| Name: | Maine |
|---|---|
| Abbreviation: | ME |
| Title of System | Maine Health Care Claims Database |
| Website | http://mhdo.maine.gov/imhdo/ |
| Who Maintains the System | Maine Health Data Organization |
| Versions: | 2010-03-16 v1.1 v1.2 |
Dental Claims File Submission - v1.1| Data Element ID | Data Element | Description | Type | Format | Length |
|---|---|---|---|---|---|
| DC001 |
Payer | This field contains the MHDO submitter code for the payer submitting claims. The first character of the submitter code indicates the type of submitter. This field is primarily used for tracking compliance by Payer. | CHAR | 6 | |
| DC002 |
National Plan ID | CMS National Plan ID | CHAR | 30 | |
| DC003 |
Insurance Type/Product Code - Original | The insurance type or product code indicates the type of Insurance coverage the individual has. | CHAR | 2 | |
| DC004 |
Payer Claim Control Number Original | This field contains the claim number used by the payer to Internally track the claim. | CHAR | 35 | |
| DC005 |
Line Counter | This field is the line number of the service | NUMBER | 4 | |
| DC006 |
Insured Group or Policy Number | This field contains the group or policy number associated with the entity which has purchased the insurance. For self insured individuals this relates to the purchaser. For the majority of eligibility and claims data the group relates to the employer. | CHAR | 30 | |
| DC007 |
Encrypted Subscriber Social Security Number Original | This field contains the Encrypted Social Security Number for the subscriber. If the social security number was not available from the payer this field will be null and the Contract field will be populated. This field has been encrypted using the same algorithm across all payers. If this field is populated, it forms the core of the unique member identification code(MEMBERID). | CHAR | 32 | |
| DC008 |
Plan Specific Contract Number Original | This field contains the payer assigned contract number for the subscriber. If the Encrypted Subscriber Social Security Number is null, this field forms the core of the unique member number (MEMBERID). | CHAR | 64 | |
| DC009 |
Member Suffix or Sequence Number | This payer supplied code uniquely identifies the member within the context of the subscriber Encrypted Social Security Number or the Contract. | CHAR | 20 | |
| DC010 |
Member Identification Code Original | This field is used to record the member's social security number when available. If the member is the subscriber, this field should contain the same value as the ENCRYPTED SOCIAL SECURITY NUMBER. If the member is not the subscriber, this field will not equal the ENCRYPTED SOCIAL SECURITY NUMBER. | CHAR | 30 | |
| DC011 |
Individual Relationship Code | This field contains the member's relationship to the subscriber or the insured. | CHAR | 2 | |
| DC012 |
Member Gender | This field contains the gender of the member. | CHAR | 1 | |
| DC013 |
Member Date of Birth | This field contains the member's data of birth with a format of CCYYMMDD. This field is used to calculate age as of the from date of service. | DATE | CCYYMMDD | 8 |
| DC014 |
Member City Name of Residence | This field contains the member's city of residence. | CHAR | 50 | |
| DC015 |
Member State or Province | The Member State or Province contains the 2 character abbreviation code used by the US Postal Service. | CHAR | 2 | |
| DC016 |
Member ZIP Code | This field contains ZIP Code of the member. Payers are encouraged to provide a full 9 character zip code. | CHAR | 11 | |
| DC017 |
Date Service Approved (AP Date) | This field contains the date the record was approved for payment. This is generally referred to as the Paid Date. In the CCYYMMDD format. | DATE | 8 | |
| DC030 |
Facility Type - Professional | For professional claims, this field records the type of facility where the service was performed. | CHAR | 2 | |
| DC031 |
Claim Status | This field contains the status of the claim as reported by the payer. | NUMBER | 2 | |
| DC032 |
CDT Code | This field is used to report the procedure performed. Common Dental Terminology (CDT) coding is required. | CHAR | 5 | |
| DC033 |
Procedure Modifier - 1 | A modifier is used to indicate that a service or procedure has been altered by some specific circumstance but not changed in its definition or code. Modifiers may be used to indicate a service or procedure that has both a professional and a technical component, only part of a service was performed, a bilateral procedure was performed, or a service or procedure was provided more than once. | CHAR | 2 | |
| DC034 |
Procedure Modifier - 2 | Procedure modifier required when a modifier clarifies/improves | CHAR | 2 | |
| DC035 |
Date of Service From | This field contains the first date of service for this service line in a CCYYMMDD format. | DATE | CCYYMMDD | 8 |
| DC036 |
Date of Service Thru | This field contains the thru date of service for this service line in a CCYYMMDD format. | DATE | CCYYMMDD | 8 |
| DC037 |
Charge Amount | This field contains the total charges for the service as reported by the provider. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. | NUMBER | 10 | |
| DC038 |
Paid Amount | This field includes all health plan payments, including withhold amounts, and excludes all member payments. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. | NUMBER | 10 | |
| DC039 |
Copay Amount | This field contains the pre-set, fixed dollar amount Payable by a member, often on a per visit/service basis. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. | NUMBER | 10 | |
| DC040 |
Coinsurance Amount | This amount is paid by the member and reflects the Percentage a member must pay toward the cost of a covered service. In many health insurance plans the coinsurance a member is responsible for is capped after a certain dollar amount of eligible expenses have been incurred. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. | NUMBER | 10 | |
| DC041 |
Deductible Amount | This is an amount that is required to be paid by a member Before health plan benefits will begin to reimburse for Services. It is usually an annual amount of all health care costs that is not covered by the member's insurance plan. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. | NUMBER | 10 | |
| DC042 |
Record Type | This field indicates the type of record. | CHAR | 2 | |
| DC901 |
Member Age | This field contains the age of the member in years as of the first day of service. Children under the age of 1 have an age of zero. If no date of birth is available, this field is null. | NUMBER | 3 | |
| DC902 |
Record ID # | This field contains a Data Processing Center assigned Record number that is unique across all data types. This field is used for tracking purposes. | NUMBER | 12 | |
| DC903 |
MHDO Extract Date | This is the date the record was extracted by the Data Processing Center for inclusion in the MHDO Data Warehouse. The format is CCYYMMDD. | DATE | CCYYMMDD | 8 |
| DC904 |
Unique Member ID | The MEMBERID is a combination of fields which generally represent a unique individual. For those members with a value in the Encrypted Subscriber Social Security Number, the MEMBERID is comprised of Encrypted Subscriber Social Security Number + Year and Month of Birth + Gender + Individual Relationship Code. If the Encrypted Subscriber Social Security Number is blank, the MEMBERID is comprised of the Plan Specific Contract Number + Year and Month of Birth + Gender + Individual Relationship Code. | CHAR | 71 | |
| DC905 |
Submission Id # | This field contains a unique submission number Assigned by the Data Processing Center for tracking Purposes. Each payer submission receives a submission number that is unique across all data types. | NUMBER | 12 | |
| DC906 |
Double Encrypted Payer Control Claim Number | This field contains the encrypted version of the Payer Claim Control Number reported in DC004. The claim number used by the payer to internally track the claim. In general the claim number is associated with all service lines of the bill. Therefore, multiple medical records may share the same claim number. | CHAR | 100 | |
| DC907 |
Double Encrypted Subscriber Social Security Number | This field contains an encryption of the information Originally submitted by the payer in field DC007 - the Encrypted Social Security Number for the subscriber. If the social security number was not available from the payer this field will be null and the CONTRACT field will be populated. This field has been encrypted using the same algorithm across all payers. If this field is populated, it forms the core of the unique member identification code(MHDO_MEMBERID). | CHAR | 64 | |
| DC908 |
Double Encrypted Contract Number | This field contains an encryption of the information Originally submitted by the payer in field DC008 - the payer assigned contract number for the subscriber. If the Encrypted Subscriber Social Security Number is null, this field forms the core of the unique member number (MHDO_MEMBERID). This field has been encrypted using the same algorithm across all payers. | CHAR | 128 | |
| DC909 |
Double Encrypted Member Identification Code | This field is used to record the member's social security number when available. If the member is the subscriber, this field should contain the same value as the ENCRYPTED SOCIAL SECURITY NUMBER. If the member is not the subscriber, this field will not equal the ENCRYPTED SOCIAL SECURITY NUMBER. | CHAR | 128 | |
| DC910 |
Double Encrypted Member ID # | The Double Encrypted Member ID is a combination of fields which generally represent a unique individual. For those members with a value in the Encrypted Subscriber Social Security Number, the Double Encrypted Member ID is comprised of Double Encrypted Subscriber Social Security Number + Year and Month of Birth + Gender + Individual Relationship Code. If the Double Encrypted Subscriber Social Security Number is blank, the Double Encrypted MEMBERID is comprised of the Encrypted Plan Specific Contract Number + Year and Month of Birth + Gender + Individual Relationship Code. | CHAR | 135 | |
| DC911 |
Provider ID # | This is the provider identification number that links to the Dental Service Provider file using DCSPC001. | INTEGER | 12 | |
| DC912 |
Standardized Insurance Type/Product Code | The insurance type or product code indicates the type of insurance coverage the individual has. | CHAR | 2 | |
| DC913 |
Year Paid | This field is derived from Date Service Approved (DC017) and contains the year of payment (YYYY format). | Number | 4 | |
| DC914 |
Month Paid | This field is derived from Date Service Approved (DC017) and contains the month of payment (MM format). | Number | 2 | |
| DC915 |
Year of Service | This field is derived from the From Date of Service (DC035) and contains the year the service was performed (YYYY format). | Number | YYYY | 4 |
| DC916 |
Month of Service | This field is derived from the From Date of Service (DC035) and contains the month the service was performed (MM format). | Number | MM | 2 |
| DC917 |
Payment Quarter | This field is derived from Date Service Approved (DC017) and contains the quarter of payment. | Number | 1 | |
| DC918 |
Quarter Service Performed | This field is derived from the From Date of Service (DC035) and contains the quarter of service. | Number | 1 |
Dental Eligibility File Submission - v1.1| Data Element ID | Data Element | Description | Type | Format | Length |
|---|---|---|---|---|---|
| DE001 |
Payer | This field contains the MHDO submitter code for the payer submitting payments. The first character of the submitter code indicates the type of submitter. This field is primarily used for tracking compliance by payer. | CHAR | 6 | |
| DE002 |
National Plan ID | CMS National Plan ID | CHAR | 30 | |
| DE003 |
Insurance Type/Product Code | This field contains the insurance type or product code that indicates the type of insurance coverage the individual has. | CHAR | 2 | |
| DE004 |
Year | The year during which the member is eligible for services. This field is generally used in conjunction with Month to determine a specific period of eligibility. | NUMBER | 4 | |
| DE005 |
Month | Month indicates the month during which the member is eligible for services. This field is generally used in conjunction with Year to determine a specific period of eligibility. | NUMBER | 2 | |
| DE006 |
Insured Group or Policy Number | The group or policy number is associated with the entity that has purchased the insurance. For self insured individuals this relates to the purchaser. For the majority of eligibility and claims data the group relates to the employer. | CHAR | 31 | |
| DE007 |
Coverage Level Code | This field indicates the type of coverage or type of contract. | CHAR | 3 | |
| DE008 |
Encrypted Subscriber Social Security Number | This field contains the encrypted social security number for the subscriber. If the social security number was not available from the payer this field will be null and the Contract field will be populated.This field has been encrypted using the same algorithm across all payers. If this field is populated, it forms the core of the unique member identification code(Memberid). | CHAR | 32 | |
| DE009 |
Plan Specific Contract Number | This field contains the payer assigned contract number for the subscriber. If the Encrypted Social Security Number is null, this field forms the core of the unique member number (Memberid). | CHAR | 64 | |
| DE010 |
Member Suffix or Sequence Number | This payer supplied code uniquely identifies the member within the context of the subscriber Encrypted Social Security Number or the Contract. | CHAR | 20 | |
| DE011 |
Member Identification Code | This field is used to record the member's social security number when available. If the member is the subscriber, this field should contain the same value as the Encrypted Social Security Number. If the member is not the subscriber, this field will not equal the Encrypted Social Security Number. | CHAR | 64 | |
| DE012 |
Individual Relationship Code | This field contains the member's relationship to the subscriber or the insured. | CHAR | 2 | |
| DE013 |
Member Gender | This field contains the gender of the member. | CHAR | 1 | |
| DE014 |
Member Date of Birth | This field contains the member's data of birth with a format of CCYYMMDD. This field is used to calculate age as of the first day of the membership month. | DATE | CCYYMMDD | 8 |
| DE015 |
Member City Name | This field contains the member's city of residence and was not required reporting until 2004. | CHAR | 30 | |
| DE016 |
Member State or Province | The Member State or Province contains the 2 character abbreviation code used by the US Postal Service and was not required reporting until 2004. Since this database has been built for Maine residents the code will generally be ME for Maine. | CHAR | 2 | |
| DE017 |
Member ZIP Code | This field contains ZIP Code of the member. Payers are encouraged to provide a full 9 character zip code. | CHAR | 11 | |
| DE018 |
Medical Coverage | The medical coverage flag indicates whether this member is covered for medical expenses or not. | CHAR | 1 | |
| DE019 |
Prescription Drug Coverage | The prescription drug coverage flag indicates whether this member is covered for prescription drug expenses or not. | CHAR | 1 | |
| DE020 |
Dental Coverage | The dental coverage flag indicates whether this member is covered for dental expenses or not. | CHAR | 1 | |
| DE021 |
Record Type | This field indicates the type of record. | CHAR | 2 | |
| DE901 |
Member Age | This field contains the age of the member in years as of the last day of the previous eligibility month. Children under the age of 1 have an age of zero. If no date of birth is available, this field is null. | NUMBER | 3 | |
| DE902 |
Record ID # | This field contains a Data Processing Center assigned record number that is unique across all data types. This field is used for tracking purposes. | NUMBER | 12 | |
| DE903 |
MHDO Extract Date | This is the date the record was extracted by the Data Processing Center for inclusion in the MHDO Data Warehouse. The format is CCYYMMDD. | DATE | CCYYMMDD | 8 |
| DE904 |
Unique Member ID | The MEMBERID is a combination of fields which generally represent a unique individual. For those members with a value in the Encrypted Subscriber Social Security Number, the Memberid is comprised of Encrypted Subscriber Social Security Number + Year and Month of Birth + Gender + Individual Relationship Code. If the Encrypted Subscriber Social Security Number is blank, the Memberid is comprised of the Plan Specific Contract Number + Year and Month of Birth + Gender + Individual Relationship Code. | CHAR | 71 | |
| DE905 |
Medicare Coverage | This field is used to flag all Medical Eligibility records associated with supplemental Medicare Coverage. Medicare eligibility does not apply to dental data. | CHAR | 1 | |
| DE906 |
Submission ID # | This field contains a unique submission number assigned by the Data Processing Center for tracking purposes. Each payer submission receives a submission number that is unique across all data types. | NUMBER | 12 | |
| DE907 |
Double Encrypted Social Security Number | This field contains an encryption of the information originally submitted by the payer in field DC007 - the Encrypted Social Security Number for the subscriber. If the social security number was not available from the payer this field will be null and the CONTRACT field will be populated. This field has been encrypted using the same algorithm across all payers. If this field is populated, it forms the core of the unique member identification code(MHDO_MEMBERID). | CHAR | 64 | |
| DE908 |
Double Encrypted Contract Number | This field contains an encryption of the information originally submitted by the payer in field DC008 - the payer assigned contract number for the subscriber. If the Encrypted Subscriber Social Security Number is null, this field forms the core of the unique member number (MHDO_MEMBERID). This field has been encrypted using the same algorithm across all payers. | CHAR | 128 | |
| DE909 |
Double Encrypted Member Identification Code | This field is used to record the member's social security number when available. If the member is the subscriber, this field should contain the same value as the Double Encrypted Social Security Number. If the member is not the subscriber, this field will not equal the Double Encrypted Social Security Number. | CHAR | 128 | |
| DE910 |
Double Encrypted Member ID | The Double Encrypted Member ID is a combination of fields which generally represent a unique individual. For those members with a value in the Encrypted Subscriber Social Security Number, the Double Encrypted MemberID is comprised of Double Encrypted Subscriber Social Security Number + Year and Month of birth + Gender + Individual Relationship Code. If the Double Encrypted Subscriber Social Security Number is blank, the Double Encrypted Memberid is comprised of the Encrypted Plan Specific Contract Number + Year and Month of birth + Gender + Individual Relationship Code. This field contains the member's relationship to the | CHAR | 135 | |
| DE911 |
Standardized Relationship Code | Subscriber or the insured. | INTEGER | 2 | |
| DE912 |
Standardized Insurance Type/Product Code | The insurance type or product code indicates the type of insurance coverage the individual has. | CHAR | 2 | |
| DE913 |
Duplicate Member Flag | This field flags duplicate eligibility records that should not be released. | INTEGER | 1 | |
| DE914 |
Eligibility Year and Month | This field combines YEAR (DE004) and MONTH (DE005) into a single field with a format of YYYYMM. | NUMBER | YYYYMM | 6 |
Dental Provider File Submission - v1.2| Data Element ID | Data Element | Description | Type | Format | Length |
|---|---|---|---|---|---|
| DCPM901 |
Data Processing Center Provider Code | This field contains the unique provider identifier that crosses all payers. This field is the link to the Dental Services Provider file (DCSP001). | NUMBER | 12 | |
| DCPM902 |
Service Provider Tax ID Number | This field should contain the provider's tax identification number. For an individual this code is often the social security number. This field is derived from DC026 in the dental claims data. | CHAR | 10 | |
| DCPM903 |
Service Provider Facility Name | This field contains the normalized first name of the practitioner. If the provider is a facility, this field will be blank. This field is derived from DC024 in the dental claims data. | CHAR | 60 | |
| DCPM904 |
Service Provider Facility Code | This field is reserved for future use. | CHAR | 10 | |
| DCPM905 |
Service Provider First Name | This field contains the normalized first name of the practitioner. If the provider is a facility, this field will be blank. This field is derived from DC022 in the dental claims data. | CHAR | 25 | |
| DCPM906 |
Service Provider Middle Name | This field contains the normalized middle name or Initial or initial of the practitioner. This field is derived from DC023 in the dental claims data. | CHAR | 25 | |
| DCPM907 |
Service Provider Last Name | This field contains the normalized full name of individual practitioner. This field is derived from DC024 in the dental claims data. | CHAR | 60 | |
| DCPM908 |
Service Provider Suffix | This field contains the normalized generational suffix for the individual. This field is derived from DC025 in the dental claims data. | CHAR | 10 | |
| DCPM909 |
Service Provider Title | Not Provided | CHAR | 10 | |
| DCPM910 |
Service Provider State or Province | This is the normalized two character abbreviation for city as defined by the US Postal Service. This field is derived from DC028 in the dental claims data. | CHAR | 2 | |
| DCPM911 |
Taxonomy Code | This field is used to standardize the specialty coding of the provider records. It is based upon the service provider specialty code (DC026) and the linkage activity. A single DPCID will have only one national TAXONOMY code. | CHAR | 10 | |
| DCPM912 | National Provider Identifier | This field contains the National Provider ID as established under HIPAA. This field is derived from DC020. | CHAR | 20 |
Dental Service Providers File Submission - v1.2| Data Element ID | Data Element | Description | Type | Format | Length |
|---|---|---|---|---|---|
| DCSP001 |
Provider ID # | This field is used to link the Dental provider data to the Dental claims data (DC912). It is the primary identification number for each Dental Service Provider record. | CHAR | 12 | |
| DCSP002 |
Payer | This field contains the MHDO submitter code for the payer submitting payments. The first character of the submitter code indicates the type of submitter. This field is primarily used for tracking compliance by payer. It is derived from DC001 in the dental claims data. | CHAR | 6 | |
| DCSP003 |
Service Provider Number | This is the provider number assigned by the payer. This field is derived from DC018 in the dental claims data. | CHAR | 30 | |
| DCSP004 |
Service Provider Tax ID Number | This field should contain the provider's tax identification number. For an individual, this code is often the social security number. This field is derived from DC019 in the dental claims data. | CHAR | 10 | |
| DCSP005 |
Service Provider Entity Type Qualifier | This field is used to distinguish an individual practitioner from a business entity. This field is derived from DC021 in the dental claims data. | CHAR | 1 | |
| DCSP006 |
Service Provider First Name | This field contains the first name of the practitioner. If the provider is a facility, this field will be blank. This field is derived from DC022 in the dental claims data. | CHAR | 25 | |
| DCSP007 |
Service Provider Middle Name | This field contains the practitioner's middle name or initial. This field is derived from DC023 in the dental claims data. | CHAR | 25 | |
| DCSP008 |
Service Provider Last Name or Organization Name | This field contains the full name of provider organization or last name of individual provider. This field is derived from DC024 in the dental claims data. | CHAR | 60 | |
| DCSP009 |
Service Provider Suffix | This field contains the generational suffix for the individual. This field is derived from DC025 in the dental claims data. | CHAR | 10 | |
| DCSP010 |
Service Provider Specialty | This field contains the specialty code assigned by the payer. Use this field to link to the provider specialty table (SP901). Since specialty codes are not unique across payers, you must also link on Payer. This field is derived from DC026 in the dental claims data. | CHAR | 10 | |
| DCSP011 |
Service Provider City Name | This field contains the city name of provider - preferably practice location. This field is derived from DC027 in the dental claims data. | CHAR | 30 | |
| DCSP012 |
Service Provider State or Province | This is the two character abbreviation for city as defined by the US Postal Service. This field is derived from DC028in the dental claims data. | CHAR | 2 | |
| DCSP013 |
Service Provider ZIP Code | This field contains the zip code of provider practice location. It may contain non US codes. This field is derived from DC029 in the dental claims data. | CHAR | 11 | |
| DCSP014 |
Data Processing Center Provider Code | This field contains the unique provider identifier that crosses all payers. This field is the link to the Dental Provider Master file (DCPM901). | NUMBER | 12 | |
| DCSP015 |
Taxonomy Code | This field is used to standardize the specialty coding of the provider records. It is based upon the service provider specialty code (DC032) and the linkage activity. A DPCID will have only one national TAXONOMY code. | CHAR | 10 | |
| DCSP016 |
Individual Practitioner Flag | This field is used to determine if the provider name may be released. Eliminated 04//01/2007 upon the release of practitioner identifiable data elements. | NUMBER | 1 | |
| DCSP017 |
National Provider Identifier | Not Provided | CHAR | 20 |
Medical Claims File Submission - v1.2| Data Element ID | Data Element | Description | Type | Format | Length |
|---|---|---|---|---|---|
| MC001 |
Payer | This field contains the MHDO submitter code for the payer submitting payments. The first character of the submitter code indicates the type of submitter. This field is primarily used for tracking compliance by Payer. | CHAR | 6 | |
| MC002 |
National Plan ID | CMS National Plan ID | CHAR | 30 | |
| MC003 |
Insurance Type/Product Code | The insurance type or product code indicates the type of Insurance coverage the individual has. | TEXT | 2 | |
| MC004 |
Payer Claim Control Number | This field contains the claim number used by the payer to internally track the claim. | CHAR | 35 | |
| MC005 |
Line Counter | This field contains the line number for this service | NUMBER | 30 | |
| MC006 |
Insured Group or Policy Number | The group or policy number is associated with the entity that has purchased the insurance. For self insured individuals this relates to the purchaser. For the majority of eligibility and claims data the group relates to the employer. | CHAR | 30 | |
| MC007 |
Encrypted Subscriber Social Security Number | This field contains the Encrypted Social Security Number for the subscriber. If the social security number was not available from the payer this field will be null and the Contract field will be populated. This field has been encrypted using the same algorithm across all payers. If this field is populated, it forms the core of the unique member identification code (MEMBERID). | CHAR | 32 | |
| MC008 |
Plan Specific Contract Number | This field contains the payer assigned contract number for the subscriber. If the Encrypted Social Security Number is null, this field forms the core of the unique member number (MEMBERID). | CHAR | 64 | |
| MC009 |
Member Suffix or Sequence Number | This payer supplied code uniquely identifies the member within the context of the subscriber Encrypted Social Security Number or Contract. | CHAR | 20 | |
| MC010 |
Member Identification Code | This field is used to record the member's social security number when available. If the member is the subscriber, this field should contain the same value as the Encrypted Social Security Number. If the member is not the subscriber, this field will not equal the Encrypted Social Security Number. | CHAR | 64 | |
| MC011 |
Individual Relationship Code | This field contains the member's relationship to the subscriber or the insured. | CHAR | 2 | |
| MC012 |
Member Gender | This field contains the gender of the member. | CHAR | 1 | |
| MC013 |
Member Date of Birth | This field contains the member's data of birth with a format of CCYYMMDD. This field is used to calculate age as of the from date of service (MC059). | DATE | CCYYMMDD | 8 |
| MC014 |
Member City Name | This field contains the member's city of residence and was not required reporting until 2004. | CHAR | 30 | |
| MC015 |
Member State or Province | The Member State or Province contains the 2 character abbreviation code used by the US Postal Service and was not required reporting until 2004. Since this database has been built for Maine residents the code will generally be ME for Maine. | CHAR | 2 | |
| MC016 |
Member ZIP Code | This field contains ZIP Code of the member. Payers are encouraged to provide a full 9 character zip code. | CHAR | 11 | |
| MC017 |
Date Service Approved (AP Date) | This field contains the date the record was approved for payment. This is generally referred to as the Paid Date with a CCYYMMDD format. | DATE | CCYYMMDD | 8 |
| MC018 |
Admission Date | This field contains the date of the inpatient admission with a CCYYMMDD format. | DATE | CCYYMMDD | 8 |
| MC019 |
Admission Hour | This field contains the hour the inpatient was admitted to the hospital in military time. | NUMBER | 4 | |
| MC020 |
Admission Type | This field is used to record the type of admission for all inpatient hospital bills. | NUMBER | 2 | |
| MC021 |
Admission Source | This field is required for inpatient hospital bills. It records the source of admission. For newborns (ADMSR = 4) | CHAR | 1 | |
| MC022 |
Discharge Hour | This field contains the hour the inpatient was discharged from the hospital in military time. | NUMBER | 2 | |
| MC023 |
Member Status | This field contains the status for the patient discharged from the hospital. | NUMBER | 2 | |
| MC036 |
Type of Bill - Institutional | Not Provided | NUMBER | 2 | |
| MC037 |
Facility Type - Professional | For professional claims, this field records the type of facility where the service was performed. | CHAR | 2 | |
| MC038 |
Claim Status | This field contains the status of the claim as reported by the payer. | NUMBER | 2 | |
| MC039 |
Admitting Diagnosis | This field contains the ICD-9 diagnosis code indicating the reason for the inpatient admission. | CHAR | 5 | |
| MC040 |
E-Code | This field describes an injury, poisoning or adverse effect using an ICD-9 E-code diagnosis. | CHAR | 5 | |
| MC041 |
Principal Diagnosis | This field contains the ICD-9 diagnosis code for the principal diagnosis. | CHAR | 5 | |
| MC042 |
Other Diagnosis 1 | This field contains the ICD-9 diagnosis code for the first secondary diagnosis . This was not required reporting until 2004. | CHAR | 5 | |
| MC043 |
Other Diagnosis 2 | This field contains the ICD-9 diagnosis code for the second secondary diagnosis and was not required reporting until | CHAR | 5 | |
| MC044 |
Other Diagnosis 3 | This field contains the ICD-9 diagnosis code for the third secondary diagnosis and was not required reporting until 2004. | CHAR | 5 | |
| MC045 |
Other Diagnosis 4 | This field contains the ICD-9 diagnosis code for the fourth secondary diagnosis and was not required reporting until 2004. | CHAR | 5 | |
| MC046 |
Other Diagnosis 5 | This field contains the ICD-9 diagnosis code for the fifth secondary diagnosis and was not required reporting until 2004. | CHAR | 5 | |
| MC047 |
Other Diagnosis 6 | This field contains the ICD-9 diagnosis code for the sixth secondary diagnosis and was not required reporting until 2004. | CHAR | 5 | |
| MC048 |
Other Diagnosis 7 | This field contains the ICD-9 diagnosis code for the seventh secondary diagnosis and was not required reporting until 2004. | CHAR | 5 | |
| MC049 |
Other Diagnosis 8 | This field contains the ICD-9 diagnosis code for the eighth secondary diagnosis and was not required reporting until 2004. | CHAR | 5 | |
| MC050 |
Other Diagnosis 9 | This field contains the ICD-9 diagnosis code for the ninth secondary diagnosis and was not required reporting until 2004. | CHAR | 5 | |
| MC051 |
Other Diagnosis 10 | This field contains the ICD-9 diagnosis code for the tenth secondary diagnosis and was not required reporting until 2004. | CHAR | 5 | |
| MC052 |
Other Diagnosis 11 | This field contains the ICD-9 diagnosis code for the eleventh secondary diagnosis and was not required reporting until 2004. | CHAR | 5 | |
| MC053 |
Other Diagnosis 12 | This field contains the ICD-9 diagnosis code for the twelfth secondary diagnosis and was not required reporting until 2004. | CHAR | 5 | |
| MC054 |
Revenue Code | This field is used to report the revenue code for hospital claims. It is one of three fields used to report type of service. National Uniform Billing Committee codes are used in this field. | CHAR | 10 | |
| MC055 |
Procedure Code | This field contains the HCPC or CPT code for the procedure performed. It is one of three fields used to report the service. | CHAR | 10 | |
| MC056 |
Procedure Modifier 1 | A modifier is used to indicate that a service or procedure has been altered by some specific circumstance but not changed in its definition or code. Modifiers may be used to indicate a service or procedure that has both a professional and a technical component, only part of a service was performed, a bilateral procedure was performed, or a service or procedure was provided more than once. | CHAR | 2 | |
| MC057 |
Procedure Modifier 2 | A modifier is used to indicate that a service or procedure has been altered by some specific circumstance but not changed in its definition or code. Modifiers may be used to indicate a service or procedure that has both a professional and a technical component, only part of a service was performed, a bilateral procedure was performed, or a service or procedure was provided more than once. | CHAR | 2 | |
| MC058 |
ICD-9-CM Procedure Code | This is used to report the ICD-9 procedure code. The decimal point is not coded. This is one of three fields used to report type of service. | CHAR | 4 | |
| MC059 |
Date of Service From | This field contains the first date of service for this service line in a CCYYMMDD format. | DATE | CCYYMMDD | 8 |
| MC060 |
Date of Service Thru | This field contains the last date of service for this service line in a CCYYMMDD format. | DATE | CCYYMMDD | 8 |
| MC061 |
Quantity | This field contains a count of services performed. This field may be negative. | NUMBER | 3 | |
| MC062 |
Charge Amount | This field contains the total charges for the service as reported by the provider. This is a money field Containing dollars and cents with an implied decimal Point. This field may contain a negative value. | NUMBER | 10 | |
| MC063 |
Paid Amount | This field includes all health plan payments, including withhold amounts, and excludes all member payments. This is a money field containing dollars and cents with an Implied decimal point. This field may contain a negative Value. | NUMBER | 10 | |
| MC064 |
Prepaid Amount | This field contains the fee for service equivalent that would have been paid by the health care claims processor for a specific service if the service had not been capitated. "Capitated services" means services rendered by a provider through a contract where payments are based upon a fixed dollar amount for each member on a monthly basis. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. | NUMBER | 10 | |
| MC065 |
Copay Amount | This field contains the pre-set, fixed dollar amount Payable by a member, often on a per visit/service basis. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. | NUMBER | 10 | |
| MC066 |
Coinsurance Amount | This amount is paid by the member and reflects the percent a member must pay toward the cost of a covered service. In many health insurance plans the coinsurance a member is responsible for is capped after a certain dollar amount of eligible expenses have been incurred. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. | NUMBER | 10 | |
| MC067 |
Deductible Amount | This is an amount that is required to be paid by a member before health plan benefits will begin to reimburse for services. It is usually an annual amount of all health care costs that is not covered by the member's insurance plan. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. | NUMBER | 10 | |
| MC068 |
Record Type | This field indicates the type of record. | CHAR | 2 | |
| MC069 |
Patient Account/Control Number | This field is used by hospitals to identify a patient. | CHAR | 38 | |
| MC070 | Discharge Date | This field contains the date the patient was discharged from the hospital. The format is CCYYMMDD. | DATE | CCYYMMDD | 8 |
| MC901 |
Member Age | This field contains the age of the member in years as of the from date of service (MC059). Children under the age of 1 have an age of zero. If no date of birth is available, this field is null. | NUMBER | 3 | |
| MC902 |
Record ID # | This field contains a Data Processing Center assigned record number that is unique across all data types. This field is used for tracking purposes. | NUMBER | 12 | |
| MC903 |
MHDO Extract Date | This is the date the record was extracted by the Data Processing Center for inclusion in the MHDO Data Warehouse. The format is CCYYMMDD. | DATE | CCYYMMDD | 8 |
| MC904 |
Encrypted Member ID # | The MEMBERID is a combination of fields which generally represent a unique individual. For those members with a value in the Encrypted Subscriber Social Security Number, the Memberid is comprised of Encrypted Subscriber Social Security Number + Year and Month of birth + Gender + Individual Relationship Code. If the Encrypted Subscriber Social Security Number is blank, the Memberid is comprised of the Plan Specific Contract Number + Year and Month of Birth + Gender + Individual Relationship Code. | CHAR | 71 | |
| MC905 |
Medicare Coverage | This field indicates whether the claim is for a member who also has Medicare coverage. It is derived from the insurance type/product code field (MC003). | CHAR | 1 | |
| MC906 |
Submission ID # | This field contains a unique submission number assigned by the Data Processing Center for tracking purposes. Each payer submission receives a submission number that is unique across all data types. | NUMBER | 12 | |
| MC907 |
Double Encrypted Payer Claim Control Number | This field contains the encrypted version of the Payer Claim Control Number reported in DC004. The claim number used by the payer to internally track the claim. In general the claim number is associated with all service lines of the bill. Therefore, multiple medical records may share the same claim number. | CHAR | 100 | |
| MC908 |
Double Encrypted Subscriber Social Security Number | This field contains an encryption of the information originally submitted by the payer in field DC007 - the Encrypted Social Security Number for the subscriber. If the social security number was not available from the payer this field will be null and the CONTRACT field will be populated. This field has been encrypted using the same algorithm across all payers. If this field is populated, it forms the core of the unique member identification code(MHDO_MEMBERID). | CHAR | 64 | |
| MC909 |
Double Encrypted Plan Specific Contract Number | This field contains an encryption of the information originally submitted by the payer in field DC008 - the payer assigned contract number for the subscriber. If the Encrypted Subscriber Social Security Number is null, this field forms the core of the unique member number (MHDO_MEMBERID). This field has been encrypted using the same algorithm across all payers. | CHAR | 128 | |
| MC910 |
Double Encrypted Member Social Security Number | This field is used to record the member's social security number when available. If the member is the subscriber, this field should contain the same value as the Encrypted Social Security Number. If the member is not the subscriber, this field will not equal the Encrypted Social Security Number. | CHAR | 128 | |
| MC911 |
Double Encrypted Member ID # | The Double Encrypted Member ID is a combination of fields which generally represent a unique individual. For those members with a value in the Encrypted Subscriber Social Security Number, the Double Encrypted Memberid is comprised of Double Encrypted Subscriber Social | CHAR | 135 | |
| MC912 |
Provider ID # | This is the provider identification number that links to the Medical Service Provider file using MCSP001. | INTEGER | 12 | |
| MC913 |
Standardized Insurance Type/Product Code | The insurance type or product code indicates the type of insurance coverage the individual has. | CHAR | 2 | |
| MC914 |
Abortion Flag | This field flags all records associated with a possible abortion claim. | INTEGER | 1 | |
| MC915 |
Year Paid | This field is derived from Date Service Approved (MC017) and contains the year of payment (YYYY format). | Number | YYYY | 4 |
| MC916 |
Month Paid | This field is derived from Date Service Approved (MC017) and contains the month of payment (MM format). | Number | MM | 2 |
| MC917 |
Year of Service | This field is derived from the From Date of Service (MC059) and contains the year the service was performed (YYYY format). | Number | YYYY | 4 |
| MC918 |
Month of Service | This field is derived from the From Date of Service (MC059) and contains the month the service was performed (MM format). | Number | MM | 2 |
| MC919 |
Payment Quarter | This field is derived from Date Service Approved (MC017) and contains the quarter of payment. | Number | 1 | |
| MC920 |
Quarter Service Performed | This field is derived from the From Date of Service (MC059) and contains the quarter of service. | Number | 1 |
Medical Eligibility File Submission - v1.1| Data Element ID | Data Element | Description | Type | Format | Length |
|---|---|---|---|---|---|
| ME001 |
Payer | This field contains the MHDO submitter code for the payer submitting payments. The first character of the submitter code indicates the type of submitter. | CHAR | 6 | |
| ME002 |
National Plan ID | CMS National Plan ID | CHAR | 30 | |
| ME003 |
Insurance Type/Product Code | This field contains the insurance type or product code that indicates the type of insurance coverage the individual has. | CHAR | 2 | |
| ME004 |
Year | The year during which the member is eligible for services. This field is generally used in conjunction with Month to determine a specific period of eligibility. | NUMBER | 4 | |
| ME005 |
Month | Month indicates the month during which the member is eligible for services. This field is generally used in conjunction with Year to determine a specific period of eligibility. | NUMBER | 2 | |
| ME006 |
Insured Group or Policy Number | The group or policy number is associated with the entity that has purchased the insurance. For self insured individuals this relates to the purchaser. For the majority of eligibility and claims data the group relates to the employer. | CHAR | 31 | |
| ME007 |
Coverage Level Code | This field indicates the type of coverage or type of contract. | CHAR | 3 | |
| ME008 |
Encrypted Subscriber Social Security Number | This field contains the encrypted social security number for the subscriber. If the social security number was not available from the payer this field will be null and the Contract field will be populated.This field has been encrypted using the same algorithm across all payers. If this field is populated, it forms the core of the unique member identification code(Memberid). | CHAR | 32 | |
| ME009 |
Plan Specific Contract Number | This field contains the payer assigned contract number for the subscriber. If the Encrypted Social Security Number is null, this field forms the core of the unique member number (Memberid). | CHAR | 64 | |
| ME010 |
Member Suffix or Sequence Number | This payer supplied code uniquely identifies the member within the context of the subscriber Encrypted Social Security Number or the Contract. | CHAR | 20 | |
| ME011 |
Member Identification Code | This field is used to record the member's social security number when available. If the member is the subscriber, this field should contain the same value as the Encrypted Social Security Number. If the member is not the subscriber, this field will not equal the Encrypted Social Security Number. | CHAR | 64 | |
| ME012 |
Individual Relationship Code | This field contains the member's relationship to the subscriber or the insured. | CHAR | 2 | |
| ME013 |
Member Gender | This field contains the gender of the member. | CHAR | 1 | |
| ME014 |
Member Date of Birth | This field contains the member's data of birth with a format of CCYYMMDD. This field is used to calculate age as of the first day of the membership month. | DATE | CCYYMMDD | 8 |
| ME015 |
Member City Name | This field contains the member's city of residence and was not required reporting until 2004. | CHAR | 30 | |
| ME016 |
Member State or Province | The Member State or Province contains the 2 character abbreviation code used by the US Postal Service and was not required reporting until 2004. Since this database has been built for Maine residents the code will generally be ME for Maine. | CHAR | 2 | |
| ME017 |
Member ZIP Code | This field contains ZIP Code of the member. Payers are encouraged to provide a full 9 character zip code. | CHAR | 11 | |
| ME018 |
Medical Coverage | The medical coverage flag indicates whether this member is covered for medical expenses or not. | CHAR | 1 | |
| ME019 |
Prescription Drug Coverage | The prescription drug coverage flag indicates whether this member is covered for prescription drug expenses or not. | CHAR | 1 | |
| ME020 |
Dental Coverage | The dental coverage flag indicates whether this member is covered for dental expenses or not. | CHAR | 1 | |
| ME021 |
Record Type | This field indicates the type of record. | CHAR | 2 | |
| ME901 |
Member Age | This field contains the age of the member in years as of the last day of the previous eligibility month. Children under the age of 1 have an age of zero. If no date of birth is available, this field is null. | NUMBER | 3 | |
| ME902 |
Record ID # | This field contains a Data Processing Center assigned record number that is unique across all data types. This field is used for tracking purposes. | NUMBER | 12 | |
| ME903 |
MHDO Extract Date | This is the date the record was extracted by the Data Processing Center for inclusion in the MHDO Data Warehouse. The format is CCYYMMDD. | DATE | CCYYMMDD | 8 |
| ME904 |
Unique | The MEMBERID is a combination of fields which generally represent a unique individual. For those members with a value in the Encrypted Subscriber Social Security Number, the Memberid is comprised of Encrypted Subscriber Social Security Number + Year and Month of Birth + Gender + Individual Relationship Code. If the Encrypted Subscriber Social Security Number is blank, the Memberid is comprised of the Plan Specific Contract Number + Year and Month of Birth + Gender + Individual Relationship Code. | CHAR | 71 | |
| ME905 |
Medicare Coverage | This field is used to flag all Medical Eligibility records associated with supplemental Medicare Coverage. This field is derived from the insurance type/product code field (ME003). | CHAR | 1 | |
| ME906 |
Submission ID # | This field contains a unique submission number assigned by the Data Processing Center for tracking purposes. Each payer submission receives a submission number that is unique across all data types. | NUMBER | 12 | |
| ME907 |
Double Encrypted Social Security Number | This field contains an encryption of the information originally submitted by the payer in field DC007 - the encrypted social security number for the subscriber. If the social security number was not available from the payer this field will be null and the CONTRACT field will be populated. This field has been encrypted using the same algorithm across all payers. If this field is populated, it forms the core of the unique member identification code(MHDO_MEMBERID). | CHAR | 64 | |
| ME908 |
Double Encrypted Contract Number | This field contains an encryption of the information originally submitted by the payer in field DC008 - the payer assigned contract number for the subscriber. If the Encrypted Subscriber Social Security Number is null, this field forms the core of the unique member number (MHDO_MEMBERID). This field has been encrypted using the same algorithm across all payers. | CHAR | 128 | |
| ME909 |
Double Encrypted Member Identification Code | This field is used to record the member's social security number when available. If the member is the subscriber, this field should contain the same value as the Double Encrypted Social Security Number. If the member is not the subscriber, this field will not equal the Double Encrypted Social Security Number. | CHAR | 128 | |
| ME910 |
Double Encrypted Member ID | The Double Encrypted Member ID is a combination of fields which generally represent a unique individual. For those members with a value in the Encrypted Subscriber Social Security Number, the Double Encrypted MemberID is comprised of Double Encrypted Subscriber Social Security Number + Year and Month of birth + Gender + Individual Relationship Code. If the Double Encrypted Subscriber Social Security Number is blank, the Double Encrypted Memberid is comprised of the Encrypted Plan Specific Contract Number + Year and Month of birth + Gender + Individual Relationship Code. | CHAR | 135 | |
| ME911 |
Standardized Relationship Code | This field contains the member's relationship to the Subscriber or the insured. | INTEGER | 2 | |
| ME912 |
Standardized Insurance Type/Product Code | The insurance type or product code indicates the type of insurance coverage the individual has. | CHAR | 2 | |
| ME913 |
Duplicate Member Flag | This field flags duplicate eligibility records that should not be released. | INTEGER | 1 | |
| ME914 |
Eligibility Year and Month | This field combines YEAR (ME004) and MONTH (ME005) into a single field with a format of YYYYMM. | NUMBER | YYYYMM | 6 |
Medical Providers File Submission - v1.2| Data Element ID | Data Element | Description | Type | Format | Length |
|---|---|---|---|---|---|
| MPM901 |
Data Processing Center Provider Code | This field contains the unique provider identifier that crosses all payers. This field is the link to the Medical Service Providers file (MCSP014). | NUMBER | 12 | |
| MPM902 |
Service Provider Tax ID Number | This field should contain the provider's tax identification number. For an individual this code is often the social security number. This field is derived from MC026 in the medical claims data. | CHAR | 10 | |
| MPM903 |
Service Provider Facility Name | This field contains the first name of the practitioner. If the provider is a facility, this field will be blank. This field is derived from MC030 in the medical claims data and from Medical Service Providers file (MCSP008). | CHAR | 60 | |
| MPM904 |
Service Provider Facility Code | For Maine hospitals, this field contains the tax id of the facility. All Maine hospital tax identification numbers begin with 2000xx. This is the identification number released in the MHDO Outpatient data. The MHDO Inpatient data reports the last two digits. | CHAR | 10 | |
| MPM905 |
Service Provider First Name | This field contains the first name of the practitioner. If the provider is a facility, this field will be blank. This field is derived from MC028 in the medical claims data and from Medical Service Providers file (MCSP006). | CHAR | 25 | |
| MPM906 |
Service Provider Middle Name | This field contains the practitioner's middle name or initial. This field is derived from MC029 in the medical claims data and from Medical Service Providers file (MCSP007). | CHAR | 25 | |
| MPM907 |
Service Provider Last Name | This field contains the full name of provider organization or last name of individual provider. This field is derived from MC030 in the medical claims data and from Medical Service Providers file (MCSP008). | CHAR | 60 | |
| MPM908 |
Service Provider Suffix | This field contains the generational suffix for the individual. This field is derived from MC031 in the medical claims data and from Medical Service Providers file (MCSP009). | CHAR | 10 | |
| MPM909 |
Service Provider Title | Not Provided | CHAR | 10 | |
| MPM910 |
Service Provider State or Province | This is the two character abbreviation for city as defined by the US Postal Service. This field is derived from MC034 in the medical claims data and from Medical Service Providers MCSP012. | CHAR | 2 | |
| MPM911 |
Taxonomy Code | This field is used to standardize the specialty coding of provider records. It is based upon the service provider specialty code (MC032) and the linkage activity. A single DPCID will have only one national TAXONOMY code. | CHAR | 10 | |
| MPM912 |
Unique Physician Identifier | This field contains the UPIN code used by CMS | CHAR | 20 | |
| MPM913 |
National Provider Identifier | Not Provided | CHAR | 20 | |
| MPM914 |
Prescribing Physician | This field contains the prescribing physician's DEA (Drug Enforcement Authority) registration number. This field is derived from PC047. | CHAR | 9 |
Medical Service Providers File Submission - v1.2| Data Element ID | Data Element | Description | Type | Format | Length |
|---|---|---|---|---|---|
| MCSP001 |
Provider ID # | This field is used to link to the Medical Claims data (MC912). It is the primary identification number for each Medical Service Provider record. | CHAR | 12 | |
| MCSP002 |
Payer | This field contains the MHDO submitter code for the payer Submitting payments. The first character of the submitter code indicates the type of submitter. | CHAR | 6 | |
| MCSP003 |
Service Provider Number | This is the provider number assigned by the payer. This Field is derived from MC024 in the medical claims data. | CHAR | 30 | |
| MCSP004 |
Service Provider Tax ID Number | This field should contain the provider's tax identification Number. For an individual this code is often the social security number. This field is derived from MC025 in the medical claims data. | CHAR | 10 | |
| MCSP005 |
Service Provider Entity Type Qualifier | This field is used to distinguish an individual Practitioner from a business entity. This field is derived from MC027 in the medical claims data. | CHAR | 1 | |
| MCSP006 |
Service Provider First Name | This field contains the first name of the practitioner. If the provider is a facility, this field will be blank. This field is derived from MC028 in the medical claims data or from PC044 in the pharmacy claims data. | CHAR | 25 | |
| MCSP007 |
Service Provider Middle Name | This field contains the practitioner's middle name or initial. This field is derived from MC029 in the medical claims data or from PC045 in the pharmacy claims data. | CHAR | 25 | |
| MCSP008 |
Service Provider Last Name or Organization Name | This field contains the full name of provider organization or last name of individual provider. This field is derived from MC030 in the medical claims data or from PC046 in the pharmacy claims data. | CHAR | 60 | |
| MCSP009 |
Service Provider Suffix | This field contains the generational suffix for the individual. This field is derived from MC031 in the medical claims data. | CHAR | 10 | |
| MCSP010 |
Service Provider Specialty | This field contains the specialty code assigned by the payer. Use this field to link to the provider specialty table (SP901). Since specialty codes are not unique across payers, you must also link on Payer. This field is derived from MC032 in the medical claims data. | CHAR | 10 | |
| MCSP011 |
Service Provider City Name | This field contains the city name of provider - preferably practice location. This field is derived from MC033 in the medical claims data. | CHAR | 30 | |
| MCSP012 |
Service Provider State or Province | This is the two character abbreviation for city as defined by the US Postal Service. This field is derived from MC034 in the medical claims data. | CHAR | 2 | |
| MCSP013 |
Service Provider ZIP Code | This field contains the zip code of provider practice location. It may contain non-US codes. This field is derived from MC035 in the medical claims data. | CHAR | 11 | |
| MCSP014 |
Data Processing Center Provider Code | This field contains the unique provider identifier that crosses all payers. This field is the link to the Medical Provider Master file (MPM901). | NUMBER | 12 | |
| MCSP015 |
Taxonomy Code | This field is used to standardize the specialty coding of the provider records. It is based upon the service provider specialty code (MC032) and the linkage activity. A DPCID will have only one national TAXONOMY code. | CHAR | 10 | |
| MCSP016 |
Individual Practitioner Flag | This field is used to determine if the provider name may be released. Eliminated 04/01/2007 upon the release of practitioner identifiable data elements. | NUMBER | 1 | |
| MCSP017 |
Prescribing Physician | This field contains the prescribing physician's DEA (Drug Enforcement Authority) registration number. This field is derived from PC047. | CHAR | 9 | |
| MCSP018 |
National Provider Identifier | This field is reserved for future use. | CHAR | 20 | |
| MCSP019 |
File Individual | Indicates the source of information as coming from the Medical or Pharmacy files. | CHAR | 1 |
Pharmacy Claims File Submission - v1.2| Data Element ID | Data Element | Description | Type | Format | Length |
|---|---|---|---|---|---|
| PC001 |
Payer | This field contains the MHDO submitter code for the payer submitting payments. The first character of the submitter code indicates the type of submitter. This field is primarily used for tracking compliance by Payer. | CHAR | 6 | |
| PC002 |
Plan ID | CMS National Plan ID | CHAR | 30 | |
| PC003 |
Insurance Type/Product Code | The insurance type or product code indicates the type of insurance coverage the individual has. | CHAR | 2 | |
| PC004 |
Payer Claim Control Number | This field contains the claim number used by the payer to internally track the claim. In general the claim number is associated with all service lines of the bill. Therefore, multiple medical records may share the same claim number. | CHAR | 35 | |
| PC005 |
Line Counter | This field contains the line number for this service. | CHAR | 5 | |
| PC006 |
Insured Group Number | The group or policy number is associated with the entity thaThas purchased the insurance. For self insured individuals this relates to the purchaser. For the majority of eligibility and claims data the group relates to the employer. | CHAR | 31 | |
| PC007 |
Encrypted Subscriber Social Security Number | This field contains the Encrypted Social Security Number for the subscriber. If the social security number was not available from the payer this field will be null and the contract field will be populated. This field has been encrypted using the same algorithm across all payers. If this field is populated, it forms the core of the unique member identification code(MEMBERID). | CHAR | 32 | |
| PC008 |
Plan Specific Contract Number | This field contains the payer assigned contract number for The subscriber. If the Encrypted Social Security Number is Null, this field forms the core of the unique member number (MEMBERID). | CHAR | 64 | |
| PC009 |
Member Suffix or Sequence Number | This payer supplied code uniquely identifies the member Within the context of the subscriber Encrypted Social Security Number or the Contract. | CHAR | 20 | |
| PC010 |
Member Identification Code | This field is used to record the member's social security number when available. If the member is the subscriber, this field should contain the same value as the Encrypted Social Security Number. If the member is not the Subscriber, this field will not equal the Encrypted Social Security Number. | CHAR | 30 | |
| PC011 |
Individual Relationship Code | This field contains the member's relationship to the subscriber or the insured. | CHAR | 2 | |
| PC012 |
Member Gender | This field contains the gender of the member. | CHAR | 1 | |
| PC013 |
Member Date of Birth | This field contains the member's data of birth with a format of CCYYMMDD. This field is used to calculate age as of the from date of service. | DATE | CCYYMMDD | 8 |
| PC014 |
Member City Name of Residence | This field contains the member's city of residence and was not required reporting until 2004. | CHAR | 50 | |
| PC015 |
Member State or Province | The Member State or Province contains the 2 character abbreviation code used by the US Postal Service and was not required reporting until 2004. Since this database has been built for Maine residents the code will generally be ME for Maine. | CHAR | 2 | |
| PC016 |
Member ZIP Code | This field contains ZIP Code of the member. Payers are encouraged to provide a full 9 character zip code. | CHAR | 11 | |
| PC017 |
Date Service Approved (AP Date) | This field contains the date the record was approved for Payment with a CCYYMMDD format. This is generally referred to as the Paid Date. | DATE | CCYYMMDD | 8 |
| PC025 |
Claim Status | This field contains the status of the claim as reported by the payer. | NUMBER | 2 | |
| PC026 |
Drug Code | Each drug product listed under Section 510 of the Federal Food, Drug, and Cosmetic Act is assigned a unique 10-digit, 3-segment number. This number, known as the National Drug Code (NDC), identifies the labeler/vendor, product, and trade package size. The first segment, the labeler code, is assigned by the FDA. A labeler is any firm that manufactures, re-packs or distributes a drug product. The second segment, the product code, identifies a specific strength, dosage form, and formulation for a particular firm. The third segment, the package code, identifies package sizes. Both the product and package codes are assigned by the firm. The NDC will be in one of the following configurations: 4-4-2, 5-3-2, or 5-4-1. | CHAR | 11 | |
| PC027 |
Drug Name | This field contains the text name of drug as supplied by the payer. | CHAR | 80 | |
| PC028 |
New Prescription | This field can be used to determine if this is a new prescription. It contains the prescription number. | NUMBER | 2 | |
| PC029 |
Generic Drug Indicator | This field indicates whether the drug is a branded drug or a generic drug. | CHAR | 1 | |
| PC030 |
Dispense as Written Code | This field indicates the instructions given to the pharmacist For filling the prescription. For example, a prescription for a brand name drug that also has a generic equivalent may not have the generic equivalent substituted. In this case, the code is 1 - physician requires the script be filled as written. | NUMBER | 1 | |
| PC031 |
Compound Drug Indicator | This field indicates if this is a compound drug or not. | CHAR | 1 | |
| PC032 |
Date Prescription Filled | This field contains the date the prescription was filled In a CCYYMMDD format. | DATE | CCYYMMDD | 8 |
| PC033 |
Quantity Dispensed | This field contains the total unit dosage in metric units. This field may be negative. | NUMBER | 5 | |
| PC034 |
Days Supply | This field contains the actual days supply for the Prescription based on the metric quantity dispensed. This field may contain a negative value. | NUMBER | 3 | |
| PC035 |
Charge Amount | This field contains the total charges for the service as Reported by the provider. This is a money field Containing dollars and cents with an implied decimal point. This field may contain a negative value. | NUMBER | 10 | |
| PC036 |
Paid Amount | This field includes all health plan payments and excludes all member payments. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. | NUMBER | 10 | |
| PC037 |
Ingredient Cost/List Price | This field contains the cost of the drug that was dispensed as reported by the payer. This is a money field containing Dollars and cents with an implied decimal point. | NUMBER | 10 | |
| PC038 |
Postage Amount Claimed | This field contains the postage amount included in the charges. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. | NUMBER | 10 | |
| PC039 |
Dispensing Fee | This field contains the amount charged for dispensing. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. | NUMBER | 10 | |
| PC040 |
Copay Amount | This field contains the pre-set, fixed dollar amount payable by a member, often on a per visit/service basis. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. | NUMBER | 10 | |
| PC041 |
Coinsurance Amount | This amount is paid by the member and reflects the Percentage a member must pay toward the cost of a covered service. In many health insurance plans the coinsurance a member is responsible for is capped after a certain dollar amount of eligible expenses have been incurred. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. | NUMBER | 10 | |
| PC042 |
Deductible Amount | This is an amount that is required to be paid by a member Before health plan benefits will begin to reimburse for Services. It is usually an annual amount of all health care costs that is not covered by the member's insurance plan. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. | NUMBER | 10 | |
| PC043 |
Record Type | This field indicates the type of record. | CHAR | 2 | |
| PC901 |
Member Age | This field contains the age of the member in years as of the date the prescription was filled. Children under the age of 1 have an age of zero. If no date of birth is available, this field is null. | NUMBER | 3 | |
| PC902 |
Record ID # | This field contains a Data Processing Center assigned record number that is unique across all data types. This field is used for tracking purposes. This is the date the record was extracted by the Data Processing Center for inclusion in the MHDO Data Warehouse. The format is CCYYMMDD. | NUMBER | CCYYMMDD | 12 |
| PC903 |
MHDO Extract Date | This is the date the record was extracted by the Data Processing Center for inclusion in the MHDO Data Warehouse. The format is CCYYMMDD. | DATE | CCYYMMDD | 8 |
| PC904 |
Unique Member ID | The MEMBERID is a combination of fields which generally represent a unique individual. For those members with a value in the Encrypted Subscriber Social Security Number, the Memberid is comprised of Encrypted Subscriber Social Security Number + Year and Month of Birth + Gender + Individual Relationship Code. If the Encrypted Subscriber Social Security Number is blank, the Memberid is comprised of the Plan Specific Contract Number + Year and Month of Birth + Gender + Individual Relationship Code. | CHAR | 71 | |
| PC905 |
Submission ID # | This field contains a unique submission number assigned by the Data Processing Center for tracking purposes. Each payer submission receives a submission number that is unique across all data types. | NUMBER | 12 | |
| PC906 |
Double Encrypted Payer Control Claim Number | This field contains the encrypted version of the Payer Claim Control Number reported in DC004. The claim number used by the payer to internally track the claim. | CHAR | 100 | |
| PC907 |
Double Encrypted Subscriber Social Security Number | This field contains an encryption of the information Originally submitted by the payer in field DC007 - the Encrypted Social Security Number for the subscriber. If the social security number was not available from the payer this field will be null and the CONTRACT field will be populated. This field has been encrypted using the same algorithm across all payers. If this field is populated, it forms the core of the unique member identification code(MHDO_MEMBERID). | CHAR | 64 | |
| PC908 |
Double Encrypted Plan Specific Contract Number | This field contains an encryption of the information originally submitted by the payer in field DC008 - the payer assigned contract number for the subscriber. If the Double Encrypted Subscriber Social Security Number is null, this field forms the core of the unique member number (MHDO_MEMBERID). This field has been encrypted using the same algorithm across all payers. | CHAR | 128 | |
| PC909 |
Double Encrypted Member Social Security Number | The Double Encrypted Member ID is a combination of fields which generally represent a unique individual. For those members with a value in the Double Encrypted Subscriber Social Security Number, the Double Encrypted MemberID is comprised of Double Encrypted Subscriber Social Security Number + Year and Month of Birth + Gender + Individual Relationship Code. If the Double Encrypted Subscriber Social Security Number is blank, the Double Encrypted Memberid is comprised of the Double Encrypted Plan Specific Contract Number + Year and Month of Birth + Gender + Individual Relationship Code. | CHAR | 128 | |
| PC910 |
Double Encrypted Member ID | The Double Encrypted Member ID is a combination of fields which generally represent a unique individual. For those members with a value in the Encrypted Social Security Number, the Double Encrypted Member ID is comprised of Double Encrypted Subscriber Social Security Number + Year and Month of Birth + Gender + Individual Relationship Code. If the Double Encrypted Social Security Number is blank, the Double Encrypted Memberid is comprised of the Double Encrypted Plan Specific Contract Number + Year and Month of Birth + Gender + Indvidual Relationship Code. | CHAR | 135 | |
| PC911 |
Standardized Member Gender | This field contains the standardized gender code originally reported in PC012. | CHAR | 1 | |
| PC912 |
Standardized Insurance Type/Product Code | The insurance type or product code indicates the type of insurance coverage the individual has. | CHAR | 2 | |
| PC913 |
Pharmacy ID # | This is the provider identification number that links to the Pharmacy Name File file using PCSPC001. | INTEGER | 12 | |
| PC914 |
Year Paid | This field is derived from Data Service Approved (PC017) and contains the year of payment (YYYY format). | Number | YYYY | 4 |
| PC915 |
Month Paid | This field is derived from Date Service Approved (PC017) and contains the month of payment (MM format). | Number | MM | 2 |
| PC916 |
Year of Service | This field is derived from the From Date of Service (PC032) and contains the year the service was performed (YYYY format). | Number | YYYY | 4 |
| PC917 |
Month of Service | This field is derived from the From Date of Service (PC032) and contains the month the service was performed (MM) format). | Number | MM | 2 |
| PC918 |
Payment Quarter | This field is derived from Date Service Approved (PC017) and contains the quarter of payment. | Number | 1 | |
| PC919 |
Quarter Service Performed | This field is derived from the From Date of Service (PC032) and contains the quarter of payment. | Number | 1 | |
| PC920 |
Prescribing Physician ID | This is the prescribing physician identification number that links to the Medical Service Provider file using MCSP001. | INTEGER | 12 |
Pharmacy Eligibility File Submission - v1.1| Data Element ID | Data Element | Description | Type | Format | Length |
|---|---|---|---|---|---|
| PE001 |
Payer | This field contains the MHDO submitter code for the payer submitting payments. The first character of the submitter code indicates the type of submitter. This field is primarily used for tracking compliance by payer. | CHAR | 6 | |
| PE002 |
National Plan ID | CMS National Plan ID | CHAR | 30 | |
| PE003 |
Insurance Type/Product Code | This field contains the insurance type or product code that indicates the type of insurance coverage the individual has. | CHAR | 2 | |
| PE004 |
Year | The year during which the member is eligible for services. This field is generally used in conjunction with Month to determine a specific period of eligibility. | NUMBER | 4 | |
| PE005 |
Month | Month indicates the month during which the member is eligible for services. This field is generally used in conjunction with Year to determine a specific period of eligibility. | NUMBER | 2 | |
| PE006 |
Insured Group or Policy Number | The group or policy number is associated with the entity that has purchased the insurance. For self insured individuals this relates to the purchaser. For the majority of eligibility and claims data the group relates to the employer. | CHAR | 31 | |
| PE007 |
Coverage Level Code | This field indicates the type of coverage or type of contract. | CHAR | 3 | |
| PE008 |
Encrypted Subscriber Social Security Number | This field contains the encrypted social security number for the subscriber. If the social security number was not available from the payer this field will be null and the Contract field will be populated. This field has been encrypted using the same algorithm across all payers. If this field is populated, it forms the core of the unique member identification code(Memberid). | CHAR | 32 | |
| PE009 |
Plan Specific Contract Number | This field contains the payer assigned contract number for the subscriber. If the Encrypted Social Security Number is null, this field forms the core of the unique member number (Memberid). | CHAR | 64 | |
| PE010 |
Member Suffix or Sequence Number | This payer supplied code uniquely identifies the member within the context of the subscriber Encrypted Social Security Number or the Contract. | CHAR | 20 | |
| PE011 |
Member Identification Code | This field is used to record the member's social security number when available. If the member is the subscriber, this field should contain the same value as the Encrypted Social Security Number. If the member is not the subscriber, this field will not equal the Encrypted Social Security Number. | CHAR | 64 | |
| PE012 |
Individual Relationship Code | This field contains the member's relationship to the subscriber or the insured. | CHAR | 2 | |
| PE013 |
Member Gender | This field contains the gender of the member. | CHAR | 1 | |
| PE014 |
Member Date of Birth | This field contains the member's data of birth with a Format of CCYYMMDD. This field is used to calculate age as of the first day of the membership month. | DATE | CCYYMMDD | 8 |
| PE015 |
Member City Name | This field contains the member's city of residence and was not required reporting until 2004. | CHAR | 30 | |
| PE016 |
Member State or Province | The Member State or Province contains the 2 character Abbreviation code used by the US Postal Service and was not required reporting until 2004. | CHAR | 2 | |
| PE017 |
Member ZIP Code | This field contains ZIP Code of the member. Payers are encouraged to provide a full 9 character zip code. | CHAR | 11 | |
| PE018 |
Medical Coverage | The medical coverage flag indicates whether this member is covered for medical expenses or not. | CHAR | 1 | |
| PE019 |
Prescription Drug Coverage | The prescription drug coverage flag indicates whether this member is covered for prescription drug expenses or not. | CHAR | 1 | |
| PE020 |
Dental Coverage | The dental coverage flag indicates whether this member is covered for dental expenses or not. | CHAR | 1 | |
| PE021 |
Record Type | This field indicates the type of record. | CHAR | 2 | |
| PE901 |
Member Age | This field contains the age of the member in years as of the last day of the previous eligibility month. Children under the age of 1 have an age of zero. If no date of birth is available, this field is null. | NUMBER | 3 | |
| PE902 |
Record ID # | This field contains a Data Processing Center assigned record number that is unique across all data types. This field is used for tracking purposes. | NUMBER | 12 | |
| PE903 |
MHDO Extract Date | This is the date the record was extracted by the Data Processing Center for inclusion in the MHDO Data Warehouse. The format is CCYYMMDD. | DATE | CCYYMMDD | 8 |
| PE904 |
Unique Member ID | The MEMBERID is a combination of fields which generally represent a unique individual. For those members with a value in the Encrypted Subscriber Social Security Number, the Memberid is comprised of Encrypted Subscriber Social Security Number + Year and Month of Birth + Gender + Individual Relationship Code. If the Encrypted Subscriber Social Security Number is blank, the Memberid is comprised of the Plan Specific Contract Number + Year and Month of Birth + Gender + Individual Relationship Code. | CHAR | 71 | |
| PE905 |
Medicare Coverage | This field is used to flag all Eligibility records associated with supplemental Medicare Coverage. This field is derived from the insurance type/product code field (PE003). Medicare eligibility does not apply to pharmacy data. | CHAR | 1 | |
| PE906 |
Submission ID # | This field contains a unique submission number assigned by the Data Processing Center for tracking purposes. Each payer submission receives a submission number that is unique across all data types. | NUMBER | 12 | |
| PE907 |
Double Encrypted Social Security Number | This field contains an encryption of the information originally submitted by the payer in field DC007 - the Encrypted Social Security Number for the subscriber. If the social security number was not available from the payer this field will be null and the CONTRACT field will be populated. This field has been encrypted using the same algorithm across all payers. If this field is populated, it forms the core of the unique member identification code(MHDO_MEMBERID). | CHAR | 64 | |
| PE908 |
Double Encrypted Contract Number | This field contains an encryption of the information originally submitted by the payer in field DC008 - the payer assigned contract number for the subscriber. If the Encrypted Subscriber Social Security Number is null, this field forms the core of the unique member number (MHDO_MEMBERID). This field has been encrypted using the same algorithm across all payers. | CHAR | 128 | |
| PE909 |
Double Encrypted Member Identification Code | This field is used to record the member's social security number when available. If the member is the subscriber, this field should contain the same value as the Double Encrypted Social Security Number. If the member is not the subscriber, this field will not equal the Double Encrypted Social Security Number. | CHAR | 128 | |
| PE910 |
Double Encrypted Member ID | The Double Encrypted Member ID is a combination of fields which generally represent a unique individual. For those members with a value in the Encrypted Subscriber Social Security Number, the Double Encrypted MemberID is comprised of Double Encrypted Subscriber Social Security Number + Year and Month of birth + Gender + Individual Relationship Code. If the Double Encrypted Subscriber Social Security Number is blank, the Double Encrypted Memberid is comprised of the Encrypted Plan Specific Contract Number + Year and Month of birth + Gender + Individual Relationship Code. | CHAR | 135 | |
| PE911 |
Standardized Relationship Code | This field contains the member's relationship to the Subscriber or the insured. | INTEGER | 2 | |
| PE912 |
Standardized Insurance Type/Product Code | The insurance type or product code indicates the type of insurance coverage the individual has. | CHAR | 2 | |
| PE913 |
Duplicate Member Flag | This field flags duplicate eligibility records that should not be released. | INTEGER | 1 | |
| PE914 |
Eligibility Yearand Month | This field combines YEAR (PE004) and MONTH (PE005) into a single field with a format of YYYYMM. | NUMBER | YYYYMM | 6 |
Pharmacy Provider File Submission - v1.1| Data Element ID | Data Element | Description | Type | Format | Length |
|---|---|---|---|---|---|
| PM901 |
Data Processing Center Code | This field contains the unique pharmacy identifier that crosses all payers. This field is the link to the Pharmacy Detail file (PCSP902). | NUMBER | 12 | |
| PM902 |
Pharmacy Tax ID Number | This field should contain the pharmacy's tax identification number. This field is normalized from PC019 in the medical claims data. | CHAR | 10 | |
| PM903 |
Pharmacy Name | This field contains the name of the pharmacy filling the prescription. This field is derived from normalizingPCSP905 in the Pharmacy Detail file | CHAR | 100 | |
| PM906 |
National Pharmacy ID Number | This field is derived from PC021 in the pharmacy claims data. | CHAR | 20 | |
| PM907 |
Pharmacy City Name | This field contains the city name of the pharmacy. This field is derived from PCSP907 in the Pharmacy Detail file. | CHAR | 30 | |
| PM908 |
Pharmacy State or Province | This is the two character abbreviation for city as defined by the US Postal Service. This field is derived from normalizing PCSP908 in the Pharmacy Detail file. | CHAR | 2 | |
| PM909 | Pharmacy Zip Code | This field contains the zip code of the pharmacy location. It may contain non US codes. This field is derived from normalizing PCSP909 in the Pharmacy Detail file. | VARCHAR | 11 |
Pharmacy Service Providers File Submission - v1.1| Data Element ID | Data Element | Description | Type | Format | Length |
|---|---|---|---|---|---|
| PCSP901 |
Payer | This field contains the MHDO submitter code for the payer submitting payments. The first character of the submitter code indicates the type of submitter. This field is primarily used for tracking compliance by payer. It is derived from PC001 in the pharmacy claims data. | CHAR | 6 | |
| PCSP902 |
Data Processing Center Code | This field contains the unique pharmacy identifier that crosses all payers. This field is the link to the Pharmacy Master file (PM901). | NUMBER | 12 | |
| PCSP903 |
Pharmacy Number | This is the pharmacy number assigned by the payer. This field is derived from PC018 in the pharmacy claims data. | CHAR | 30 | |
| PCSP904 |
Pharmacy Tax ID Number | This field should contain the pharmacy''s tax identification number. This field is derived from PC019 in the pharmacy claims data. | CHAR | 10 | |
| PCSP905 |
Pharmacy Name | This field contains the name of the pharmacy filling the prescription. This field is derived from PC020 in the pharmacy claims data. | CHAR | 100 | |
| PCSP906 |
National Pharmacy ID Number | This field is derived from PC021 in the pharmacy claims data. | CHAR | 20 | |
| PCSP907 |
Pharmacy City Name | This field contains the city name of the pharmacy. This field is derived from PC022 in the pharmacy claims data. | CHAR | 30 | |
| PCSP908 |
Pharmacy State or Province | This is the two character abbreviation for city as defined by the US Postal Service. This field is derived from PC023 in the pharmacy claims data. | CHAR | 2 | |
| PCSP909 |
Pharmacy Zip Code | This field contains the zip code of the pharmacy location. It may contain non US codes. This field is derived from PC024 in the pharmacy claims data. | VARCHAR | 11 | |
| PCSP910 |
Pharmacy ID # | This field is used to link to the pharmacy claims data (PC913). It is the primary identification number for each Pharmacy Detail record. | Number | 12 |
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