Public Service Health Care Plan (PSHCP) - New Eligibility Feed Transition and Future Administration Process

Compensation Advisor Impacts

With our move to the new Eligibility file feed process and the corresponding increase in the frequency of data transmission, the need for manual intervention has been significantly reduced. Eligibility data between source systems and the Sun Life system has been automated as much as possible with the understanding that the source system is the system of record. As such, issues regarding eligibility will be re-directed to the member’s Compensation Advisor (CA) or Insurance Specialist (IS) to investigate and rectify.

It is anticipated that eligibility issues may arise in two ways. In the course of loading the weekly Eligibility feed Sun Life will produce reject reports (discussed later in this document) which will be returned to the participating organization for review and correction in the source system. The majority of these errors are anticipated to be data entry in nature, with possible scenarios such as a coverage start date reported as preceding a date of birth. The second scenario occurs in the event of a claim denial due to an eligibility discrepancy. In this instance, the member will be instructed to contact his/her CA or IS to investigate and have the error corrected. While the resolution of either problem may require a CA or IS to consult with SLF, the resolution of the discrepancy will need to flow from the source system to the SLF system. The result is that Sun Life will no longer manually amend their system based on a telephone conversation. The reason for this shift was the identification of this manual process as a leading source in the data discrepancies between source and Sun Life systems.

Note: The only instance where Sun Life will manually update a record in their system is if, following a review, the source system is found to be correct. In this event, because no change is made in the source as it is already correct the no change record would be reported in the next Eligibility feed.
New Eligibility feed fields include:

• Surname (Only first 16 characters)
• Initials
• Date of Birth (DOB)
• Gender
• Department code
• Pay List
• Pay Office
• Employee / Pensioner / Survivor / Student / Guardian flag
• PSHCP Certificate Number
• Coverage Start Date
• Coverage End Date
• Coverage Type (Single / Family)
• Hospital Level (I, II or III)
• Coverage Category (Supplementary / Comprehensive)

Three key fields used to identify a member are: Surname, DOB and PSHCP Certificate Number.

Types of Changes

A further distinction in the new Eligibility feed process will be a change in the amount of data being transmitted. Currently, a record is sent at the end of the month for each plan member. In contrast, the new Eligibility feed will only produce a record where a change to a member’s record has occurred since the last Eligibility file was run, i.e., a change processed over the previous week. If there is no change to a member’s coverage or personal identifier information, a record for that member will not be sent. Changes that will result in a record being sent include:

1. New applications
2. Surname corrections / changes
3. Date of Birth corrections
4. PSHCP certificate number changes
5. Coverage changes (must always be accompanied by a revised start date)
6. Transfer that results in a change to department name, pay office or pay list
7. Discharges with no coverage
8. Retirements / Deferred Annuities / Work Force Adjustments

A coverage change in the new Eligibility file will include such amendments as changes between supplementary and comprehensive coverage, changes in family status, i.e., single to family, and changes to the hospital levels of coverage. A coverage change will be reported should any one, or a combination of the three, aforementioned changes occur. Should a complex coverage change result in a requirement to report different start dates, then multiple records for the one member will be reported.

Example: A member requests a change as per the following:

• Supplementary Family Level II to
  Supplementary Single Level I

If the change in family status is received within 60 days of an event requiring a change, the change will be effective the first of the month following, otherwise a three-month waiting period applies. The decrease in the level of hospital coverage, however, becomes effective on the first day of the month following 60 days from the date of receipt of the application. If this request was received on March 8, 2011, and not within the 60 day window, then the decrease in hospital coverage would become effective June 1, 2011 while the Single status change would be effective July 1, 2011.

To effect this type of change, two separate records will be sent for this member as the changes requested become effective on different dates. For Compensation Advisors (CA) utilizing the Compensation Web Application (CWA), your system will automatically generate the required records and associated start dates. For organizations not using the CWA tool, there will be a need to split this type of amendment request over successive reporting periods to ensure one record does not overwrite the other when reporting this change within the weekly Eligibility feed. If two separate records are used to report this change but both are sent in the same weekly Eligibility file, Sun Life will reject both records as duplicate error files for the CA or IS to investigate.

With the introduction of the CWA tool, the ability to amend PSHCP certificate number was removed. While the tool maintains historical information, enabling a returning employee to be issued his/her original certificate number without self identifying, there is still a possibility of second certificate issuance where employees join/transfer from organizations that do not use CWA. These cases will only be discovered should the member later identify the existence of a previous number. In these situations, the member will retain the newly issued certificate number. A CA should inform/remind the member to complete their positive enrolment under the new certificate number and to no longer use their previously issued certificate number.

When a certificate number is found to be shared by two members, the member who had the certificate number the longest will retain the number and a new number will be generated for the second member. This member will need to be advised that a new number was generated and that he/she needs to complete positive enrolment under this new number in order to ensure claim issues do not arise.

Sun Life System Update Schedule

Beginning May 3, 2011, eligibility updates/changes will be communicated on a weekly basis. While there may continue to be situations for which a resolution requires a compensation advisor to contact Sun Life on behalf of the member, should it be deemed that the SLF systems require a coverage amendment, the change must be reported through the weekly Eligibility feed process. Currently Sun Life updates over 10,000 records per month based on individual discussions with compensation advisors. While this practise may have been a necessary evil when eligibility information was transmitted on a monthly basis, the problem will be significantly reduced once the weekly file transfer process begins on May 3, 2011.

In addition, while the new Eligibility file will be sent every Tuesday, the Sun Life system update will only occur Tuesday evening. As a result, Sun Life will not be in a position to, in turn, update their sub-contractor’s systems (TELUS Health Solutions) until Wednesday evening at the earliest. Members for whom a change was submitted on a Tuesday Eligibility feed will, therefore, not be able to submit an electronic claim through a pharmacy until Thursday morning once the new Eligibility file transfer process is complete.

Future Dated Transactions

In addition, a CA should be aware that Sun Life is able to accept future dated amendment requests (start date only) up to 90 days in the future. While CWA users will have their amendment requests reported based on the processing schedule established by PWGSC and the CWA tool, non-CWA users will have their own particular system enhancements and restrictions. Whatever system you are working with, please keep this 90-day rule in mind while processing changes, as anything sent in excess of a 90 days will result in a reject transaction report. Rejected transactions will be discussed further in this document.

Back Dated Transactions

Previously, back-dated transactions required the approval of the Federal PSHCP Administration Authority if the action was in excess of 6 months. This requirement has been relaxed under the new process with the following provisions. Given that the new weekly feed is automated, Sun Life will process retroactive amendments provided they meet the following conditions: the change does not precede the last change on file with Sun Life and the change does not precede a member’s ability to submit a claim.

Example 1: Change request submitted on March 11, 2014 to amend coverage effective June 1, 2013. The last record on file at Sun Life is dated Sept. 1, 2010.

• Sun Life will process change

If either condition is not met, Sun Life will not update their systems and will send the file to their Coverage Team for review (Annex B). During the course of this review the Sun Life Coverage Team may contact a CA to verify and possibly request a source system amendment in order to ensure the information for the member in question is loaded into the Sun Life system properly

Example 2: Change request submitted on March 11, 2014, to amend coverage effective January 1, 2012. The last record on file at Sun Life is dated Sept. 1, 2010. However, the request exceeds the period for which a claim can be submitted.

• Sun Life will not automatically process the change and will assign it to their Coverage Team.

Given the new automation of the Eligibility file load process, be advised that reports will be made available to the Federal PSHCP Administration Authority in order that they may monitor the frequency of back dated transactions.

Leave without Pay (LWOP)

You will note that Leave without Pay (LWOP) scenarios were not included in the list of changes that will generate a new record to Sun Life. In the future Sun Life will not be aware that a member has proceeded on LWOP and will continue to process claims from these members until such time as a termination of coverage record is received. Members’ coverage under the plan continues automatically when they proceed on leave without pay unless they confirm in writing that they wish to cancel coverage (members can pay in advance or when they return from leave); therefore the collection of contributions from members on LWOP, whether it be member only or both the member and employer share will be a separate issue, apart from the issue of the member’s eligibility to continue coverage under the PSHCP. While eligibility issues and the remittance processes are being separated through the introduction of the new Eligibility feed, the completion of PWGSC form 2278 will still be required for employees who are paying their remittance in advance and for those employees residing in Quebec in order for the collection and recording of contributions from members on LWOP to continue.

Transfers

In situations where an employee transfers between different departments, a change record will be generated as department code, pay list and possibly pay office will change. Where eligibility is administered through the CWA tool and a pay office is not changing as a result of the transfer, the CWA tool will automatically generate the change file on behalf of the member when the transfer is complete in the system. If the pay office is also changing, two records will be generated. The first will come from the originating department that will report a coverage termination date. When the new department enters the employee’s pay information into their system a second record will be generated that will report a coverage start date. Close coordination of these types of transfers will be essential to ensure coverage is not terminated without a corresponding start coverage record being sent.

If your organization does not use the CWA tool to administer PSHCP eligibility, internal transfers will proceed much in the same way they are currently handled. That is to say, if there is no change to the department code, pay list or pay office, there will be no change record generated. In the event of a transfer between a CWA and non-CWA organization, the preceding change process where pay offices are changing will prevail.

Workforce Adjustments

A member is eligible to continued coverage for a period of one year following discharge for reasons of workforce adjustment. Collection of contributions will continue as per the current practice; however, the reporting of coverage termination in these instances will need to occur through the Eligibility feed. As this future-dated transaction pertains to the Coverage Start Date and not the Coverage End Date, the Sun Life 90 day limit for future-dated transactions does not apply. For those who utilize CWA to administer eligibility, the system will report the future date once you have confirmed it within the tool. If you are not using CWA, you will need to ensure a record is transmitted to Sun Life to ensure coverage termination occurs in accordance with the Directive.  Issues surrounding required contribution payments associated with these situations will still require the completion of PWGSC form 2278.

Retirement / Deferred Annuity

A deferred annuitant is not eligible to continue coverage post discharge and before their annual allowance starts. For these individuals a termination record will be sent on discharge and a new start record will not be sent until their annual allowance begins and they have applied for coverage. There is no change from the current practise.

A member who is eligible for an immediate annuity can experience a temporary “coverage gap” until his/her first award is processed. While this “coverage gap” will be eliminated once pension payments start and any eligible services or products will be reimbursed retroactively, it can cause issues for the member. For this reason a communications strategy to inform newly retiring members of this possibility is being put in place by the Public Service Pension Centre (PSPC) while work is underway to develop a permanent system solution.

Sun Life E-mail Notification Messages and Error Reports

Following receipt of each participating organization’s new weekly Eligibility file, the Sun Life system will generate an automated e-mail notification. This message will notify each participating organization that its file was processed with or without errors. If an error report was generated, the organization will be advised to pick-up its error report from the secure message file transfer service. For participating organizations not utilizing the RPS system, these e-mail notifications will be sent to the e-mail address each organization provided during the start-up phase of this initiative. Government departments for whom Public Works and Government Services Canada (PWGSC) is producing the weekly Eligibility file will also receive an e-mail message but only in the event of an error report being generated. Government departments will not receive an e-mail in the event their records where processed successfully. If you receive an email message and the error report is not posted for your review, please contact the SLF Service Desk at 1-800-263-4053 Monday to Friday between 8:30 am to 5:00 pm Eastern Standard Time.

As reported, Sun Life will, upon receipt of a participating organization’s eligibility file, conduct system tests on the information supplied before loading the changes into their system. Should there be a problem with the entire file, i.e., it is corrupt, an automated message as discussed above will be sent back to the organization in question, informing them of the problem and the need to correct and re-submit. Should the file be acceptable, further record testing will occur as each record is loaded into the Sun Life system. At this stage, should a problem with any record within the file be encountered, the Sun Life load procedure will reject only that record and not the entire file. Once all records have been processed, error reports will be generated based on department code supplied with the record and broken down by pay office and pay list. Information contained within the error report will include the information which was originally provided to Sun Life along with a numeric reject code associated with the error. A list of error codes and their corresponding messages is provided in Annex A to this document and is anticipated to be available through the PWGSC Insurance Administration Manual shortly.

It will be the organization’s responsibility to review and amend the source system to correct the problem, thereby generating a new record in the next weekly feed. In the event that a organization’s review of the rejected record deems the record to be correct, the reviewer must then contact the Sun Life Coverage Team at (613) 560-7512 to request that they manually load the record in order to keep source and Sun Life systems aligned.

Weekly Member Files and Annual Reconciliation Files

As already mentioned, eligibility information will be communicated to Sun Life on a weekly basis. These weekly files will contain only change files (start, stop or amendments) that have occurred since the previous weekly file was processed. If your department is small and no changes are processed in a given week, then no file will be sent to Sun Life.

Because the Eligibility feed process will report changes only, there exists the potential for the eligibility information contained in both the source and Sun Life systems to diverge. To guard against this possibility, a process has also been developed to produce an annual Reconciliation file from source systems that will report all active plan members enrolled in the PSHCP. The production of this file will be coordinated by Treasury Board of Canada Secretariat (TBS) officials and will always transpire on a Tuesday following the production of the weekly Eligibility file. This information will not be loaded into the Sun Life system but rather compared with the Sun Life information and a discrepancy report will be issued. Where discrepancies are discovered, a report similar to the weekly error reports will be supplied to each organization in order for source systems to be reviewed and corrected accordingly. The report will be generated within 20 days of the production of the annual reconciliation file.

Secure File Transfer

Eligibility files and returning error reports will be transmitted between participating organizations and Sun Life through the Public Works and Government Services of Canada’s (PWGSC) Managed Secure File Transfer (MSFT) service. Work is underway to establish an MSFT link with each participating organization. In the case of departments and agencies for which PWGSC produces the Eligibility file, work is also underway to establish an MSFT link with each department, thereby ensuring Sun Life error reports are securely delivered to the source for corrective action. It is recommended that a generic PSHCP e-mail account be established by each department and participating organization that can be used for this service and can be regularly monitored to ensure any error reports are investigated and corrective action taken as soon as possible. Failure to investigate and correct the errors identified in this report will result in claims disruptions. When such a disruption causes a denial of a claim, the member will be instructed by Sun Life to contact his/her CA or IS for resolution as the source system is now the system of record.

Remittances

Important: The old Remittance file process served two purposes. An electronic copy of this report was used to communicate eligibility information to Sun Life and a copy was sent to the TBS along with each participating organization’s contribution. It is and always has been a TBS responsibility to fund the benefits paid to employees through the claims submission process and as such, contributions are remitted to TBS for this purpose. While the Remittance file will no longer be used to communicate eligibility to Sun Life, it will continue to be used in support of the monthly PSHCP contribution remittance process with TBS, until further notice.

Non-Source System Changes

A member’s gender information will be passed with each file but this information will only be captured by Sun Life during the initial load of a new member’s record. Should a member notice/complain that his/her gender is incorrectly captured by Sun Life, it will be the member’s responsibility to visit the PSHCP Sun Life positive enrolment tool to make the necessary amendment.

Transition Period

Most organizations currently produce their monthly Remittance file between the 17th and 25th of the month. The last month the Remittance file will be used for communicating eligibility information to Sun Life will be in the March 2011 extract. As the new Eligibility file process will only commence on May 3, 2011, there is a need to capture all changes that occur between the time the last Remittance file is generated and when the new Eligibility file process starts. For this reason, TBS and Sun Life have been working with business and IT professionals in all participating organizations over the past year to ensure the new reporting standard is in place and that source systems can capture and report changes only.

While the technical aspects of this change have been developed, each Compensation Advisor should be aware that coverage changes being processed between the date of your participating organization’s last Remittance file and May 3rd will not be sent to Sun Life until May 3rd. As a result, members submitting changes during this period should be advised of this transition period and that they should expect the information to be supplied to Sun Life on May 3rd.

ANNEX A