| Name: | Pharmacy Eligibility File Submission |
|---|---|
| State: | Maine |
| Definition: | Not Provided |
| Version | 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 |
| Data Element ID | Data Element | Code | Value |
|---|---|---|---|
| PE001 | Payer | C | Commercial carrier |
| T | Third Party Administrator | ||
| U | Unlicensed entity | ||
| PE003 | Insurance Type/Product Code | 12 | Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan |
| 13 | Medicare Secondary End-Stage Renal Disease Beneficiary in the 12 month coordination period with an employer's group health plan | ||
| 14 | Medicare Secondary, No-fault insurance including Auto is primary | ||
| 15 | Medicare Secondary Worker's Compensation | ||
| 16 | Medicare Secondary Public Health Service or Other Federal Agency | ||
| 41 | Medicare Secondary Black Lung | ||
| 42 | Medicare Secondary Veteran's Administration | ||
| 43 | Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP) | ||
| 47 | Medicare Secondary, Other Liability Insurance is Primary | ||
| AP | Auto Insurance Policy | ||
| CP | Medicare Conditionally Primary | ||
| D | Disability | ||
| DB | Disability Benefits | ||
| EP | Exclusive Provider Organization | ||
| HM | Health Maintenance Organization (HMO) | ||
| HN | Health Maintenance Organization (HMO) Medicare Risk | ||
| HS | Special Low Income Medicare Beneficiary | ||
| IN | Indemnity | ||
| LC | Long Term Care | ||
| LD | Long Term Policy | ||
| LI | Life Insurance | ||
| LT | Litigation | ||
| MA | Medicare Part A | ||
| MB | Medicare Part B | ||
| MC | Medicaid | ||
| MH | Medigap Part A | ||
| MI | Medigap Part B | ||
| MP | Medicare Primary | ||
| PE007 | Coverage Level Code | CHD | Children Only |
| DEP | Dependents Only | ||
| ECH | Employee and Children | ||
| EMP | Employee Only | ||
| ESP | Employee and Spouse | ||
| FAM | Family | ||
| IND | Individual | ||
| SPC | Spouse and Children | ||
| SPO | Spouse Only | ||
| PE012 | Individual Relationship Code | 01 | Spouse |
| 18 | Self/Employee | ||
| 19 | Child | ||
| 21 | Unknown | ||
| 34 | Other Adult | ||
| PE013 | Member Gender | F | Female |
| M | Male | ||
| U | Unknown | ||
| PE018 | Medical Coverage | N | No |
| Y | Yes | ||
| PE019 | Prescription Drug Coverage | N | No |
| Y | Yes | ||
| PE020 | Dental Coverage | N | No |
| Y | Yes | ||
| PE021 | Record Type | PE | Pharmacy Eligibility |
| PE905 | Medicare Coverage | N | No supplemental Medicare Coverage |
| Y | Yes supplemental Medicare Coverage | ||
| PE911 | Standardized Relationship Code | 1 | Spouse |
| 4 | Grandfather or Grandmother | ||
| 5 | Grandson or Granddaughter | ||
| 7 | Nephew or Niece | ||
| 10 | Foster Child | ||
| 15 | Ward | ||
| 17 | Stepson or Stepdaughter | ||
| 19 | Child | ||
| 20 | Self/Employee | ||
| 21 | Unknown | ||
| 22 | Handicapped Dependent | ||
| 23 | Sponsored Dependent | ||
| 24 | Dependent of a Minor Dependent | ||
| 29 | Significant Other | ||
| 32 | Mother | ||
| 33 | Father | ||
| 34 | Other Adult | ||
| 36 | Emancipated Minor | ||
| 39 | Organ Donor | ||
| 40 | Cadaver Donor | ||
| 41 | Injured Plaintiff | ||
| 43 | Child Where Insured Has No Financial Responsibility | ||
| 53 | Life Partner | ||
| 76 | Dependent | ||
| PE912 | Standardized Insurance Type/Product Code | 11 | Other non Federal program |
| 12 | Medicare secondary working aged beneficiary or spouse with employer group health plan | ||
| 13 | Medicare secondary end-stage renal disease beneficiary in the 12 month coordination period with an employer's group health plan | ||
| 14 | Medicare secondary, no-fault insurance including auto is primary | ||
| 15 | Medicare secondary worker's compensation | ||
| 15 | Medicare secondary public health service (PHS) or other federal agency | ||
| 41 | Medicare secondary black lung | ||
| 42 | Medicare secondary veteran's administration | ||
| 43 | Medicare secondary disabled beneficiary under age 65 with large group health plan (LGHP) | ||
| 47 | Medicare secondary, other liability insurance is primary | ||
| AM | Auto insurance policy | ||
| CP | Medicare conditionally primary | ||
| DB | Disability benefits | ||
| DS | Disability | ||
| EP | Exclusive Provider Organization (EPO) | ||
| HM | Health Maintenance Organization (HMO) | ||
| HN | Health Maintenance Organization (HMO) Medicare risk | ||
| HS | Special low income Medicare beneficiary | ||
| IN | Indemnity Insurance | ||
| LC | Long term care | ||
| LD | Long term policy | ||
| LI | Life insurance | ||
| LM | Liability medical | ||
| LT | Litigation | ||
| MA | Medicare part A | ||
| MB | Medicare part B | ||
| MC | Medicaid | ||
| MH | Medigap part A | ||
| MI | Medigap part B | ||
| MP | Medicare primary | ||
| OF | Other federal program (e.g. black lung) | ||
| OT | Other | ||
| PE | Property Insurance - Personal | ||
| PR | Preferred Provider Organization (PPO) | ||
| PS | Point of Service (POS) | ||
| QM | Qualified Medicare beneficiary | ||
| SP | Supplemental policy | ||
| TV | Title V | ||
| VA | Veteran administration plan | ||
| WC | Workers' compensation | ||
| PE913 | Duplicate Member Flag | 1 | Same member, same month, same payer |
| 2 | Same member, same month, administrative relationship between payers |
Agency for Healthcare Research and Quality • 5600 Fishers Lane, Rockville, MD 20857 • Telephone: (301) 427-1364
