USHIK: APCD File Submission Comparison

File Submission Comparison

Selected Items

Item Name	Version	State	Type	Organization
Pharmacy Eligibility File Submission	2010-03-16	Maine	File Specification	Maine Health Data Organization (MHDO)
Pharmacy Eligibility File Submission	v1.1	Maine	File Specification	Maine Health Data Organization (MHDO)

Identifying Attributes

File Specification:	Pharmacy Eligibility File Submission - 2010-03-16 (Maine)	Pharmacy Eligibility File Submission - v1.1 (Maine)
Responsible Organization:	Maine Health Data Organization	Maine Health Data Organization
Definition:	Not Provided	Not Provided

Data Elements & Codes

File Specification:

Pharmacy Eligibility File Submission - 2010-03-16 (Maine)

Pharmacy Eligibility File Submission - v1.1 (Maine)

PE001

Name:	Payer
Type:	varchar
Length:	8
Codes:

Name:	Payer
Type:	CHAR
Length:	6
Codes:
C	Commercial carrier
T	Third Party Administrator
U	Unlicensed entity

PE002

Name:	National Plan ID
Type:	varchar
Length:	30

Name:	National Plan ID
Type:	CHAR
Length:	30

PE003

Name:	Insurance Type/Product Code
Type:	varchar
Length:	2
Codes:

Name:	Insurance Type/Product Code
Type:	CHAR
Length:	2
Codes:
12	Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
13	Medicare Secondary End-Stage Renal Disease Beneficiary in the 12 month coordination period with an employer's group health plan
14	Medicare Secondary, No-fault insurance including Auto is primary
15	Medicare Secondary Worker's Compensation
16	Medicare Secondary Public Health Service or Other Federal Agency
41	Medicare Secondary Black Lung
42	Medicare Secondary Veteran's Administration
43	Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
47	Medicare Secondary, Other Liability Insurance is Primary
AP	Auto Insurance Policy
CP	Medicare Conditionally Primary
D	Disability
DB	Disability Benefits
EP	Exclusive Provider Organization
HM	Health Maintenance Organization (HMO)
HN	Health Maintenance Organization (HMO) Medicare Risk
HS	Special Low Income Medicare Beneficiary
IN	Indemnity
LC	Long Term Care
LD	Long Term Policy
LI	Life Insurance
LT	Litigation
MA	Medicare Part A
MB	Medicare Part B
MC	Medicaid
MH	Medigap Part A
MI	Medigap Part B
MP	Medicare Primary

PE004

Name:	Year
Type:	integer
Length:	4

Name:	Year
Type:	NUMBER
Length:	4

PE005

Name:	Month
Type:	integer
Length:	2

Name:	Month
Type:	NUMBER
Length:	2

PE006

Name:	Insured Group or Policy Number
Type:	varchar
Length:	30

Name:	Insured Group or Policy Number
Type:	CHAR
Length:	31

PE007

Name:	Coverage Level Code
Type:	varchar
Length:	3
Codes:

Name:	Coverage Level Code
Type:	CHAR
Length:	3
Codes:
CHD	Children Only
DEP	Dependents Only
ECH	Employee and Children
EMP	Employee Only
ESP	Employee and Spouse
FAM	Family
IND	Individual
SPC	Spouse and Children
SPO	Spouse Only

PE008

Name:	Encrypted Subscriber Social Security Number
Type:	varchar
Length:	128

Name:	Encrypted Subscriber Social Security Number
Type:	CHAR
Length:	32

PE009

Name:	Plan Specific Contract Number
Type:	varchar
Length:	128

Name:	Plan Specific Contract Number
Type:	CHAR
Length:	64

PE010

Name:	Member Suffix or Sequence Number
Type:	integer
Length:	20

Name:	Member Suffix or Sequence Number
Type:	CHAR
Length:	20

PE011

Name:	Member Identification Code
Type:	varchar
Length:	128

Name:	Member Identification Code
Type:	CHAR
Length:	64

PE012

Name:	Individual Relationship Code
Type:	integer
Length:	2
Codes:

Name:	Individual Relationship Code
Type:	CHAR
Length:	2
Codes:
01	Spouse
18	Self/Employee
19	Child
21	Unknown
34	Other Adult

PE013

Name:	Member Gender
Type:	varchar
Length:	1
Codes:

Name:	Member Gender
Type:	CHAR
Length:	1
Codes:
F	Female
M	Male
U	Unknown

PE014

Name:	Member Date of Birth
Type:	date
Length:	Not Provided

Name:	Member Date of Birth
Type:	DATE
Length:	8

PE015

Name:	Member City Name
Type:	varchar
Length:	30

Name:	Member City Name
Type:	CHAR
Length:	30

PE016

Name:	Member State or Province
Type:	varchar
Length:	2

Name:	Member State or Province
Type:	CHAR
Length:	2

PE017

Name:	Member ZIP Code
Type:	varchar
Length:	11

Name:	Member ZIP Code
Type:	CHAR
Length:	11

PE018

Name:	Medical Coverage
Type:	varchar
Length:	1
Codes:

Name:	Medical Coverage
Type:	CHAR
Length:	1
Codes:
N	No
Y	Yes

PE019

Name:	Prescription Drug Coverage
Type:	varchar
Length:	1
Codes:

Name:	Prescription Drug Coverage
Type:	CHAR
Length:	1
Codes:
N	No
Y	Yes

PE020

Name:	Dental Coverage
Type:	varchar
Length:	1
Codes:

Name:	Dental Coverage
Type:	CHAR
Length:	1
Codes:
N	No
Y	Yes

PE021

Name:	Race 1
Type:	varchar
Length:	6
Codes:

Name:	Record Type
Type:	CHAR
Length:	2
Codes:
PE	Pharmacy Eligibility

PE022

Name:	Race 2
Type:	varchar
Length:	6

Data Element: PE022
not present in this file submission.

PE023

Name:	Other Race
Type:	varchar
Length:	15

Data Element: PE023
not present in this file submission.

PE024

Name:	Hispanic Indicator
Type:	varchar
Length:	1

Data Element: PE024
not present in this file submission.

PE025

Name:	Ethnicity 1
Type:	varchar
Length:	6

Data Element: PE025
not present in this file submission.

PE026

Name:	Ethnicity 2
Type:	varchar
Length:	6

Data Element: PE026
not present in this file submission.

PE027

Name:	Other Ethnicity
Type:	varchar
Length:	20

Data Element: PE027
not present in this file submission.

PE028

Name:	Primary Insurance Indicator
Type:	varchar
Length:	1
Codes:
1	Yes
2	No

Data Element: PE028
not present in this file submission.

PE029

Name:	Coverage Type
Type:	varchar
Length:	3

Data Element: PE029
not present in this file submission.

PE030

Name:	Market Category Code
Type:	varchar
Length:	4

Data Element: PE030
not present in this file submission.

PE031

Name:	Special Coverage
Type:	varchar
Length:	3

Data Element: PE031
not present in this file submission.

PE032

Name:	Group Name
Type:	varchar
Length:	128

Data Element: PE032
not present in this file submission.

PE101

Name:	Encryped Subscriber Last Name
Type:	varchar
Length:	128

Data Element: PE101
not present in this file submission.

PE102

Name:	Encryped Subscriber First Name
Type:	varchar
Length:	128

Data Element: PE102
not present in this file submission.

PE103

Name:	Encryped Subscriber Middle Initial
Type:	varchar
Length:	1

Data Element: PE103
not present in this file submission.

PE104

Name:	Encryped Member Last Name
Type:	varchar
Length:	128

Data Element: PE104
not present in this file submission.

PE105

Name:	Encryped Member First Name
Type:	varchar
Length:	128

Data Element: PE105
not present in this file submission.

PE106

Name:	Encryped Member Middle Initial
Type:	varchar
Length:	1

Data Element: PE106
not present in this file submission.

PE899

Name:	Record Type
Type:	varchar
Length:	2
Codes:
PE

Data Element: PE899
not present in this file submission.

PE901

Name:	Member Age
Type:	integer
Length:	Not Provided

Name:	Member Age
Type:	NUMBER
Length:	3

PE902

Name:	Record ID#
Type:	integer
Length:	Not Provided

Name:	Record ID #
Type:	NUMBER
Length:	12

PE903

Name:	Date of Transfer to MHDO
Type:	date
Length:	Not Provided

Name:	MHDO Extract Date
Type:	DATE
Length:	8

PE904

Name:	Encrypted Member ID# (longer of ESSN or Contract) + DOB
Type:	varchar
Length:	71

Name:	Unique Member ID
Type:	CHAR
Length:	71

PE905

Name:	Medicare coverage
Type:	varchar
Length:	1
Codes:

Name:	Medicare Coverage
Type:	CHAR
Length:	1
Codes:
N	No supplemental Medicare Coverage
Y	Yes supplemental Medicare Coverage

PE906

Name:	Submission ID#
Type:	integer
Length:	Not Provided

Name:	Submission ID #
Type:	NUMBER
Length:	12

PE907

Name:	Double Encrypted Subscriber Social Security Number
Type:	varchar
Length:	64

Name:	Double Encrypted Social Security Number
Type:	CHAR
Length:	64

PE908

Name:	Double Encrypted Plan Specific Contract Number
Type:	varchar
Length:	128

Name:	Double Encrypted Contract Number
Type:	CHAR
Length:	128

PE909

Name:	Double Encrypted Member Identification Code
Type:	varchar
Length:	128

Name:	Double Encrypted Member Identification Code
Type:	CHAR
Length:	128

PE910

Name:	Double Encrypted Member ID# (longer of MHDO_ESSN or
Type:	varchar
Length:	135

Name:	Double Encrypted Member ID
Type:	CHAR
Length:	135

PE911

Name:	Standardized Insurance Individual Relationship Code
Type:	integer
Length:	2
Codes:

Name:	Standardized Relationship Code
Type:	INTEGER
Length:	2
Codes:
1	Spouse
4	Grandfather or Grandmother
5	Grandson or Granddaughter
7	Nephew or Niece
10	Foster Child
15	Ward
17	Stepson or Stepdaughter
19	Child
20	Self/Employee
21	Unknown
22	Handicapped Dependent
23	Sponsored Dependent
24	Dependent of a Minor Dependent
29	Significant Other
32	Mother
33	Father
34	Other Adult
36	Emancipated Minor
39	Organ Donor
40	Cadaver Donor
41	Injured Plaintiff
43	Child Where Insured Has No Financial Responsibility
53	Life Partner
76	Dependent

PE912

Name:	Standardized Insurance Type/Product Code
Type:	varchar
Length:	2
Codes:

Name:	Standardized Insurance Type/Product Code
Type:	CHAR
Length:	2
Codes:
11	Other non Federal program
12	Medicare secondary working aged beneficiary or spouse with employer group health plan
13	Medicare secondary end-stage renal disease beneficiary in the 12 month coordination period with an employer's group health plan
14	Medicare secondary, no-fault insurance including auto is primary
15	Medicare secondary public health service (PHS) or other federal agency
41	Medicare secondary black lung
42	Medicare secondary veteran's administration
43	Medicare secondary disabled beneficiary under age 65 with large group health plan (LGHP)
47	Medicare secondary, other liability insurance is primary
AM	Auto insurance policy
CP	Medicare conditionally primary
DB	Disability benefits
DS	Disability
EP	Exclusive Provider Organization (EPO)
HM	Health Maintenance Organization (HMO)
HN	Health Maintenance Organization (HMO) Medicare risk
HS	Special low income Medicare beneficiary
IN	Indemnity Insurance
LC	Long term care
LD	Long term policy
LI	Life insurance
LM	Liability medical
LT	Litigation
MA	Medicare part A
MB	Medicare part B
MC	Medicaid
MH	Medigap part A
MI	Medigap part B
MP	Medicare primary
OF	Other federal program (e.g. black lung)
OT	Other
PE	Property Insurance - Personal
PR	Preferred Provider Organization (PPO)
PS	Point of Service (POS)
QM	Qualified Medicare beneficiary
SP	Supplemental policy
TV	Title V
VA	Veteran administration plan
WC	Workers' compensation

PE913

Name:	Duplicate
Type:	varchar
Length:	1
Codes:

Name:	Duplicate Member Flag
Type:	INTEGER
Length:	1
Codes:
1	Same member, same month, same payer
2	Same member, same month, administrative relationship between payers

PE914

Name:	MTIME
Type:	integer
Length:	Not Provided

Name:	Eligibility Yearand Month
Type:	NUMBER
Length:	6

United States Health Information Knowledgebase

File Submission Comparison

Identifying Attributes

Data Elements & Codes