Name: | Medical Eligibility File Submission |
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State: | Colorado |
Definition: | Not Provided |
Version | March 2014 - v6 |
Data Element ID | Data Element | Description | Type | Format | Length |
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Record Type | Not Provided | char | 2 | |
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Payer Code | Distributed by CIVHC | varchar | 8 | |
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Payer Name | Distributed by CIVHC | varchar | 75 | |
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Beginning Month | Not Provided | date | CCYYMM | 6 |
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Ending Month | Not Provided | date | CCYYMM | 6 |
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Record count | Total number of records submitted in the medical eligibility file, excluding header and trailer records | int | 10 | |
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Payer Code | Distributed by CIVHC | varchar | 8 | |
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Payer Name | Distributed by CIVHC | varchar | 30 | |
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Insurance Type Code/Product | changes: Required field; codes added to Lookup Table. | char | 2 | |
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Year | 4 digit Year for which eligibility is reported in this submission | int | 4 | |
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Month | Month for which eligibility is reported in this submission expressed numerical from 01 to 12. | char | 2 | |
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Insured Group or Policy Number | Group or policy number - not the number that uniquely identifies the subscriber | varchar | 30 | |
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Coverage Level Code | Benefit coverage level | char | 3 | |
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Subscriber Social Security Number | Subscriber's social security number; Set as null if unavailable | varchar | 9 | |
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Plan Specific Contract Number | Plan assigned subscriber's contract number; Set as null if contract number = subscriber's social security number or use an alternate unique identifier such as Medicaid ID. Must be an identifier that is unique to the subscriber. | varchar | 128 | |
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Member Suffix or Sequence Number | Unique number of the member within the contract. Must be an identifier that is unique to the member. This column is the unique identifying column for membership and related medical and pharmacy claims. Only one record per eligibility month. | varchar | 128 | |
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Member Identification Code | Member's social security number; Set as null if contract number = subscriber's social security number or use an alternate unique identifier such as Medicaid ID. Must be an identifier that is unique to the member. | varchar | 9 | |
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Individual Relationship Code | Member's relationship to insured | char | 2 | |
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Member Gender | Not Provided | char | 1 | |
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Member Date of Birth | Not Provided | char | YYYYMMDD | 8 |
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Member City Name | City location of member | varchar | 30 | |
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Member State or Province | As defined by the US Postal Service | char | 2 | |
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Member ZIP Code | ZIP Code of member - may include non-US codes. Do not include dash. Plus 4 optional but desired. | varchar | 11 | |
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Medical Coverage | Not Provided | char | 1 | |
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Prescription Drug Coverage | Not Provided | char | 1 | |
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Dental Coverage | Not Provided | char | 1 | |
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Race 1 | Not Provided | varchar | 6 | |
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Race 2 | Not Provided | varchar | 6 | |
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Other Race | List race if MC021or MC022 are coded as R9. | varchar | 15 | |
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Hispanic Indicator | Not Provided | char | 1 | |
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Ethnicity 1 | Not Provided | varchar | 6 | |
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Ethnicity 2 | Not Provided | varchar | 6 | |
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Other Ethnicity | List ethnicity if MC025 or MC026 are coded as OTHER. | varchar | 20 | |
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Primary Insurance Indicator | Not Provided | char | 1 | |
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Coverage Type | Insurers using this code shall obtain prior approval. | char | 3 | |
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Market Category Code | Not Provided | varchar | 4 | |
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Employer Tax ID | Employer tax ID | varchar | 50 | |
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Member Street Address | Street address of member | varchar | 50 | |
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Employer Group Name | Employer Group Name or IND for individual Policies | varchar | 128 | |
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Subscriber Last Name | The subscriber last name | varchar | 128 | |
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Subscriber First Name | The subscriber first name | varchar | 128 | |
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Subscriber Middle Initial | The subscriber middle initial | char | 1 | |
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Member Last Name | The member last name | varchar | 128 | |
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Member First Name | The member first name | varchar | 128 | |
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Plan Effective Date | Date eligibility started for this member under this plan type. The purpose of this data element is to maintain eligibility span for each member. | char | YYYYMMDD | 8 |
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Exchange Offering | Identifies whether or not a policy was purchased through the Colorado Health Benefits Exchange (COBHE). | char | 1 | |
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Group Size | Code indicating Group Size consistent with Colorado Insurance Law and Regulation Required only for plans sold in the commercial large, small and non-group markets. The following plan/products do not need to report this value: Student plans Medicare supplemental Medicaid-funded plans Stand-alone behavioral health, dental and vision | char | 2 | |
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Risk Basis | Default to "F" for grandfathered Plans | char | 1 | |
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High Deductible/ Health Savings Account Plan | Default to "N" for grandfathered Plans | char | 1 | |
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Actuarial Value | Report value as calculated in the most recent version of the HHS Actuarial Value Calculator available at http://cciio.cms.gov/resources/regulations/index.html Size includes decimal point. Required as of January 1, 2014 for small group and non-group (individual) plans sold inside or outside the Exchange. Default to "0" for Grandfathered plans | decimal | 6 | |
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Metallic Value | Metal Level (percentage of Actuarial Value) per federal regulations... Required as of January 1, 2014 for small group and non-group (individual) plans sold inside or outside the Exchange. Use values provided in the most recent version of the HHS Actuarial Value Calculator available at : http://cciio.cms.gov/resources/regulations/index.html Default to "0" for Grandfathered plans | int | 1 | |
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Grandfather Status | See definition of "grandfathered plans" in HHS rules CFR 147.140 Required as of January 1, 2014 for small group and non-group (individual) plans sold inside or outside the Exchange. Default to "0" for Grandfathered plans | Char | 1 | |
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Record Type | Not Provided | char | 2 | |
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Record Type | Not Provided | char | 2 | |
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Payer Code | Distributed by CIVHC | varchar | 8 | |
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Payer Name | Distributed by CIVHC | varchar | 75 | |
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Beginning Month | Not Provided | date | CCYYMM | 6 |
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Ending Month | Not Provided | date | CCYYMM | 6 |
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Extraction Date | Not Provided | date | YYYYMMDD | 8 |
Data Element ID | Data Element | Code | Value |
---|---|---|---|
HD001 | Record Type | ME | |
ME003 | Insurance Type Code/Product | 12 | Preferred Provider Organization (PPO) |
13 | Point of Service (POS) | ||
15 | Indemnity Insurance | ||
16 | Health Maintenance Organization (HMO) Medicare Advantage | ||
17 | Dental Maintenance Organization (DMO) | ||
99 | Other | ||
CI | Commercial Insurance Company | ||
DN | Dental | ||
HM | Health Maintenance Organization | ||
HN | HMO Medicare Risk/ Medicare Part C | ||
MA | Medicare Part A | ||
MB | Medicare Part B | ||
MC | Medicaid | ||
MD | Medicare Part D | ||
MP | Medicare Primary | ||
QM | Qualified Medicare Beneficiary | ||
SP | Supplemental Policy | ||
SP | Medicare Supplemental (Medi-gap) plan | ||
TV | Title V | ||
ME007 | Coverage Level Code | CHD | Children Only |
DEP | Dependents Only | ||
ECH | Employee and Children | ||
ELF | Employee and Life Partner | ||
EMP | Employee Only | ||
EPN | Employee plus N where N equals the number of other covered dependents | ||
ESP | Employee and Spouse | ||
FAM | Family | ||
IND | Individual | ||
SPC | Spouse and Children | ||
SPO | Spouse Only | ||
ME012 | Individual Relationship Code | 01 | Spouse |
04 | Grandfather or Grandmother | ||
05 | Grandson or Granddaughter | ||
07 | Nephew or Niece | ||
10 | Foster Child | ||
15 | Ward | ||
17 | Stepson or Stepdaughter | ||
19 | Child | ||
20 | Employee/Self | ||
21 | Unknown | ||
22 | Handicapped Dependent | ||
23 | Sponsored Dependent | ||
24 | Dependent of a Minor Dependent | ||
29 | Significant Other | ||
32 | Mother | ||
33 | Father | ||
36 | Emancipated Minor | ||
39 | Organ Donor | ||
40 | Cadaver Donor | ||
41 | Injured Plaintiff | ||
43 | Child Where Insured Has No Financial Responsibility | ||
53 | Life Partner | ||
76 | Dependent | ||
ME013 | Member Gender | F | Female |
M | Male | ||
U | UNKNOWN | ||
ME018 | Medical Coverage | 3 | UNKNOWN |
N | NO | ||
Y | YES | ||
ME019 | Prescription Drug Coverage | 3 | UNKNOWN |
N | NO | ||
Y | YES | ||
ME020 | Dental Coverage | 3 | UNKNOWN |
N | NO | ||
Y | YES | ||
ME021 | Race 1 | R1 | American Indian/Alaska Native |
R2 | Asian | ||
R3 | Black/African American | ||
R4 | Native Hawaiian or other Pacific Islander | ||
R5 | White | ||
R9 | Other Race | ||
UNKNOW | Unknown/Not Specified | ||
ME022 | Race 2 | R1 | American Indian/Alaska Native |
R2 | Asian | ||
R3 | Black/African American | ||
R4 | Native Hawaiian or other Pacific Islander | ||
R5 | White | ||
R9 | Other Race | ||
UNKNOW | Unknown/Not Specified | ||
ME024 | Hispanic Indicator | N | Patient is not Hispanic/Latino/Spanish |
U | Unknown | ||
Y | Patient is Hispanic/Latino/Spanish | ||
ME025 | Ethnicity 1 | 2028-9 | Asian |
2029-7 | Asian Indian | ||
2033-9 | Cambodian | ||
2034-7 | Chinese | ||
2036-2 | Filipino | ||
2039-6 | Japanese | ||
2040-4 | Korean | ||
2041-2 | Laotian | ||
2047-9 | Vietnamese | ||
2058-6 | African American | ||
2060-2 | African | ||
2071-9 | Haitian | ||
2108-9 | European | ||
2118-8 | Middle Eastern | ||
2148-5 | Mexican, Mexican American, Chicano | ||
2155-0 | Central American (not otherwise specified) | ||
2157-6 | Guatemalan | ||
2158-4 | Honduran | ||
2161-8 | Salvadoran | ||
2165-9 | South American (not otherwise specified) | ||
2169-1 | Columbian | ||
2180-8 | Puerto Rican | ||
2182-4 | Cuban | ||
2184-0 | Dominican | ||
AMERCN | American | ||
BRAZIL | Brazilian | ||
CARIBI | Caribbean Island | ||
CVERDN | Cape Verdean | ||
EASTEU | Eastern European | ||
OTHER | Other Ethnicity | ||
PORTUG | Portuguese | ||
RUSSIA | Russian | ||
UNKNOW | Unknown/Not Specified | ||
ME026 | Ethnicity 2 | 2028-9 | Asian |
2029-7 | Asian Indian | ||
2033-9 | Cambodian | ||
2034-7 | Chinese | ||
2036-2 | Filipino | ||
2039-6 | Japanese | ||
2040-4 | Korean | ||
2041-2 | Laotian | ||
2047-9 | Vietnamese | ||
2058-6 | African American | ||
2060-2 | African | ||
2071-9 | Haitian | ||
2108-9 | European | ||
2118-8 | Middle Eastern | ||
2148-5 | Mexican, Mexican American, Chicano | ||
2155-0 | Central American (not otherwise specified) | ||
2157-6 | Guatemalan | ||
2158-4 | Honduran | ||
2161-8 | Salvadoran | ||
2165-9 | South American (not otherwise specified) | ||
2169-1 | Columbian | ||
2180-8 | Puerto Rican | ||
2182-4 | Cuban | ||
2184-0 | Dominican | ||
AMERCN | American | ||
BRAZIL | Brazilian | ||
CARIBI | Caribbean Island | ||
CVERDN | Cape Verdean | ||
EASTEU | Eastern European | ||
OTHER | Other Ethnicity | ||
PORTUG | Portuguese | ||
RUSSIA | Russian | ||
UNKNOW | Unknown/Not Specified | ||
ME028 | Primary Insurance Indicator | N | No, secondary or tertiary insurance |
Y | Yes, primary insurance | ||
ME029 | Coverage Type | OTH | any other plan. Insurers using this code shall obtain prior approval. |
STN | short-term, non-renewable health insurance (ie COBRA) | ||
UND | plans underwritten by the insurer | ||
ME030 | Market Category Code | FCH | policies sold and issued directly to individuals on a franchise basis |
GS3 | policies sold and issued directly to employers having 50 or more employees | ||
GSA | policies sold and issued directly to small employers through a qualified association trust | ||
IND | policies sold and issued directly to individuals (non-group) | ||
MED | Medicare and Retiree products. | ||
OTH | policies sold to other types of entities. Insurers using this market code shall obtain prior approval. | ||
SMG | Policies sold and issued to employers having less than 50 employees | ||
ME045 | Exchange Offering | N | Commercial small or non-group QHP purchased outside the Exchange |
U | Not applicable (plan/product is not offered in the commercial small or non-group market or grandfathered ) | ||
Y | Commercial small or non-group QHP purchased through the Exchange | ||
ME106 | Group Size | A | 1 |
B | 2 to 50 | ||
C | 51 - 100 | ||
D | 100+ | ||
ME107 | Risk Basis | F | Fully insured |
S | Self-insured | ||
ME108 | High Deductible/ Health Savings Account Plan | N | Plan is not High Deductible/HSA eligible |
Y | Plan is High Deductible/HSA eligible | ||
ME121 | Metallic Value | 0 | Not Applicable |
1 | Platinum | ||
2 | Gold | ||
3 | Silver | ||
4 | Bronze | ||
ME122 | Grandfather Status | N | No |
Y | Yes | ||
ME899 | Record Type | ME | |
TR001 | Record Type | ME |