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Member File Submission

Tennessee



Name:Member File Submission
State:Tennessee
Definition:Not Provided
VersionJanuary 31, 2014 - v1.0

File Specification for Member File Submission

Data Element ID Data Element Description Type Format Length
AGE Age This field contains the member's age. Note that: Children under the age of 1 are reported using a value of 0. If no date of birth is available, this value will be -1. Numeric 3
COVERAGE_LEVEL Coverage Level This field indicates the level of coverage. Its source is the Coverage Level Code element reported by the payer in the member eligibility data. Text 3
COVERAGE_TYPE Coverage Type This field indicates the type of coverage and is used to distinguish self-funded plans from commercially insured plans. Its source is the Coverage Type element reported by the payer in the member eligibility data. Text 3
COVG_EFF_DATE Coverage Effective Date Not Available Date 8
COVG_TERM_DATE Coverage Termination Date Not Available Date 8
GENDER Standardized Member Gender This field indicates the member's gender. Its source is the Member Gender element reported by the payer in the pharmacy claims data and medical claims data. Text 1
GROUP_NAME Insured Group Name This field contains the name of the group that covers the member as reported by the payer. If the member is part of a group of one or part of a non-group policy (i.e., when the Market Category Code (MARKET_CATEGORY) is coded as IND, FCH, GCV, or GS1), this field will be null (or display the value BLANK). Its source is the Group Name element in the member eligibility data. Text 128
INS_GROUP Insured Group or Policy Number This payer-supplied field contains the Insured Group or Policy Number associated with the entity that has purchased the insurance. If submitting an individual policy, use IND. For self-insured individuals, this relates to the purchaser. For the majority of eligibility and claims data, the group relates to the employer. The group number does not uniquely identify the subscriber. Text 30
MARKET_CATEGORY Market Category Code This field indicates the type of policy sold by the insurer. Its source is the Market Category Code element reported by the payer in the member eligibility data. Text 4
MEDICAL_COV_FLAG Medical Coverage Flag The medical coverage flag indicates whether this member is covered for medical expenses. Text 1
MEMBER_CITY Member City Name The city of residence for the person, for the most recent month of eligibility. Text 30
MEMBER_COUNTY Member County The county description for the residence of the person. Text 30
MEMBER_STATE Member State The state abbreviation for the residence of the person, for the most recent month of eligibility. Text 2
MEMBERIDN Member ID Number This field generally represents a unique combination of member fields unique to the payer. This field should not be used to aggregate all records associated with a member. Numeric 15
PAT_ZIPCODE Member Zip Code This payer-supplied field contains the member's ZIP code. Text 9
PAYER_NAME Payer Name Not Available Text 12
PAYER PAYER This field contains the Payer ID Number. This code is used to identify the data reporter. Its source is the Payer element reported by the payer in the pharmacy claims data and Payer element reported by the payer in the medical claims data. Text 8
PHARMACY_COV_FLAG Prescription Drug Coverage Flag This field indicates whether or not the member has prescription drug coverage. Text 1
PLAN_CODE Plan Code Not Available Text 8
PLAN_NPI National Plan ID This payer-supplied field contains the National Plan ID for the data reporter. This field is not populated. Char 30
PRIMARY_INS Primary Insurance Indicator This field indicates if the member has primary coverage or secondary/tertiary coverage. Text 1
PRODUCT Standardized Product Code or Insurance Type This field contains the code identifying the member's type of insurance or insurance product. Char 6
REL Individual Relationship to Subscriber This field contains the code indicating the member's relationship to the subscriber or the insured. Text 2
SPECIAL_COVERAGE Special Coverage This field indicates special coverage. Text 3
FILLER FILLER This field is reserved for additional fields that may be added in the future. Char 500

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Data Element ID Data Element Code Value
COVERAGE_LEVEL Coverage Level 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
COVERAGE_TYPE Coverage Type ASO self-funded plans that are administered by a third party administrator, where the employer has not purchased stop-loss, or group excess insurance coverage
ASW self-funded plans that are administered by a third party administrator, where the employer has purchased stop-loss, or group excess insurance coverage
OTH any other plan
STN short-term non-renewable health insurance
UND plans underwritten by the carrier
GENDER Standardized Member Gender F Female
M Male
U Unkown
MARKET_CATEGORY Market Category Code FCH For policies sold and issued directly to individuals on a franchise basis as defined pursuant to T.C.A. § 56-26-101(3)
GCV For policies sold and issued directly to individuals as group conversion policies as required pursuant to T.C.A. § 56-7-2312
GLG1 For policies sold and issued directly to employers having between 51 and 99 employees
GLG2 For policies sold and issued directly to employers having 100 or more employees
GS1 For policies sold and issued directly to employers having exactly one employee
GS2 For policies sold and issued directly to employers having between two and nine employees
GS3 For policies sold and issued directly to employers having between 10 and 25 employees
GS4 For policies sold and issued directly to employers having between 26 and 50 employees
GSA For policies sold and issued directly to small employers through a qualified association trust
IND For policies sold and issued directly to individuals, other than those sold on a franchise basis, as defined pursuant to T.C.A. § 56-26-101(3), or as group conversion policies as defined pursuant to T.C.A. § 56-7-2312
OTH For policies sold to other types of entities
MEDICAL_COV_FLAG Medical Coverage Flag N No
Y Yes
PRODUCT Standardized Product Code or Insurance Type 12 Medicare Secondary Working Aged Beneficiary or Spouse with an Employer's 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 Workers Compensation
16 Medicare Secondary Public Health Service or Other Federal Agency
41 Medicare Secondary Black Lung
42 Medicare Secondary Veterans Administration
43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health
47 Medicare Secondary, Other Liability Insurance is Primary
ACA Affordable Care Act
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 / Medicare Part C
HS Special Low Income Medicare Beneficiary
IN Indemnity
MA Medicare Part A
MB Medicare Part B
MCTNCR Tennessee Medicaid (TennCare)
MD Medicare Part D
MH Medigap Part A
MI Medigap Part B
MP Medicare Primary
PR Preferred Provider Organization (PPO)
PS Point of Service (POS)
QM Qualified Medicare Beneficiary
SP Supplemental Policy
WC Worker's Compensation
XXTNAC AccessTN
XXTNCV CoverTN
XXTNKD CoverKids
REL Individual Relationship to Subscriber 1 Spouse
4 Grandfather or Grandmother
5 Grandson or Granddaughter
7 Nephew or Niece
10 Foster Child
15 Ward
17 Stepson or Stepdaughter
18 Self
19 Child
20 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
SPECIAL_COVERAGE Special Coverage 0 Not applicable
41 yes, member is enrolled in a TennCare plan
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