Eligibility Overview

User eligibility records are imported to the CirrusMD platform via the ingestion of properly formatted eligibility files encoded in UTF-8 .csv format. Each user record in an eligibility file specifies data for a user that is allowed to access the CirrusMD platform.

User Registration

Eligible users register via a program-specific registration form. Data entered on the registration form is matched against eligibility data. If a match is found, the system sends an email invitation to the unique and valid email address provided by the user. The user must confirm receipt of the email, which triggers a password creation and “terms and agreements” acceptance workflow, completing the registration process.

Automatic Sending of Invitation Emails

For users whose eligibility file record provides an email address, the CirrusMD system can, optionally, automatically send the “invitation” email to the user. This allows the user to receive and accept an invitation without having to complete the registration form. This streamlined workflow can accelerate user access to the system and is an effective way to increase user registrations and utilization of the CirrusMD platform. CirrusMD will only send automatic invitation emails when this is agreed to by the client.

When sending automatic invitations to users, CirrusMD assumes that the client has validated that their users can legally be sent the invitation emails to their business or personal email address.

Eligibility File Format

CSV File Format

The required format for eligibility files is UTF-8 encoded Comma Separated Value (CSV) files. Characteristics of the required file format:

• UTF-8 encoding with MS-DOS-style lines that end with (CR/LF) characters (optional for the last line).

• A header record with individual column names, as documented below. If a field is not required, and not used, the field may be omitted from the file.

• Each user record must contain the same number of comma-separated fields.

• Any field data may be enclosed in double-quotes. Fields containing a line break, a double quote, or commas must be enclosed in double-quotes. CirrusMD recommends enclosing all fields in double quotes to reduce errors.

Custom File Formats

CirrusMD can import almost any flat-file format such as fixed width and pipe delimited files, as long as the data is consistent. Parsing non-CSV file formats, or files with field names that deviate from the specifications described below may incur custom development and ongoing maintenance fees. Please consult with your Client Success Manager.

Available Fields

Below are all the available fields that can be uploaded for eligibility. The order is not critical but, the spelling and format of the headers are critical to ensure consistent data exchange. Columns containing no data may be omitted.

All fields listed in the tables below are available for use in client reporting. Please work with your Client Success Manager for assistance with mapping your desired data fields to these standard fields

Required Fields
Name	Type	Description	Format, Example, or Validation
External Id	String	Unique Identifier Each user must have a unique External Id. The Member Id and the External Id may be the same value. Required	ABC 123345-001 MUST BE UNIQUE
Member Id	String	Patient Member or Program Id Each user must have a unique Member Id. The Member Id and the External Id may be the same value. Required	10ABFRED MUST BE UNIQUE
First Name	String	User First Name Required	Jim
Last Name	String	User Last Name Required	Smith
Date of Birth	ISO8601	Patient Date of Birth  Required	2000-12-12
Gender	String	Patient Sex (Biological) Required	One of: Male or m female or f unknown or u other or o
Effective Date	ISO8601	Access Active Since Date the user’s access to the system begins Required	2019-01-01
Expiry Date	ISO8601	Access Expires On Date after which the user no longer has access to the system . Required	2023-12-31
Zip Code	String	User Zip Code Required	07649
Primary Phone	Digit string	User’s primary phone number Required if available	9035557777 (North American Numbering Plan 10 digit)
Street Address	String	Users Street Address Required when filing claims. Required when available when not filing claims.	23 Fake St Apt 6

Additional Fields Required When Filing Claims Note in the descriptions below, the “Subscriber” may be the primary insured, the head of household, the covered employee, or some other designation, depending on the client.
Name	Type	Description	Format, Example, or Validation
City	String	User’s City	Atlanta
State	String	Patient State	NJ (2-character abbreviation)
Subscriber Id	String	Subscriber Id Number (Primary)	AB 123456
Subscriber DOB	ISO8601	Subscriber (aka Insured) Date of Birth	1977-12-10
Subscriber First Name	String	Subscriber (aka Insured) First Name	Jacob
Subscriber Last Name	String	Subscriber (aka Insured) Last Name	Smith

Optional Fields Some options fields may be required or “highly desirable” depending on the requirements of a specific implementation. Consult with your Client Success Manager.
Name	Type	Description	Format, Rules, or Example
Email	String	User’s email address. Required if doing email marketing, including sending automatic invitation emails.	user@example.com MUST BE UNIQUE (if provided). No 2 users can share the same email address.
Allergies	String	User’s Allergies	Latex, Bees
Medical History	String	User’s Medical History	High Blood Pressure, Chronic Fatigue
Medications	String	Patient Medications	Daily ibuprofen
Middle Name	String	Patient Middle Name	Albert
Personal Representative External Id	String	Optional and populated for the user records of minors only. A list of External IDs identifying adult users to whom the minor’s data record should be linked, for the purpose of enabling the adult to get care on the minor user’s behalf. The Personal Representative External Id is discussed in detail in a later section of this document.	ABC123, ABC123-001
Primary Care Physician	String	Primary Care Physician	Luiz Parisi MD
Customer Type	String	High level identifier for customer type associated with the record	Health System
LOB	String	"Line of Business." Business unit or classification for the record	Distribution Center
Group Id	String	A sub group within a user population. The Group Id is typically associated with plan benefit coverage. Applies more to Coverage benefits (health plans).	ABC123
Group Name	String	The normalized name associated with the Group Id. Please see Group Id. Applies more to Coverage benefits (health plans).	John Smith's Apple Picking Company
Payor Plan	String	Identifies the payor associated with medical coverage or claims. Required if performing Real-Time Eligibility (RTE) queries.	Insurance Provider
Medical Plan Description	String	Identifies the detailed plan description of the user's medical coverage	High Deductible Health Plan
Medical Plan Type	String	Identifies the broad category of the user’s medical coverage	HDHP
Medical Provider	String	An association to a non-CirrusMD medical provider (typically PCP). NPI is preferable though can be set by the client. If NPI, CirrusMD can maintain a lookup to common NPI databases.	1234567999
Behavioral Provider	String	An association to a non-CirrusMD behavioral provider (Typically therapist or psychologist). NPI is preferable though can be set by the client. If NPI, CirrusMD can maintain a lookup to common NPI databases.5	1234567888
Subscriber Relationship	String	Identification if user record is a Primary or Dependent. Required if CirrusMD invoicing is based on the number of Primary users in the user population.	Primary
Relationship Code	String	Identification of the user in relation to the Primary user. Supported values are: 'SPONSORED MOTHER' 'SPONSORED FATHER' 'CHILD' 'DAUGHTER' 'CHILDREN (2)' 'SPONSORED' 'CHILDREN (3)' 'CHILDREN (4)' 'CHILDREN (+6)' 'SPONSORED MALE CHILD' 'SPONSORED FEMALE CHILD' 'SON' 'SPONSORED FEMALE' 'SPONSORED MALE' 'HUSBAND' 'WIFE' 'SPOUSE' 'COMMON LAW SPOUSE' 'DOMESTIC PARTNER' 'DIVORCED SPOUSE'	CHILD
Ethnicity Code	String	Standard Ethnicity Classifications: Hispanic White alone, non-Hispanic Black or African American alone, non-Hispanic American Indian and Alaska Native alone, non-Hispanic Asian alone, non-Hispanic Native Hawaiian and Other Pacific Islander alone, non-Hispanic Some Other Race alone, non-Hispanic Multiracial, non-Hispanic https://www.census.gov/newsroom/blogs/random-samplings/2021/08/measuring-racial-ethnic-diversity-2020-census.html	Hispanic
County	String	The user’s county.	Hudson
Gender Identity	String	Gender that a person identifies themselves as. This gender could be different than the Sex Assigned at Birth.	One of: ·       Male or m ·       female or f ·       unknown or u ·       other or o
Medical Enrollment	Boolean	User is actually enrolled in client/company provided medical coverage.	True/False
Medical Eligibility	Boolean	User is eligible to enroll in client/company provided medical coverage. A user can be eligible without being enrolled.	True/False
Behavioral Enrollment	Boolean	User is enrolled in client/company provided behavioral coverage.	True/False
Behavioral Eligibility	Boolean	User is eligible to enroll in client/company provided behavioral coverage. A user can be eligible without being enrolled.	True/False
Patient Utilization Category	String	An identifier, of the clients choosing. May be used to segment utilization reporting.	Emergency Department High Utilize

Additional Fields - Metadata Fields

In addition to the “pre-defined” fields described above, clients can add additional data fields to the eligibility file, as desired. These are known as “metadata” fields and there is no limit on the number of metadata fields that can be added. Each field should appear in the eligibility file as its own column, with its own unique header name. Metadata fields are stored as part of the user data, just like any pre-defined fields.

Notes on the “External Id” Field

The CirrusMD system uses the External Id value to uniquely identify each user in the system. When importing an eligibility file, if a user record with an External Id value not already in the system is processed, a new user with that External Id value is created. If a record with the given External Id value is found in the system, the record is updated.

External Id validation rules:

• External Ids must be unique per file. If multiple records are encountered with the same External Id, the first record encountered will be imported and the rest will be ignored.

• The External Id for a given user must be consistent between files. If a large number of records with changed or incorrect External Id values is imported, resulting in the unintended creation of a large number of duplicate records, the client may be charged to fix the problem.

Full vs. Incremental Files

“Full files” are eligibility files that contain a record for every eligible user, including users whose data has not changed since the last eligibility file. A user not present in a full eligibility file is considered to not be eligible. This means that a user who is eligible prior to the import of a full eligibility file, who does not have a record in the file, will have their eligibility terminated.

“Incremental files” are eligibility files that only contain records for users who are being added to the system, or who are already in the system and are having their data updated. Any user not having a record in an incremental file will not have any of their data changed. A user’s eligibility is not terminated simply by virtue of their being absent from an incremental file.

All eligibility files received before October 1, 2022 are treated by CirrusMD as “incremental files.” Starting on October 1, 2022 clients can designate their eligibility files as full or incremental files. Work with your Client Success Manager on preparing your eligibility file.

Terminating a User’s Eligibility

Full files: Any user eligible in the CirrusMD system that does not appear in a processed full file will have their eligibility terminated. The expiry date for the user will be set to the day before the date the full file is processed. This is known as “termination by absence.” A user’s eligibility can also be terminated via a full file by including the user’s record in the file and setting the expiry date for the record to a date in the past.

Incremental files: A user eligible in the CirrusMD system can only have their eligibility terminated by explicitly setting the expiry date for the user to a date in the past via an incremental file. Termination by absence is not possible with incremental files.

File Delivery

Eligibility files are delivered to CirrusMD via a CirrusMD-owned Secure File Transfer Protocol (SFTP) server.

File Name Requirements

Every file must follow a consistent location and naming pattern such as My_Program_YYYYMMDD.csv. The file must be placed in the same folder on a scheduled basis (The root/directory is acceptable.) We recommend a static prefix like My_Program_ in the example. The suffix changes based on the current date. The file extension must remain static.

SFTP Server Setup

CirrusMD creates and configures an SFTP server for the client’s exclusive use. The server meets healthcare compliance standards including restricted access and data encrypted at rest. The client is required to generate a Secure Shell (SSH) public/private key pair of at least 2048 bits in length and to share the public key with CirrusMD. The public key may be sent to CirrusMD over insecure means such as email. The private key should be protected like a password and not be shared with CirrusMD. CirrusMD will provide the client with a server address and a username. The client uses the username and their private key to access the server. SSH public/private key pairs can be generated by following these instructions.

File Delivery Frequency

Eligibility files can be delivered to CirrusMD via the SFTP server as frequently as daily, as desired by the client. CirrusMD will poll the SFTP server at the end of every business day. If a new file is found, the file is imported. Allow up to 2 business days for files to be imported.

Program Launch Timeline

The table below shows the expected eligibility file milestone completion dates, relative to the program launch date.

Milestone	Weeks before launch for completion	Responsible party
SSH public key to CirrusMD	4	Client
SFTP server available	3	CirrusMD
Test file placed on SFTP server.	3	Client
Sample/Test eligibility file to CirrusMD	3	Client
Production eligibility file to CirrusMD	1	Client

Eligibility File Requirements for Automatic Minor Dependent/Personal Representative Linking

This capability uses the “Personal Representative External Id” field in the standard CirrusMD eligibility file. The Personal Representative External Id field should be populated for minor records only. When populated, the Personal Representative External Id field should contain a comma-separated list of External Ids identifying adult users to whom the minor’s data record should be linked. This linkage establishes a personal representative/minor dependent relationship between the adult and the minor.

This example illustrates the use of the Personal Representative External Id.

External Id	Member Id	Personal Representative External Id	First Name	Last Name	Date of Birth
EX123456-01	MEM123456-01		Mary	Snow	1980-12-06
EX123456-02	MEM123456-02		John	Snow	1980-12-10
EX123456-03	MEM123456-03	EX123456-01, EX123456-02	Sally	Snow	2011-11-10
EX123456-04	MEM123456-04		Paul	Snow	2001-12-20
EX123457-01	MEM123457-01		Tom	Hill	1979-06-11
EX123457-02	MEM123457-02		Jenna	Hill	1979-03-11
EX123457-03	MEM123457-03	EX123457-01	Franklin	Hill	2010-05-16
EX987654-01	MEM987654-01		Darren	Woods	1971-06-11

In this example:

• Sally Snow is a minor. Mary Snow and John Snow are adults.

• The Personal Representative External Id field is populated for Sally Snow to indicate that when the eligibility file is imported, Sally’s record should be linked to Mary Snow’s record and John Snow’s record. Sally is a minor dependent of Mary Snow and of John Snow. Both Mary Snow and John Snow are personal representatives of Sally Snow

• Paul Snow is an adult child of John and Mary Snow. Because Paul is an adult and must get care on his own behalf, there is no Personal Representative External Id information populated for Paul.

• Franklin Hill is a minor. Tom Hill and Jenna Hill are adults.

• The Personal Representative External Id field is populated for Franklin Hill to indicate that when the eligibility file is imported, Franklin’s record should be linked to Tom Hill’s record. Franklin Hill is a minor dependent of Tom Hill. Tom Hill is a personal representative for Franklin Hill.

• There is no minor dependent / personal representative relationship between Franklin Hill and Jenna Hill.