| Name: | Oregon |
|---|---|
| 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 |
Claims File Control Totals File Submission - 2015.0.1| Data Element ID | Data Element | Description | Type | Format | Length |
|---|---|---|---|---|---|
| CFCT1 |
Payer | Payer abbreviation. | Text | 6 | |
| CFCT2 |
File | Not Provided | Text | 10 | |
| CFCT3 |
Data_Rows | Count of data rows in the submitted file | Numeric | 8 | |
| CFCT4 |
Amt_Billed | Sum of MC062 (medical) or PC035 (pharmacy). Two explicit decimal places. Leave blank if File is enrollment or provider | Numeric | 12 | |
| CFCT5 |
Amt_Paid | Sum of MC063 (medical) or PC036 (pharmacy). Two explicit decimal places. Leave blank if File is enrollment or provider | Numeric | 12 |
Medical Claims File Submission - 2015.0.1| Data Element ID | Data Element | Description | Type | Format | Length |
|---|---|---|---|---|---|
| MC001 |
Payer type | Not Provided | Text | 1 | |
| MC003 |
Product code | Not Provided | Text | 3 | |
| MC004 |
Claim ID | Payer's unique claim identifier | Text | 80 | |
| MC005 |
Service line counter | Increments of 1 for each claim line | Numeric | 4 | |
| MC010 |
Member ID | Plan-specific unique member identifier | Text | 30 | |
| MC017 |
Payment date | example: 20090624) | Date | CCYYMMDD | 8 |
| MC018 |
Admission date | example: 20090603 | Date | CCYYMMDD | 8 |
| MC023 |
Discharge status | Not Provided | Text | 2 | |
| MC024 |
Rendering provider ID | Identifier for the rendering provider as assigned by the reporting entity | Text | 30 | |
| MC036 |
Type of bill | Required only for institutional claims. | Numeric | 3 | |
| MC037 |
Place of service | Required only for professional claims. | Text | 2 | |
| MC038 |
Claim status | Was claim paid, denied, CCO encounter, or MCO encounter only? | Text | 1 | |
| MC038A |
COB status | Was claim a COB claim? | Text | 1 | |
| MC041 |
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 | |
| MC041P |
POA flag 1 | Present on admission flag for principal diagnosis. | Text | 1 | |
| MC042 |
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 | |
| MC042P |
POA flag 2 | Present on admission flag for diagnosis 2. Required if MC042 is populated. | Text | 1 | |
| MC043 |
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 | |
| MC043P |
POA flag 3 | Present on admission flag for diagnosis 3. Required if MC043 is populated. | Text | 1 | |
| MC044 |
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 | |
| MC044P |
POA flag 4 | Present on admission flag for diagnosis 4. Required if MC044 is populated. | Text | 1 | |
| MC045 |
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 | |
| MC045P |
POA flag 5 | Present on admission flag for diagnosis 5. Required if MC045 is populated. | Text | 1 | |
| MC046 |
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 | |
| MC046P |
POA flag 6 | Present on admission flag for diagnosis 6. Required if MC046 is populated. | Text | 1 | |
| MC047 |
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 | |
| MC047P |
POA flag 7 | Present on admission flag for diagnosis 7. Required if MC047 is populated. | Text | 1 | |
| MC048 |
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 | |
| MC048P |
POA flag 8 | Present on admission flag for diagnosis 8. Required if MC048 is populated. | Text | 1 | |
| MC049 |
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 | |
| MC049P |
POA flag 9 | Present on admission flag for diagnosis 9. Required if MC049 is populated. | Text | 1 | |
| MC050 |
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 | |
| MC050P |
POA flag 10 | Present on admission flag for diagnosis 10. Required if MC050 is populated. | Text | 1 | |
| MC051 |
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 | |
| MC051P |
POA flag 11 | Present on admission flag for diagnosis 11 Required if MC051 is populated. | Text | 1 | |
| MC052 |
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 | |
| MC052P |
POA flag 12 | Present on admission flag for diagnosis 12 Required if MC052 is populated. | Text | 1 | |
| MC053 |
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 | |
| MC053P |
POA flag 13 | Present on admission flag for diagnosis 13 Required if MC053 is populated. | Text | 1 | |
| MC054 |
Revenue code | Include all digits (example: 0320) | Text | 4 | |
| MC055 |
CPT/CPT II/HCPCS procedure code | CPT, CPT II or HCPCS code. Include all digits (examples: 29870 or G0289) | Text | 5 | |
| MC056 |
Procedure modifier 1 | CPT or HCPCS modifier. Include all digits (examples: 50 or AA) | Text | 2 | |
| MC057 |
Procedure modifier 2 | CPT or HCPCS modifier. Include all digits (examples: 50 or AA) | Text | 2 | |
| MC057A |
Procedure modifier 3 | CPT or HCPCS modifier. Include all digits (examples: 50 or AA) | Text | 2 | |
| MC057B |
Procedure modifier 4 | CPT or HCPCS modifier. Include all digits (examples: 50 or AA) | Text | 2 | |
| MC058 |
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 | |
| MC058A |
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 | |
| MC058B |
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 | |
| MC058C |
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 | |
| MC058D |
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 | |
| MC058E |
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 | |
| MC058F |
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 | |
| MC058G |
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 | |
| MC058H |
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 | |
| MC058J |
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 | |
| MC058K |
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 | |
| MC058L |
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 | |
| MC058M |
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 | |
| MC059 |
Date of service - From | example: 20090603 | Date | CCYYMMDD | 8 |
| MC060 |
Date of service - Thru | example: 20090603 | Date | CCYYMMDD | 8 |
| MC061 |
Quantity | Count of units sent on claim line. | Numeric | 5 | |
| MC062 |
Charges | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
| MC062A |
Allowed amount | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
| MC063 |
Payment | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
| MC064 |
Prepaid amount | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
| MC065 |
Co-payment | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
| MC066 |
Co-insurance | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
| MC067 |
Deductible | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
| MC067A |
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 | |
| MC070 |
Discharge date | Required only for institutional claims. Use 99991231 if patient has not discharged. (example: 20090605). | Date | CCYYMMDD | 8 |
| MC076 |
Billing provider ID | Identifier for the billing provider as assigned by the reporting entity | Text | 30 | |
| QC05 |
Prior version claim number | Required for participants in Q-Corp initiative. | Text | 80 | |
| QC06 |
Claim received date | Required for participants in Q-Corp initiative. | Date | CCYYMMDD | 8 |
| QC22 |
DRG | DRG paid by payer. If not available send billed DRG. Required for participants in Q-Corp initiative. Example: 061 | Text | 3 | |
| QC23 |
DRG type | Required for participants in Q-Corp initiative. Valid values: C (CMS v.24) or M (MS-DRG) | Text | 1 | |
| QC37 |
LOINC code | Placeholder for the Q-Corp initiative. | Text | 8 | |
| QC38 |
Lab result | Placeholder for the Q-Corp initiative. | Text | 8 | |
| QC39 |
Micro/macro albumin result | Placeholder for the Q-Corp initiative. | Text | 1 | |
| OHLC1 |
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 | |
| OHLC2 |
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 | |
| MC008 |
Plan specific contract number | Plan specific contract number (aka group number) | Text | 30 | |
| MC201 |
ICD version code | Specifies the claim's ICD version. | Text | 2 | |
| MC202 |
Empty field | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| MC203 |
Empty field | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| MC204 |
Empty field | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| MC205 |
Empty field | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| MC206 |
Empty field | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| MC207 |
Empty field | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| MC208 |
Empty field | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| MC209 |
Empty field | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| MC210 |
Empty field | For future implementation | Not Supplied | Not Supplied | Not Supplied |
Medical Eligibility File Submission - 2015.0.1| Data Element ID | Data Element | Description | Type | Format | Length |
|---|---|---|---|---|---|
| ME001 |
Payer type | Not Provided | Text | 8 | |
| ME003 |
Product code | Not Provided | Text | 3 | |
| ME004A |
Eligibility date | example: 20100402. Dates before the submission date range are not valid. See Schedule A for submission data range. | Date | CCYYMMDD | 8 |
| ME005A |
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 |
| ME007 |
Subscriber ID | Plan-specific unique identifier for subscriber | Text | 30 | |
| ME009 |
Plan specific contract number | Plan-specific contract number (aka group number) | Text | 30 | |
| ME009A |
PEBB flag | Not Provided | Numeric | 1 | |
| ME009B |
OEBB flag | Not Provided | Numeric | 1 | |
| ME009C |
Medical home flag | Not Provided | Numeric | 1 | |
| ME010 |
Member ID | Plan-specific unique identifier for member | Text | 30 | |
| ME012 |
Relationship code | Not Provided | Numeric | 2 | |
| ME013 |
Member gender | Not Provided | Text | 1 | |
| ME014 |
Member date of birth | example: 19570402)\ | Date | CCYYMMDD | 8 |
| ME015A |
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 | |
| ME015 |
Member city | Example: Grants Pass | Text | 30 | |
| ME016 |
Member state | Example: OR | Text | 4 | |
| ME017 |
Member ZIP | Example: 97209-1234 or 97209 | Text | 10 | |
| ME018 |
Medical coverage flag | Not Provided | Text | 1 | |
| ME019 |
Prescription drug coverage flag | Not Provided | Text | 1 | |
| ME101 |
Subscriber last name | Not Provided | Text | 35 | |
| ME102 |
Subscriber first name | Not Provided | Text | 25 | |
| ME103 |
Subscriber middle name | Not Provided | Text | 25 | |
| ME104 |
Member last name | Not Provided | Text | 35 | |
| ME105 |
Member first name | Not Provided | Text | 25 | |
| ME106 |
Member middle name | Not Provided | Text | 25 | |
| QC013 |
ChemDep Benefit - Inpatient | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
| QC014 |
ChemDep Benefit - Day/Night | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
| QC015 |
ChemDep Benefit - Ambulatory | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
| QC016 |
Dental benefit | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
| QC018 |
Mental Health Benefit - Inpatient | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
| QC019 |
Mental Health Benefit - Day/ Night | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
| QC020 |
Mental Health Benefit - Ambulatory | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
| RE1 |
Member race | Not Provided | Text | 1 | |
| RE2 |
Member ethnicity | Not Provided | Text | 1 | |
| RE3 |
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 | |
| OHLC3 |
Oregon HVMH flag | Required for participants in OHLC high value medical home initiative. | Text | 1 | |
| OHLC4 |
Oregon HVMH clinic | Required for participants in OHLC high value medical home initiative. | Text | 3 | |
| OHLC5 |
Oregon HVMH eligibility segment effective date | Required for participants in OHLC high value medical home initiative. example: 20090603 | Date | CCYYMMDD | 8 |
| OHLC6 |
Oregon HVMH eligibility segment termination date | Required for participants in OHLC high value medical home initiative. example: 20090603) | Date | CCYYMMDD | 8 |
| OHLC7 |
Prepaid amount/ PMPM | Required for participants in OHLC high value medical home initiative. Two explicit decimal places. Example: 402.73 | Numeric | 12 | |
| ME009D |
OMIP flag | Not Provided | Numeric | 1 | |
| ME009E |
HKC flag | Not Provided | Numeric | 1 | |
| ME201 |
Medicare coverage flag | Type of Medicare coverage. | Text | 2 | |
| ME202 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| ME203 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| ME204 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| ME205 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| ME206 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| ME207 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| ME208 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| ME209 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| ME210 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
Medical Providers File Submission - 2015.0.1| Data Element ID | Data Element | Description | Type | Format | Length |
|---|---|---|---|---|---|
| MP003 |
Provider ID | Identifier for the provider as assigned by the reporting entity | Text | 30 | |
| MP004 |
Provider Tax ID | Tax ID of the provider (example: 1234567890) | Text | 9 | |
| MP006 |
Provider first name | First name of the provider (example: John); null if provider is an organization entity | Text | 25 | |
| MP007 |
Provider middle initial | Middle initial of the provider (example: M); null if provider is an organization entity | Text | 1 | |
| MP008 |
Provider last name | Last name of the provider or organization entity name | Text | 100 | |
| MP010 |
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 | |
| MP010A |
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 | |
| MP010B |
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 | |
| MP011A |
Provider street address1 | First line of physical address of practice. Example: 123 Main Street | Text | 50 | |
| MP011B |
Provider street address2 | Required if available. Second line of physical address of practice. Example: Bldg A, Suite 100 | Text | 50 | |
| MP011 |
Provider city | Physical address of practice. Example: Grants Pass | Text | 30 | |
| MP012 |
Provider state | Physical address of practice. Example: OR | Text | 2 | |
| MP013 |
Provider ZIP | Physical address of practice. Examples: 97209-1234 or 97209 | Text | 10 | |
| MP017 |
Provider DEA number | Required if available. | Text | 12 | |
| MP018 |
Provider NPI | NPI of the provider (example: 1234567890) | Text | 10 | |
| MP018A |
Provider state license number | Prefix with two-character state of licensure. Example: ORLL12345 | Text | 15 | |
| QC004 |
Provider Medicaid number | Required (if available) for participants in Q-Corp initiative. | Text | 12 | |
| QC006 |
Provider CMS UPIN | Required (if available) for participants in Q-Corp initiative. | Text | 12 | |
| QC011 |
Provider DOB | Required for participants in Q-Corp initiative. | Date | 8 | |
| QC021 |
Provider is PCP | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
| QC022 |
Provider is OBGYN | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
| QC023 |
Provider is Mental Health | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
| QC024 |
Provider is Eye Care Provider | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
| QC025 |
Provider is Dentist | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
| QC026 |
Provider is Nephrologist | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
| QC027 |
Provider is Chem. Dep | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
| QC028 |
Provider is Nurse Practitioner | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
| QC029 |
Provider is Phys Assist | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
| QC030 |
Provider can prescribe Rx | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
| MP201 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| MP202 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| MP203 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| MP204 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| MP205 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| MP206 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| MP207 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| MP208 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| MP209 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| MP210 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
Member Months Control Totals File Submission - 2015.0.1| Data Element ID | Data Element | Description | Type | Format | Length |
|---|---|---|---|---|---|
| MMCT1 |
Payer | Payer abbreviation. | Text | 6 | |
| MMCT2 |
Method | Placeholder for future compatibility | Text | 1 | |
| MMCT3 |
Month | Not Provided | Date | CCYYMM | 6 |
| MMCT4 |
Medical_Members | Count of members with medical coverage as of first of month. | Numeric | 8 | |
| MMCT5 |
Pharmacy_Members | Count of members with pharmacy coverage as of first of month | Numeric | 8 |
Pharmacy Claims File Submission - 2015.0.1| Data Element ID | Data Element | Description | Type | Format | Length |
|---|---|---|---|---|---|
| PC001 |
Payer type | Not Provided | Text | 1 | |
| PC008 |
Plan-specific contract number | Plan-specific contract number (aka group number) | Text | 30 | |
| PC010 |
Patient ID | Unique identifier for member | Text | 20 | |
| PC003 |
Insurance type/ product code | Not Provided | Text | 6 | |
| PC021 |
Pharmacy NPI | The pharmacy's National Provider Identifier (NPI) | Text | 15 | |
| PC021A |
Pharmacy alternate identifier | The pharmacy's alternate identifier as assigned by the payer; required if NPI is not available | Text | 15 | |
| PC020 |
Pharmacy Name | Not Provided | Text | 35 | |
| PC022 |
Pharmacy city | Not Provided | Text | 30 | |
| PC023 |
Pharmacy state | Not Provided | Text | 2 | |
| PC024 |
Pharmacy ZIP | Not Provided | Text | 15 | |
| PC048 |
Prescribing provider NPI | Identifier for the provider who prescribed the medication as assigned by the reporting entity | Text | 15 | |
| PC047 |
Prescribing provider DEA number | Required if available. DEA number of the provider who prescribed the medication. | Text | 12 | |
| PC025 |
Claim status | Was claim paid, denied, CCO, or encounter only? | Text | 3 | |
| PC026 |
NDC | National Drug Code (NDC) | Text | 11 | |
| PC032 |
Date filled | Date the prescription was filled. example: 20090624 | Text | CCYYMMDD | 8 |
| PC017 |
Payment date | example: 20090624 | Date | CCYYMMDD | 8 |
| PC033 |
Quantity dispensed | Not Provided | Numeric | 10 | |
| PC028A |
Alternate refill number | Required if PC028 (calculated refill number) is not available | Numeric | 2 | |
| PC034 |
Days supply | Days supply of the prescription | Numeric | 3 | |
| PC030 |
Dispense as written code | Not Provided | Text | 1 | |
| PC028 |
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 | |
| PC031 |
Compound drug indicator | Indicates if this is a compound drug. | Numeric | 1 | |
| PC004 |
Claim ID | Payer's unique claim control number | Text | 30 | |
| PC036 |
Payment | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
| PC035 |
Charges | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
| PC037 |
Ingredient cost/list price | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
| PC039 |
Dispensing fee paid | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
| PC040 |
Co-pay | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
| PC041 |
Coinsurance | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
| PC042 |
Deductible | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
| PC043 |
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 | |
| PC201 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| PC202 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| PC203 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| PC204 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| PC205 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| PC206 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| PC207 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| PC208 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| PC209 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
| PC210 |
Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
Agency for Healthcare Research and Quality • 5600 Fishers Lane, Rockville, MD 20857 • Telephone: (301) 427-1364
