services Start Date.
3. 2nd.MD will communicate with activated Members about 2nd.MD Services as
appropriate. Member agrees to terms and conditions when activating membership
through 2nd.MD portal, and can unsubscribe to 2nd.MD communications at any time.
4. Customer will participate in a minimum of three (3) awareness campaigns per contract
year. 2nd.MD awareness campaigns are offered to Customer's on a quarterly basis by
2nd.MD. 2nd.MD bears the cost of development and distribution. Light customization of
awareness campaigns is available to Customer.
2.09 Proactive Outreach: On or before the Services Start Date, the Parties may:
1. Implement a$200 or greater incentive for Hysterectomy, Musculoskeletal procedures,
and Bariatric Surgery, and properly communicate that incentive to employees, or
2. Implement and participate in 2nd.MD's REACH program, as defined in Exhibit A-1, to
include all High Impact Conditions and prior authorized services.
3. Fees. Customer agrees to pay for Expert Medical Consultations at a rate of $2,500 per
Consultation. 2nd.MD will track the number of Expert Medical Consultations, Specialty
Care Navigation, and Personalized Local Support cases each month and report the number
to Customer. If a Member fails to provide notice of cancellation or change prior to twenty-
four (24) hours in advance of the scheduled Consultation time, 2nd.MD will bill Customer
the Case Rate for the missed Consultation. Following the end of each month, 2nd.MD will
invoice Customer for the total charges incurred and Customer shall pay 2nd.MD within
thirty (30) days of invoice date.
Customer agrees to pre-pay for forty (40) Consultations ($2,500 * 40 =$100,000), payable
prior to the Services Start Date. Pre-paid Consultations do not expire. The pre-payment
fee will be waived if Customer implements one (1) Proactive Outreach approach, as
described in Section 2.09.
4. Performance Guarantees. For each Service Year, if Customer implements either of the Proactive
Outreach programs defined at Section 2.09 on or before the Services Start Date, the total
annual cost of 2nd.MD Services will be included in the Actual Accolade Fee for purposes
of calculating the Return on Investment Performance Guarantee described in Appendix 1
— Fee Adjustments of the BSA.
5. Services Start Date. The Services shall begin on: July 1, 2021 ("Services Start Date")
Exhibit A-1— REACH
This Exhibit A-1 - REACH is applicable if 2nd.MD, Customer, and Customer's Plan agree to implement 2nd.MD's
REACH.
A. Definitions.
"Customer's Plan" shall mean the Plan Sponsor or Plan Administrator.
"Participant" means a Member who has been identified by Customer or Customer's Plan or
2nd.MD as eligible to receive 2nd.MD REACH Services.
"REACH" is a comprehensive, proactive outreach program that uses claims data and predictive
model algorithms to engage Members who are on the path to a High Impact Condition before it
happens.
B. REACH Services. 2nd.MD's REACH Services include the following:
1. Customer, Customer's Plan, or 2nd.MD will identify Participants for referral to 2nd.MD for REACH
Services.
2. Customer or Customer's Plan shall send 2nd.MD usable batch files of Participants eligible to receive
2nd.MD Services via secure electronic delivery ("REACH File") on a mutually agreed upon
timeframe. 2nd.MD can accommodate daily files.
3. Once 2nd.MD receives the REACH File, 2nd.MD will make an outreach to a Participant identified in
the REACH File.
4. 2nd.MD will inform Participant that they may elect to participate in REACH to obtain 2nd.MD's
Services.
5. Once a Participant completes and submits 2nd.MD's medical records release form, the 2nd.MD
Consultation proceeds according to the Services as described in Exhibit A.
REACH File Format. REACH File shall contain the information in one or several of the REACH File Format
approaches, below. The Parties agree that the REACH File Format may be amended as mutually agreed to
by the Parties and that 2nd.MD may implement parallel outreach approaches using multiple file types, as
mutually agreed to by the Parties. The file should be in CSV format, and must be placed on the 2nd.MD
SFTP folder for privacy and protection. 2nd.MD will set up SFTP.
Approach A: 2nd.MD Identified Members throu�h Claims Data
1. File Naming Convention should be: YYMMDD_ClientName_Claims.csv"
2. 2nd.MD requests one (1) year historical claims records for initial data analysis. To activate
the Performance Guarantees described in Section 4 above, 2nd.MD requires one (1) year
historical claims records for initial data analysis, to be received by 2nd.MD within the first
thirty (30) days of the Services Start Date.
3. File Layout
. .
CaselD R Numeric (up to 20 External Unique Identifier for
digits) the case from the data
provider
FileDate R MM/DD/YYYY Date file is pulled from the
data provider's system
FirstName R Text (up to 255 First Name of the person using
characters) the service
LastName R Text (up to 255 Last Name of the person using
characters) the service
DateOfBirth R MM/DD/YYYY Date of Birth of the person
using the service
MemberlD R Text (up to 255 External Unique ID (must be
characters) specific to member and
cannotchange)
Must match the External
Unique ID provided for
eligibility
CorporatelD R* Text (up to 255 * Required for companies with
characters) a parent company; otherwise
optional
External Unique ID for the
employer
CorporateName O Text (up to 255 External Company Name for
characters) the employer
Email R* Text (up to 255 * Required if used as
characters) activation identifier; otherwise
highly recommended to send
Email address for the person
using the service
SSN R* Text (4 characters) *SSN field is available only for
legacy clients
* Required if used as
activation identifier
Last 4 digits of the SSN of the
person using the service
Gender 0* Text (1 character) * Optional but highly
recommended to send
Gender of the person using
the service
- Valid values: M, F, U
Addressl R Text (up to 255 Mailing Address Line 1 of the
characters) person using the service
Address2 O Text (up to 255 Mailing Address Line 2 of the
characters) person using the service
City R Text (up to 255 Mailing City of the person
characters) using the service
State R Text (2 characters) 2-character abbreviation of
the Mailing State of the
person using the service
ZipCode R Numeric (5 digits) 5-digit Zip Code of the person
using the service
PhoneNumber R Text (digits only) Primary contact phone
number for the person using
the service
SecondaryPhoneNumber 0* Text (digits only) * Optional but highly
recommended to send
Alternate contact phone
number for the person using
the service
ProcedureDescription R Text (up to 255 Data must coincide with a
characters) single procedure/diagnosis.
Only a single
procedure/diagnosis per row
is supported.
Brief description of the
procedure/service
ProcedureDate R MM/DD/YYYY Data must coincide with a
single procedure/diagnosis.
Only a single
procedure/diagnosis per row
is supported.
Date of the procedure/service
CPTCode R Numeric (5 digits) Data must coincide with a
single procedure/diagnosis.
Only a single
procedure/diagnosis per row
is supported.
CPT Code for the
procedure/service
PrimaryCPT R Text (up to 3 Data must coincide with a
characters) single procedure/diagnosis.
Only a single
procedure/diagnosis per row
is supported.
Indicator to identify if the
record contains the primary
CPT code
- Valid values: Yes, No
FacProvlD O Text (10 characters) Facility Provider NPI - Hospital
Unique Identifier
FacProvName R Text (up to 255 Facility Provider Name -
characters) Hospital Name
FacProvMedicareAccepted O Text (1 character) Indicator to identify if
Medicare is accepted by the
facility
- Valid values: Y, N
SvcProvTIN O Numeric (up to 15 Provider's Tax ID Number
digits)
SvcProvlD O Number (10 digits) Provider's NPI, National
Provider Number
SvcProvName O* Text (up to 255 * Optional but highly
characters) recommended to be sent
Service Provider Name -
Doctor/Surgeon Name
SvcProvMedicareAccepted O Text (1 character) Indicator to identify if
Medicare is accepted by the
service provider
- Valid values: Y, N
DiagnosticlmageDescription 0 Text (up to 255 Diagnostic Image Description
characters)
DiagnosticDescription O Text (up to 255 Diagnostic Description
characters)
Diagnostic Date O Text (up to 255 Diagnostic Date
characters)
ICD10Code R Text (up to 255 Data must coincide with a
characters) single procedure/diagnosis.
Only a single
procedure/diagnosis per row
is supported.
ICD-10 Code
MedicationDescription O Text (up to 255 Medication Description
characters)
MedicationDate O Text (up to 255 Medication Date
characters)
NDCCode R* Text (up to 255 * Required for pharmacy
characters) claims
Data must coincide with a
single procedure/diagnosis.
Only a single
procedure/diagnosis per row
is supported.
NDC Code
Carrier 0* Text (up to 255 * Optional but highly
characters) recommended to be sent
Carrier Name
BenefitPlan O Text (up to 255 Benefit Plan Name
characters)
BenefitPlanExternalld O Text (up to 255 Benefit Plan ID
characters)
CoverageTier O Text (up to 255 Coverage Tier
characters)
RelationshipType R* Text (up to 255 * Required if the person using
characters) the service is a dependent;
otherwise send blank if the
person using the service is the
subscriber
Relationship to the subscriber
- Valid values: Self, Spouse,
Child, Parent, Grandparent,
Sibling, Adult Child, Other
SubscriberlD R* Text (up to 255 * Required if the person using
characters) the service is a dependent;
otherwise send blank if the
subscriber (employee) is the
person using the service
Subscriber ID (must be specific
to subscriber and cannot
change)
Must match the External
Unique ID provided for
eligibility
SubscriberFirstName R* Text (up to 255 * Required if the person using
characters) the service is a dependent;
otherwise send blank if the
subscriber (employee) is the
person using the service
Subscriber's First Name
SubscriberLastName R* Text (up to 255 * Required if the person using
characters) the service is a dependent;
otherwise send blank if the
subscriber (employee) is the
person using the service
Subscriber's Last Name
SubscriberDateofBirth R* MM/DD/YYYY * Required if the person using
the service is a dependent;
otherwise send blank if the
subscriber (employee) is the
person using the service
Subscriber's Date of Birth
SubscriberEmail R* Text (up to 255 * Required if used as
characters) activation identifier AND if the
person using the service is a
dependent; otherwise send
blank if the subscriber
(employee) is the person using
the service
Subscriber's email address
Must match the email address
provided for eligibility
SubscriberZip R* Numeric (5 digits) * Required if used as
activation identifier AND if the
person using the service is a
dependent; otherwise send
blank if the subscriber
(employee) is the person using
the service
Subscriber's zip code
Must match the zip code
provided for eligibility
SubscriberSSN R* Text (4 characters) *SSN field is available only for
legacy clients
* Required if used as
activation identifier AND if the
person using the service is a
dependent; otherwise send
blank if the subscriber
(employee) is the person using
the service
Last 4 digits of the Subscriber's
55 N
Must match the SSN provided
for eligibility
SubscriberGuardianPhoneNumber O Text (12 digits, Blank if the subscriber
including dashes) (employee) is the person using
the service
Subscriber's primary phone
number
SubscriberGuardianGender O Text (1 character) Blank if the subscriber
(employee) is the person using
the service
Subscriber's gender
Valid values: M, F, U
Extralnfo O Text (up to 255 Customer defined field
characters)
SubscriberExtralnfo O Text (up to 255 Customer defined field
characters)
2. Approach B: Carrier ldentified Members
(a) File Naming Convention should be: YYMMDD_ClientName_Reach.csv"
(b) File Layout
. -. �. �- . . .
i. . .
CaselD R Numeric (up to 20 External Unique Identifier for
digits) the case from the data
provider
FileDate R MM/DD/YYYY Date file is pulled from the data
provider's system
FirstName R Text (up to 255 First Name of the person using
characters) the service
LastName R Text (up to 255 Last Name of the person using
characters) the service
DateOfBirth R MM/DD/YYYY Date of Birth of the person
using the service
MemberlD R Text (up to 255 External Unique ID (must be
characters) specific to member and cannot
change)
Must match the External
Unique ID provided for
eligibility
CorporatelD R* Text (up to 255 * Required for companies with
characters) a parent company; otherwise
optional
External Unique ID for the
employer
CorporateName O Text (up to 255 External Company Name for
characters) the employer
Email R* Text (up to 255 * Required if used as activation
characters) identifier; otherwise highly
recommended to send
Email address for the person
using the service
Gender 0* Text (1 character) * Optional but highly
recommended to send
Gender of the person using the
service
- Valid values: M, F, U
Addressl R Text (up to 255 Mailing Address Line 1 of the
characters) person using the service
Address2 O Text (up to 255 Mailing Address Line 2 of the
characters) person using the service
City R Text (up to 255 Mailing City of the person using
characters) the service
State R Text (2 characters) 2-character abbreviation of the
Mailing State of the person
using the service
ZipCode R Numeric (5 digits) S-digit Zip Code of the person
using the service
PhoneNumber R Text (digits only) Primary contact phone number
for the person using the service
SecondaryPhoneNumber 0* Text (digits only) * Optional but highly
recommended to send
Alternate contact phone
number for the person using
the service
ProcedureDescription R Text (up to 255 Data must coincide with a
characters) single procedure/diagnosis.
Only a single
procedure/diagnosis per row is
supported.
Brief description of the
procedure/service
ProcedureDate R MM/DD/YYYY Data must coincide with a
single procedure/diagnosis.
Only a single
procedure/diagnosis per row is
supported.
Date of the procedure/service
CPTCode R Numeric (5 digits) Data must coincide with a
single procedure/diagnosis.
Only a single
procedure/diagnosis per row is
supported.
CPT Code for the
procedure/service
PrimaryCPT R Text (up to 3 Data must coincide with a
characters) single procedure/diagnosis.
Only a single
procedure/diagnosis per row is
supported.
Indicator to identify if the
record contains the primary
CPT code
- Valid values: Yes, No
Carrier 0* Text (up to 255 * Optional but highly
characters) recommended to be sent
Carrier Name
RelationshipType R* Text (up to 255 * Required if the person using
characters) the service is a dependent;
otherwise send blank if the
person using the service is the
subscriber
Relationship to the subscriber
- Valid values: Self, Spouse,
Child, Parent, Grandparent,
Sibling, Adult Child, Other
SubscriberlD R* Text (up to 255 * Required if the person using
characters) the service is a dependent;
otherwise send blank if the
subscriber (employee) is the
person using the service
Subscriber ID (must be specific
to subscriber and cannot
change)
Must match the External
Unique ID provided for
eligibility
SubscriberFirstName R* Text (up to 255 * Required if the person using
characters) the service is a dependent;
otherwise send blank if the
subscriber (employee) is the
person using the service
Subscriber's First Name
SubscriberLastName R* Text (up to 255 * Required if the person using
characters) the service is a dependent;
otherwise send blank if the
subscriber (employee) is the
person using the service
Subscriber's Last Name
SubscriberDateofBirth R* MM/DD/YYYY * Required if the person using
the service is a dependent;
otherwise send blank if the
subscriber (employee) is the
person using the service
Subscriber's Date of Birth
SubscriberEmail R* Text (up to 255 * Required if used as activation
characters) identifier AND if the person
using the service is a
dependent; otherwise send
blank if the subscriber
(employee) is the person using
the service
Subscriber's email address
Must match the email address
provided for eligibility
SubscriberZip R* Numeric (5 digits) * Required if used as activation
identifier AND if the person
using the service is a
dependent; otherwise send
blank if the subscriber
(employee) is the person using
the service
Subscriber's zip code
Must match the zip code
provided for eligibility
ICD10DiagnosisDescription R Text (up to 255 Data must coincide with a
characters) single procedure/diagnosis.
Only a single
procedure/diagnosis per row is
supported.
Brief description of the
proced u re/service
ICD10DiagnosisDate R MM/DD/YYYY Data must coincide with a
single procedure/diagnosis.
Only a single
procedure/diagnosis per row is
supported.
Date of the procedure/service
ICD10Code R Text (up to 255 Data must coincide with a
characters) single procedure/diagnosis.
Only a single
procedure/diagnosis per row is
supported.
ICD10 Code for the
proced u re/service
NDCMedicationDescriptionCode R* Text (up to 255 * Required only for pharmacy
characters) claims
Data must coincide with a
single procedure/diagnosis.
Only a single
procedure/diagnosis per row is
supported.
Brief description of the
proced u re/service
NDCMedicationDate R* MM/DD/YYYY * Required only for pharmacy
claims
Data must coincide with a
single procedure/diagnosis.
Only a single
procedure/diagnosis per row is
supported.
Date of the procedure/service
NDCCode R* Text (up to 255 * Required only for pharmacy
characters) claims
Data must coincide with a
single procedure/diagnosis.
Only a single
procedure/diagnosis per row is
supported.
NDC Code for the
procedure/service
3. Aaproach C: Carrier-Provided Prior Authorization Files.
i. File Naming Convention should be: YYMMDD_ClientName_Reach.csv"
ii. File Layout
.
CaselD R Numeric (up to External Unique Identifier for the case
20 digits) from the data provider
FileDate R MM/DD/YYYY Date file is pulled from the data
provider's system
FirstName R Text (up to 255 First Name of the person using the
characters) service
LastName R Text (up to 255 Last Name of the person using the
characters) service
DateOfBirth R MM/DD/YYYY Date of Birth of the person using the
service
MemberlD R Text (up to 255 External Unique ID (must be specific to
characters) member and cannot change)
Must match the External Unique ID
provided for eligibility
CorporatelD R* Text (up to 255 * Required for companies with a
characters) parent company; otherwise optional
External Unique ID for the employer
CorporateName 0 Text (up to 255 External Company Name for the
characters) employer
Email R* Text (up to 255 * Required if used as activation
characters) identifier; otherwise highly
recommended to send
Email address for the person using the
service
Gender O* Text (1 character) * Optional but highly recommended to
send
Gender of the person using the service
- Valid values: M, F, U
Addressl R Text (up to 255 Mailing Address Line 1 of the person
characters) using the service
Address2 0 Text (up to 255 Mailing Address Line 2 of the person
characters) using the service
City R Text (up to 255 Mailing City of the person using the
characters) service
State R Text (2 2-character abbreviation of the Mailing
characters) State of the person using the service
ZipCode R Numeric (5 digits) 5-digit Zip Code of the person using the
service
PhoneNumber R Text (digits only) Primary contact phone number for the
person using the service
SecondaryPhoneNumber O* Text (digits only) * Optional but highly recommended to
send
Alternate contact phone number for
the person using the service
ProcedureDescription R Text (up to 255 Data must coincide with a single
characters) procedure/diagnosis. Only a single
procedure/diagnosis per row is
supported.
Brief description of the
procedure/service
ProcedureDate R MM/DD/YYYY Data must coincide with a single
procedure/diagnosis. Only a single
procedure/diagnosis per row is
supported.
Date of the procedure/service
CPTCode R Numeric (5 digits) Data must coincide with a single
procedure/diagnosis. Only a single
procedure/diagnosis per row is
supported.
CPT Code for the procedure/service
PrimaryCPT R Text (up to 3 Data must coincide with a single
characters) procedure/diagnosis. Only a single
procedure/diagnosis per row is
supported.
Indicator to identify if the record
contains the primary CPT code
- Valid values: Yes, No
Carrier O* Text (up to 255 * Optional but highly recommended to
characters) be sent
Carrier Name
RelationshipType R* Text (up to 255 * Required if the person using the
characters) service is a dependent; otherwise send
blank if the person using the service is
the subscriber
Relationship to the subscriber
- Valid values: Self, Spouse, Child,
Parent, Grandparent, Sibling, Adult
Child, Other
SubscriberlD R* Text (up to 255 * Required if the person using the
characters) service is a dependent; otherwise send
blank if the subscriber (employee) is
the person using the service
Subscriber ID (must be specific to
subscriber and cannot change)
Must match the External Unique ID
provided for eligibility
SubscriberFirstName R* Text (up to 255 * Required if the person using the
characters) service is a dependent; otherwise send
blank if the subscriber (employee) is
the person using the service
Subscriber's First Name
SubscriberLastName R* Text (up to 255 * Required if the person using the
characters) service is a dependent; otherwise send
blank if the subscriber (employee) is
the person using the service
Subscriber's Last Name
SubscriberDateofBirth R* MM/DD/YYYY * Required if the person using the
service is a dependent; otherwise send
blank if the subscriber (employee) is
the person using the service
Subscriber's Date of Birth
SubscriberEmail R* Text (up to 255 * Required if used as activation
characters) identifier AND if the person using the
service is a dependent; otherwise send
blank if the subscriber (employee) is
the person using the service
Subscriber's email address
Must match the email address
provided for eligibility
SubscriberZip R* Numeric (5 digits) * Required if used as activation
identifier AND if the person using the
service is a dependent; otherwise send
blank if the subscriber (employee) is
the person using the service
Subscriber's zip code
Must match the zip code provided for
eligibility
ICD10DiagnosisDescription R Text (up to 255 Data must coincide with a single
characters) procedure/diagnosis. Only a single
procedure/diagnosis per row is
supported.
Brief description of the
procedure/service
ICD10DiagnosisDate R MM/DD/YYYY Data must coincide with a single
procedure/diagnosis. Only a single
procedure/diagnosis per row is
supported.
Date of the procedure/service
ICD10Code R Text (up to 255 Data must coincide with a single
characters) procedure/diagnosis. Only a single
procedure/diagnosis per row is
supported.
ICD10 Code for the procedure/service
NDCMedicationDescriptionCode R* Text (up to 255 * Required only for pharmacy claims
characters)
Data must coincide with a single
procedure/diagnosis. Only a single
procedure/diagnosis per row is
supported.
Brief description of the
procedure/service
NDCMedicationDate R* MM/DD/YYYY * Required only for pharmacy claims
Data must coincide with a single
procedure/diagnosis. Only a single
procedure/diagnosis per row is
supported.
Date of the procedure/service
NDCCode R* Text (up to 255 * Required only for pharmacy claims
characters)
Data must coincide with a single
procedure/diagnosis. Only a single
procedure/diagnosis per row is
supported.
NDC Code for the procedure/service