Name: | Oregon |
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Abbreviation: | OR |
Title of System | Oregon All Payer All Claims Database |
Website | http://www.oregon.gov/OHA/OHPR/RSCH/APAC.shtml |
Who Maintains the System | Office for Oregon Health Policy and Research |
Versions: | September 27, 2011 - v2011.1.1 June 25, 2012 - v2013.0.0 June 27, 2013 - v2014.0.0 2015.0.1 |
Data Element ID | Data Element | Description | Type | Format | Length |
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Payer | Payer abbreviation. | Text | 6 | |
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File | Not Provided | Text | 10 | |
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Data_Rows | Count of data rows in the submitted file | Numeric | 8 | |
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Amt_Billed | Sum of MC062 (medical) or PC035 (pharmacy). Two explicit decimal places. Leave blank if File is enrollment or provider | Numeric | 12 | |
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Amt_Paid | Sum of MC063 (medical) or PC036 (pharmacy). Two explicit decimal places. Leave blank if File is enrollment or provider | Numeric | 12 |
Data Element ID | Data Element | Description | Type | Format | Length |
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Payer type | Not Provided | Text | 1 | |
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Product code | Not Provided | Text | 3 | |
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Claim ID | Payer's unique claim identifier | Text | 80 | |
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Service line counter | Increments of 1 for each claim line | Numeric | 4 | |
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Member ID | Plan-specific unique member identifier | Text | 30 | |
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Payment date | example: 20090624) | Date | CCYYMMDD | 8 |
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Admission date | example: 20090603 | Date | CCYYMMDD | 8 |
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Discharge status | Not Provided | Text | 2 | |
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Rendering provider ID | Identifier for the rendering provider as assigned by the reporting entity | Text | 30 | |
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Type of bill | Required only for institutional claims. | Numeric | 3 | |
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Place of service | Required only for professional claims. | Text | 2 | |
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Claim status | Was claim paid, denied, CCO encounter, or MCO encounter only? | Text | 1 | |
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COB status | Was claim a COB claim? | Text | 1 | |
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Principal diagnosis | ICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 01220) | Text | 7 | |
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POA flag 1 | Present on admission flag for principal diagnosis. | Text | 1 | |
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Diagnosis 2 | ICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 01220) | Text | 7 | |
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POA flag 2 | Present on admission flag for diagnosis 2. Required if MC042 is populated. | Text | 1 | |
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Diagnosis 3 | ICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 01220) | Text | 7 | |
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POA flag 3 | Present on admission flag for diagnosis 3. Required if MC043 is populated. | Text | 1 | |
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Diagnosis 4 | ICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 01220) | Text | 7 | |
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POA flag 4 | Present on admission flag for diagnosis 4. Required if MC044 is populated. | Text | 1 | |
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Diagnosis 5 | ICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 01220) | Text | 7 | |
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POA flag 5 | Present on admission flag for diagnosis 5. Required if MC045 is populated. | Text | 1 | |
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Diagnosis 6 | ICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 01220) | Text | 7 | |
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POA flag 6 | Present on admission flag for diagnosis 6. Required if MC046 is populated. | Text | 1 | |
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Diagnosis 7 | ICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 01220) | Text | 7 | |
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POA flag 7 | Present on admission flag for diagnosis 7. Required if MC047 is populated. | Text | 1 | |
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Diagnosis 8 | ICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 01220) | Text | 7 | |
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POA flag 8 | Present on admission flag for diagnosis 8. Required if MC048 is populated. | Text | 1 | |
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Diagnosis 9 | ICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 01220) | Text | 7 | |
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POA flag 9 | Present on admission flag for diagnosis 9. Required if MC049 is populated. | Text | 1 | |
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Diagnosis 10 | ICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 01220) | Text | 7 | |
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POA flag 10 | Present on admission flag for diagnosis 10. Required if MC050 is populated. | Text | 1 | |
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Diagnosis 11 | ICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 01220) | Text | 7 | |
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POA flag 11 | Present on admission flag for diagnosis 11 Required if MC051 is populated. | Text | 1 | |
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Diagnosis 12 | ICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 01220) | Text | 7 | |
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POA flag 12 | Present on admission flag for diagnosis 12 Required if MC052 is populated. | Text | 1 | |
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Diagnosis 13 | ICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 01220) | Text | 7 | |
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POA flag 13 | Present on admission flag for diagnosis 13 Required if MC053 is populated. | Text | 1 | |
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Revenue code | Include all digits (example: 0320) | Text | 4 | |
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CPT/CPT II/HCPCS procedure code | CPT, CPT II or HCPCS code. Include all digits (examples: 29870 or G0289) | Text | 5 | |
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Procedure modifier 1 | CPT or HCPCS modifier. Include all digits (examples: 50 or AA) | Text | 2 | |
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Procedure modifier 2 | CPT or HCPCS modifier. Include all digits (examples: 50 or AA) | Text | 2 | |
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Procedure modifier 3 | CPT or HCPCS modifier. Include all digits (examples: 50 or AA) | Text | 2 | |
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Procedure modifier 4 | CPT or HCPCS modifier. Include all digits (examples: 50 or AA) | Text | 2 | |
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Principal inpatient procedure code | ICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 0085) | Text | 7 | |
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Inpatient procedure code 2 | ICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 0085) | Text | 7 | |
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Inpatient procedure code 3 | ICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 0085) | Text | 7 | |
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Inpatient procedure code 4 | ICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 0085) | Text | 7 | |
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Inpatient procedure code 5 | ICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 0085) | Text | 7 | |
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Inpatient procedure code 6 | ICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 0085) | Text | 7 | |
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Inpatient procedure code 7 | ICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 0085) | Text | 7 | |
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Inpatient procedure code 8 | ICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 0085) | Text | 7 | |
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Inpatient procedure code 9 | ICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 0085) | Text | 7 | |
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Inpatient procedure code 10 | ICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 0085) | Text | 7 | |
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Inpatient procedure code 11 | ICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 0085) | Text | 7 | |
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Inpatient procedure code 12 | ICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 0085) | Text | 7 | |
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Inpatient procedure code 13 | ICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 0085) | Text | 7 | |
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Date of service - From | example: 20090603 | Date | CCYYMMDD | 8 |
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Date of service - Thru | example: 20090603 | Date | CCYYMMDD | 8 |
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Quantity | Count of units sent on claim line. | Numeric | 5 | |
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Charges | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Allowed amount | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Payment | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Prepaid amount | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Co-payment | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Co-insurance | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Deductible | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Patient pay amount | Required if any of MC065, MC066, or MC067 are missing. Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Discharge date | Required only for institutional claims. Use 99991231 if patient has not discharged. (example: 20090605). | Date | CCYYMMDD | 8 |
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Billing provider ID | Identifier for the billing provider as assigned by the reporting entity | Text | 30 | |
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Prior version claim number | Required for participants in Q-Corp initiative. | Text | 80 | |
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Claim received date | Required for participants in Q-Corp initiative. | Date | CCYYMMDD | 8 |
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DRG | DRG paid by payer. If not available send billed DRG. Required for participants in Q-Corp initiative. Example: 061 | Text | 3 | |
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DRG type | Required for participants in Q-Corp initiative. Valid values: C (CMS v.24) or M (MS-DRG) | Text | 1 | |
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LOINC code | Placeholder for the Q-Corp initiative. | Text | 8 | |
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Lab result | Placeholder for the Q-Corp initiative. | Text | 8 | |
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Micro/macro albumin result | Placeholder for the Q-Corp initiative. | Text | 1 | |
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COB allowed amount | Required for participants in OHLC high value medical home initiative. Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Risk withhold amount | Required for participants in OHLC high value medical home initiative. Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Plan specific contract number | Plan specific contract number (aka group number) | Text | 30 | |
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ICD version code | Specifies the claim's ICD version. | Text | 2 | |
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Empty field | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Empty field | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Empty field | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Empty field | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Empty field | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Empty field | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Empty field | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Empty field | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Empty field | For future implementation | Not Supplied | Not Supplied | Not Supplied |
Data Element ID | Data Element | Description | Type | Format | Length |
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Payer type | Not Provided | Text | 8 | |
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Product code | Not Provided | Text | 3 | |
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Eligibility date | example: 20100402. Dates before the submission date range are not valid. See Schedule A for submission data range. | Date | CCYYMMDD | 8 |
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Termination date | example: 20100702. Use 99991231 if termination date is open-ended. Dates over one year past submission due date are not valid (exception: the date of a dependent's 26th birthday is a valid value). | Date | CCYYMMDD | 8 |
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Subscriber ID | Plan-specific unique identifier for subscriber | Text | 30 | |
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Plan specific contract number | Plan-specific contract number (aka group number) | Text | 30 | |
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PEBB flag | Not Provided | Numeric | 1 | |
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OEBB flag | Not Provided | Numeric | 1 | |
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Medical home flag | Not Provided | Numeric | 1 | |
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Member ID | Plan-specific unique identifier for member | Text | 30 | |
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Relationship code | Not Provided | Numeric | 2 | |
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Member gender | Not Provided | Text | 1 | |
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Member date of birth | example: 19570402)\ | Date | CCYYMMDD | 8 |
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Member's street address | Member's primary street address. If member's address is missing then default to subscriber's address. Example: 123 Main Street | Text | 50 | |
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Member city | Example: Grants Pass | Text | 30 | |
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Member state | Example: OR | Text | 4 | |
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Member ZIP | Example: 97209-1234 or 97209 | Text | 10 | |
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Medical coverage flag | Not Provided | Text | 1 | |
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Prescription drug coverage flag | Not Provided | Text | 1 | |
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Subscriber last name | Not Provided | Text | 35 | |
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Subscriber first name | Not Provided | Text | 25 | |
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Subscriber middle name | Not Provided | Text | 25 | |
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Member last name | Not Provided | Text | 35 | |
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Member first name | Not Provided | Text | 25 | |
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Member middle name | Not Provided | Text | 25 | |
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ChemDep Benefit - Inpatient | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
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ChemDep Benefit - Day/Night | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
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ChemDep Benefit - Ambulatory | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
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Dental benefit | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
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Mental Health Benefit - Inpatient | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
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Mental Health Benefit - Day/ Night | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
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Mental Health Benefit - Ambulatory | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
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Member race | Not Provided | Text | 1 | |
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Member ethnicity | Not Provided | Text | 1 | |
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Primary spoken language | This field contains the ANSI/NISO three-character string identifying the member's primary spoken language. Please refer to most recent version of ANSI/NISO Z39.53 (Codes for the Representation of Languages for Information Interchange); the 2001 version is freely available here: http://www.niso.org/topics/ccm/ccmstandards/ | Text | 3 | |
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Oregon HVMH flag | Required for participants in OHLC high value medical home initiative. | Text | 1 | |
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Oregon HVMH clinic | Required for participants in OHLC high value medical home initiative. | Text | 3 | |
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Oregon HVMH eligibility segment effective date | Required for participants in OHLC high value medical home initiative. example: 20090603 | Date | CCYYMMDD | 8 |
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Oregon HVMH eligibility segment termination date | Required for participants in OHLC high value medical home initiative. example: 20090603) | Date | CCYYMMDD | 8 |
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Prepaid amount/ PMPM | Required for participants in OHLC high value medical home initiative. Two explicit decimal places. Example: 402.73 | Numeric | 12 | |
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OMIP flag | Not Provided | Numeric | 1 | |
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HKC flag | Not Provided | Numeric | 1 | |
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Medicare coverage flag | Type of Medicare coverage. | Text | 2 | |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
Data Element ID | Data Element | Description | Type | Format | Length |
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Provider ID | Identifier for the provider as assigned by the reporting entity | Text | 30 | |
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Provider Tax ID | Tax ID of the provider (example: 1234567890) | Text | 9 | |
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Provider first name | First name of the provider (example: John); null if provider is an organization entity | Text | 25 | |
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Provider middle initial | Middle initial of the provider (example: M); null if provider is an organization entity | Text | 1 | |
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Provider last name | Last name of the provider or organization entity name | Text | 100 | |
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Provider specialty | Report the HIPAA-compliant health care provider taxonomy code. The reference code set is extensive and is published semi-annually; version 12.0 (updated effective April 1, 2012) is freely available at the National Uniform Claims Committee's web site: http://www.nucc.org/. To access the taxonomy files, point to the Code Sets menu, then point to the Taxonomy menu, and then click on either PDF (if you want a PDF file) or CSV (if you want a comma-delimited text file). | Text | 10 | |
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Provider second specialty | Required if available. Report the HIPAA-compliant health care provider taxonomy code. The reference code set is extensive and is published semi-annually; version 12.0 (updated effective April 1, 2012) is freely available at the National Uniform Claims Committee's web site: http://www.nucc.org/. To access the taxonomy files, point to the Code Sets menu, then point to the Taxonomy menu, and then click on either PDF (if you want a PDF file) or CSV (if you want a comma-delimited text file). | Text | 10 | |
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Provider third specialty | Required if available. Report the HIPAA-compliant health care provider taxonomy code. The reference code set is extensive and is published semi-annually; version 12.0 (updated effective April 1, 2012) is freely available at the National Uniform Claims Committee's web site: http://www.nucc.org/. To access the taxonomy files, point to the Code Sets menu, then point to the Taxonomy menu, and then click on either PDF (if you want a PDF file) or CSV (if you want a comma-delimited text file). | Text | 10 | |
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Provider street address1 | First line of physical address of practice. Example: 123 Main Street | Text | 50 | |
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Provider street address2 | Required if available. Second line of physical address of practice. Example: Bldg A, Suite 100 | Text | 50 | |
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Provider city | Physical address of practice. Example: Grants Pass | Text | 30 | |
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Provider state | Physical address of practice. Example: OR | Text | 2 | |
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Provider ZIP | Physical address of practice. Examples: 97209-1234 or 97209 | Text | 10 | |
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Provider DEA number | Required if available. | Text | 12 | |
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Provider NPI | NPI of the provider (example: 1234567890) | Text | 10 | |
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Provider state license number | Prefix with two-character state of licensure. Example: ORLL12345 | Text | 15 | |
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Provider Medicaid number | Required (if available) for participants in Q-Corp initiative. | Text | 12 | |
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Provider CMS UPIN | Required (if available) for participants in Q-Corp initiative. | Text | 12 | |
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Provider DOB | Required for participants in Q-Corp initiative. | Date | 8 | |
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Provider is PCP | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
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Provider is OBGYN | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
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Provider is Mental Health | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
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Provider is Eye Care Provider | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
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Provider is Dentist | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
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Provider is Nephrologist | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
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Provider is Chem. Dep | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
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Provider is Nurse Practitioner | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
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Provider is Phys Assist | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
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Provider can prescribe Rx | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
Data Element ID | Data Element | Description | Type | Format | Length |
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Payer | Payer abbreviation. | Text | 6 | |
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Method | Placeholder for future compatibility | Text | 1 | |
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Month | Not Provided | Date | CCYYMM | 6 |
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Medical_Members | Count of members with medical coverage as of first of month. | Numeric | 8 | |
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Pharmacy_Members | Count of members with pharmacy coverage as of first of month | Numeric | 8 |
Data Element ID | Data Element | Description | Type | Format | Length |
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Payer type | Not Provided | Text | 1 | |
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Plan-specific contract number | Plan-specific contract number (aka group number) | Text | 30 | |
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Patient ID | Unique identifier for member | Text | 20 | |
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Insurance type/ product code | Not Provided | Text | 6 | |
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Pharmacy NPI | The pharmacy's National Provider Identifier (NPI) | Text | 15 | |
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Pharmacy alternate identifier | The pharmacy's alternate identifier as assigned by the payer; required if NPI is not available | Text | 15 | |
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Pharmacy Name | Not Provided | Text | 35 | |
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Pharmacy city | Not Provided | Text | 30 | |
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Pharmacy state | Not Provided | Text | 2 | |
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Pharmacy ZIP | Not Provided | Text | 15 | |
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Prescribing provider NPI | Identifier for the provider who prescribed the medication as assigned by the reporting entity | Text | 15 | |
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Prescribing provider DEA number | Required if available. DEA number of the provider who prescribed the medication. | Text | 12 | |
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Claim status | Was claim paid, denied, CCO, or encounter only? | Text | 3 | |
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NDC | National Drug Code (NDC) | Text | 11 | |
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Date filled | Date the prescription was filled. example: 20090624 | Text | CCYYMMDD | 8 |
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Payment date | example: 20090624 | Date | CCYYMMDD | 8 |
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Quantity dispensed | Not Provided | Numeric | 10 | |
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Alternate refill number | Required if PC028 (calculated refill number) is not available | Numeric | 2 | |
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Days supply | Days supply of the prescription | Numeric | 3 | |
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Dispense as written code | Not Provided | Text | 1 | |
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Calculated refill number | Processor's calculated refill number. If the processor is not able to calculate, the alternate refill number (PC028A) is to be used. | Numeric | 2 | |
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Compound drug indicator | Indicates if this is a compound drug. | Numeric | 1 | |
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Claim ID | Payer's unique claim control number | Text | 30 | |
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Payment | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Charges | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Ingredient cost/list price | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Dispensing fee paid | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Co-pay | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Coinsurance | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Deductible | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Patient pay amount | Required if any of PC040, PC041, or PC042 are missing. Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |