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Medical Eligibility File Submission

Maryland

Versions: February 20, 2013• September 13, 2013• January 9, 2014Compare Versions


Name:Medical Eligibility File Submission
State:Maryland
Definition:Not provided
VersionJanuary 9, 2014

File Specification for Medical Eligibility File Submission

Data Element ID Data Element Description Type Format Length
Multiple versions1 Record Identifier The value is 5 numeric 1
Multiple versions2 Encrypted Enrollee IdentifierP (payor encrypted) Enrollee's unique identification number assigned by payor and encrypted. alphanumeric 12
Multiple versions3 Encrypted Enrollee IdentifierU (UUID encrypted) Enrollee's universally unique identification (UUID) number generated using an encryption algorithm provided by MHCC. alphanumeric 12
Multiple versions4 Enrollee Year and Month of Birth Date of enrollee's birth using 00 instead of day. numeric CCYYMM00 8
Multiple versions5 Enrollee Sex Sex of the enrollee. numeric 1
Multiple versions6 Enrollee Zip Code of Residence +4-digit add-on Zip code of enrollee's residence. numeric 10
Multiple versions7 Enrollee County of Residence County of enrollee's residence. If known, please provide. If not known, MHCC will arbitrarily assign using Zip code of residence. numeric 3
Multiple versions8 Source of Direct Reporting of Enrollee Race Indicate the source of direct reporting of enrollee race. numeric 1
Multiple versions9 Race Category White - Direct Enter whether the self-defined race of the enrollee is White or Caucasian. White is defined as a person having lineage in any of the original peoples of Europe, the Middle East, or North Africa. numeric 1
Multiple versions10 Race Category Black or African American - Direct Enter whether the self-defined race of the enrollee is Black or African American. Black or African American is defined as a person having lineage in any of the Black racial groups of Africa. numeric 1
Multiple versions11 Race Category American Indian or Alaska Native - Direct Enter whether the self-defined race of the enrollee is American Indian or Alaska Native. American Indian or Alaska Native is defined as a person having lineage in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment. numeric 1
Multiple versions12 Race Category Asian - Direct Enter whether the self-defined race of the enrollee is Asian. Asian is defined as a person having lineage in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. numeric 1
Multiple versions13 Race Category Native Hawaiian or Other Pacific Islander - Direct Enter whether the self-defined race of the enrollee is Native Hawaiian or Other Pacific Islander. Native Hawaiian or Other Pacific Islander is defined as a person having lineage in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. numeric 1
Multiple versions14 Race Category Other - Direct Enter whether the self-defined race of the enrollee is Other. numeric 1
Multiple versions15 Race Category Declined to Answer - Direct Enter whether the enrollee declined to disclose their race. numeric 1
Multiple versions16 Race Category Unknown or Cannot Determined - Direct Enter whether the race of the enrollee is unknown or cannot be determined. numeric 1
Multiple versions17 Imputed Race with Highest Probability Race of enrollee. numeric 1
Multiple versions18 Probability of Imputed Race Assignment Specify the probability of race assignment; probability used in race determination. numeric 3
Multiple versions19 Source of Direct Reporting of Enrollee Ethnicity Indicate source of reporting enrollee ethnicity. numeric 1
Multiple versions20 Enrollee OMB Hispanic Ethnicity (Hispanic Indicator) Ethnicity of enrollee. numeric 1
Multiple versions21 Imputed Ethnicity with Highest Probability (Hispanic Indicator) Enter the Ethnicity of the enrollee. numeric 1
Multiple versions22 Probability of Imputed Ethnicity Assignment Specify the probability of ethnicity assignment; probability used in ethnicity determination. numeric 3
Multiple versions23 Enrollee Preferred Spoken Language for a Healthcare Encounter A locally relevant list of languages has been developed by the Commission. numeric 2
Multiple versions24 Coverage Type Enrollee's type of insurance coverage. alphanumeric 1
Multiple versions25 Source Company Defines the payor company that holds the beneficiary's contract; for use in characterizing contract requirements under Maryland law. alphanumeric 1
Multiple versions26 Product Type Classifies the benefit plan by key product characteristics (scope of coverage, size of network, coverage for out-of- network benefits). (Please code based on how the product is primarily marketed, and most importantly be consistent from year to year. If not sure, send an e-mail describing the product to Larry Monroe at larry.monroe@maryland.gov) numeric 1
Multiple versions27 Policy Type Type of policy. numeric 1
Multiple versions28 Encrypted Contract or Group Number (payor encrypted) Payor assigned contract or group number for the plan sponsor using an encryption algorithm generated by the payor. alphanumeric 20
Multiple versions29 Employer Federal Tax ID Number Employer Federal Tax ID number will be encrypted by the database contractor in such a way that an employer will have the same encrypted ID across all payor records and the same employer has the same encrypted number from year to year. alphanumeric 9
Multiple versions30 Medical Services Indicator Medical Coverage numeric 1
Multiple versions31 Pharmacy Services Indicator Prescription Drug Coverage numeric 1
Multiple versions32 Behavioral Health Services Indicator Behavioral Health Services Coverage numeric 1
Multiple versions33 Dental Services Indicator Dental Coverage numeric 1
34 Plan Liability Indicates if insurer is at risk for the patient's service use or the insurer is simply paying claims as an ASO. numeric 1
35 Consumer Directed Health Plan (CDHP) with HSA or HRA Indicator Consumer Directed Health Plan (CDHP) with Health Savings Account (HSA) or Health Resources Account (HRA). numeric 1
36 Start Date of Coverage (in the month) The start date for benefits in the month (for example, if the enrollee was insured at the start of the month of January in 2014, the start date is 20140101) numeric CCYYMMDD 8
37 End Date of Coverage (in the month) The end date for benefits in the month (for example, if the enrollee was insured for the entire month of January in 2014, the end date is 20140131) numeric CCYYMMDD 8
38 Date of FIRST Enrollment The date of that the patient was initially enrolled in the plan. numeric CCYYMMDD 8
39 Date of Disenrollment The end date of enrollment for the patient in this delivery system (in this data submission time period). (see Source Company on page 72) numeric CCYYMMDD 8
40 Coverage Period End Date Contract renewal date, after which benefits, such as deductibles and out of pocket maximums reset. Not Provided CCYYMMDD 8
41 Relationship to Policyholder Member's relationship to subscriber/insured. numeric 1
42 Payor ID Number Payor assigned submission identification number. alphanumeric 4
43 Source System Identify the source system (platforms or business units) from which the data was obtained by using an alphabet letter (A, B, C, D, etc...) (Note: In your documentation on page 15, please be sure to list the source system that corresponds with the letter assigned.) For payors with all data coming from one system only, leave the field blank. alphanumeric 1
44 Grandfathered Plan Indicator Indicate if the plan qualifies as a "Grandfathered or Transitional Plan" under the Affordable Care Act (ACA). numeric 1
45 Plan or Product ID Number Payor ID number associated with an enrollee's coverage and benefits in the claim adjudication system. alphanumeric 20
46 Subscriber ID Number Subscriber ID number associated with individual or family enrollment. alphanumeric 20
47 Health Insurance Oversight System (HIOS) ID Number HIOS ID number supplied by the federal government. alphanumeric 20
48 Master Patient Index Indicates the unique patient identifier assigned by Maryland's Health Information Exchange, Chesapeake Regional Information System for our Patients (CRISP). alphanumeric 40
49 Reporting Quarter Indicate the quarter number for which the data is being submitted. numeric 1

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Data Element ID Data Element Code Value
1 Record Identifier 5 Eligibility
5 Enrollee Sex 1 Male
2 Female
3 Unknown
7 Enrollee County of Residence 001 Allegany
003 Anne Arundel
005 Baltimore County
009 Calvert
011 Caroline
013 Carroll
015 Cecil
017 Charles
019 Dorchester
021 Frederick
023 Garrett
025 Harford
027 Howard
029 Kent
031 Montgomery
033 Prince George's
035 Queen Anne's
037 St. Mary's
039 Somerset
041 Talbot
043 Washington
045 Wicomico
047 Worcester
510 Baltimore City
999 Unknown
8 Source of Direct Reporting of Enrollee Race 1 Enrollee reported to payor
2 Enrollee reported to another source
9 Missing/Unknown/Not specified
9 Race Category White - Direct 0 No
1 Yes
10 Race Category Black or African American - Direct 0 No
1 Yes
11 Race Category American Indian or Alaska Native - Direct 0 No
1 Yes
12 Race Category Asian - Direct 0 No
1 Yes
13 Race Category Native Hawaiian or Other Pacific Islander - Direct 0 No
1 Yes
14 Race Category Other - Direct 0 No
1 Yes
15 Race Category Declined to Answer - Direct 0 No
1 Yes
16 Race Category Unknown or Cannot Determined - Direct 0 No
1 Yes
17 Imputed Race with Highest Probability 1 American Indian or Alaska Native
2 Asian
3 Black or African American
4 Native Hawaiian or Other Pacific Islander
5 White/Caucasian
6 Some Other Race
9 Missing/Unknown/Not specified
19 Source of Direct Reporting of Enrollee Ethnicity 1 Enrollee reported to payor
2 Enrollee reported to another source
9 Missing/Unknown/Not specified
20 Enrollee OMB Hispanic Ethnicity (Hispanic Indicator) 1 Hispanic or Latino or Spanish origin
2 Not Hispanic or Latino or Not of Spanish origin
9 Missing/Unknown/Not specified
21 Imputed Ethnicity with Highest Probability (Hispanic Indicator) 1 Hispanic or Latino or Spanish origin
2 Not Hispanic or Latino or Not of Spanish origin
7 Declined to Answer
9 Missing/Unknown/Not specified
23 Enrollee Preferred Spoken Language for a Healthcare Encounter 01 English
02 Albanian
03 Amharic
04 Arabic
05 Burmese
06 Cantonese
07 Chinese (simplified & traditional)
08 Creole (Haitian)
09 Farsi
10 French (European)
11 Greek
12 Gujarati
13 Hindi
14 Italian
15 Korean
16 Mandarin
17 Portuguese (Brazilian)
18 Russian
19 Serbian
20 Somali
21 Spanish (Latin America)
22 Tagalog (Pilipino)
23 Urdu
24 Vietnamese
98 Other and unspecified languages
99 Unknown
24 Coverage Type 1 Medicare Supplemental (i.e., Individual, Group, WRAP)
2 Medicare Advantage Plan
3 Individual Market (not MHIP; not sold in MHBE)
4 Maryland Health Insurance Plan (MHIP)
5 Private Employer Sponsored or Other Group (i.e. union or association plans)
6 Public Employee - Federal (FEHBP)
7 Public Employee - Other (state, county, local/municipal government and public school systems)
8 Comprehensive Standard Health Benefit Plan (not sold in MHBE) [a self employed individual or small businesses (public or private employers) with 2-50 eligible employees]
9 Health Insurance Partnership (HIP)
A Student Health Plan
B Individual Market (sold in MHBE)
C Small Business Options Program (SHOP) sold in MHBE
Z Unknown
25 Source Company 1 Health Maintenance Organization
2 Life & Health Insurance Company or Not-for-Profit Health Benefit Plan
3 Third-Party Administrator (TPA) Unit
26 Product Type 1 Exclusive Provider Organization (in any form)
2 Health Maintenance Organization
3 Indemnity
4 Point of Service (POS)
5 Preferred Provider Organization (PPO)
6 Limited Benefit Plan (Mini-Meds)
7 Student Health Plan
8 Catastrophic
27 Policy Type 1 Individual
2 Any combination of two or more persons
30 Medical Services Indicator 0 No
1 Yes
31 Pharmacy Services Indicator 0 No
1 Yes
32 Behavioral Health Services Indicator 0 No
1 Yes
33 Dental Services Indicator 0 No
1 Yes
34 Plan Liability 1 Risk (under Maryland contract)
2 Risk (under non-Maryland contract)
3 ASO (employer self-insured)
35 Consumer Directed Health Plan (CDHP) with HSA or HRA Indicator 0 No
1 Yes
41 Relationship to Policyholder 1 Self/employee
2 Spouse
3 Child
4 Other Dependent
5 Other Adult
9 Unknown
44 Grandfathered Plan Indicator 1 Grandfathered
2 Non-Grandfathered
3 Transitional
4 Not Applicable
49 Reporting Quarter 1 First Quarter = January 1 thru March 31
2 Second Quarter = April 1 thru June 30
3 Third Quarter = July 1 thru September 30
4 Fourth Quarter = October 1 thru December 31
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