Name: | Medical Eligibility File Submission |
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State: | Oregon |
Definition: | Eligibility files capture patient demographic information such as date of birth, gender, geography, and race/ethnicity. These also serve as the starting point for identifying claims and providers to be included in the data submissions. Criteria for inclusion are members living in Oregon, and members enrolled in a plan for which the state is a payer (such as PEBB, OEBB, or OMIP), regardless of residence. |
Version | 2015.0.1 |
Data Element ID | Data Element | Description | Type | Format | Length |
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Payer type | Not Provided | Text | 8 | |
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Product code | Not Provided | Text | 3 | |
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Eligibility date | example: 20100402. Dates before the submission date range are not valid. See Schedule A for submission data range. | Date | CCYYMMDD | 8 |
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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 |
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Subscriber ID | Plan-specific unique identifier for subscriber | Text | 30 | |
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Plan specific contract number | Plan-specific contract number (aka group number) | Text | 30 | |
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PEBB flag | Not Provided | Numeric | 1 | |
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OEBB flag | Not Provided | Numeric | 1 | |
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Medical home flag | Not Provided | Numeric | 1 | |
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Member ID | Plan-specific unique identifier for member | Text | 30 | |
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Relationship code | Not Provided | Numeric | 2 | |
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Member gender | Not Provided | Text | 1 | |
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Member date of birth | example: 19570402)\ | Date | CCYYMMDD | 8 |
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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 | |
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Member city | Example: Grants Pass | Text | 30 | |
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Member state | Example: OR | Text | 4 | |
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Member ZIP | Example: 97209-1234 or 97209 | Text | 10 | |
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Medical coverage flag | Not Provided | Text | 1 | |
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Prescription drug coverage flag | Not Provided | Text | 1 | |
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Subscriber last name | Not Provided | Text | 35 | |
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Subscriber first name | Not Provided | Text | 25 | |
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Subscriber middle name | Not Provided | Text | 25 | |
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Member last name | Not Provided | Text | 35 | |
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Member first name | Not Provided | Text | 25 | |
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Member middle name | Not Provided | Text | 25 | |
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ChemDep Benefit - Inpatient | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
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ChemDep Benefit - Day/Night | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
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ChemDep Benefit - Ambulatory | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
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Dental benefit | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
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Mental Health Benefit - Inpatient | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
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Mental Health Benefit - Day/ Night | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
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Mental Health Benefit - Ambulatory | Required for HEDIS processing for participants in Q- Corp initiative. | Text | 1 | |
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Member race | Not Provided | Text | 1 | |
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Member ethnicity | Not Provided | Text | 1 | |
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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 | |
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Oregon HVMH flag | Required for participants in OHLC high value medical home initiative. | Text | 1 | |
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Oregon HVMH clinic | Required for participants in OHLC high value medical home initiative. | Text | 3 | |
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Oregon HVMH eligibility segment effective date | Required for participants in OHLC high value medical home initiative. example: 20090603 | Date | CCYYMMDD | 8 |
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Oregon HVMH eligibility segment termination date | Required for participants in OHLC high value medical home initiative. example: 20090603) | Date | CCYYMMDD | 8 |
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Prepaid amount/ PMPM | Required for participants in OHLC high value medical home initiative. Two explicit decimal places. Example: 402.73 | Numeric | 12 | |
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OMIP flag | Not Provided | Numeric | 1 | |
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HKC flag | Not Provided | Numeric | 1 | |
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Medicare coverage flag | Type of Medicare coverage. | Text | 2 | |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
Data Element ID | Data Element | Code | Value |
---|---|---|---|
ME001 | Payer type | C | Carrier |
D | Medicaid | ||
G | Other government agency | ||
P | Pharmacy benefits manager | ||
T | Third-party administrator | ||
U | Unlicensed entity | ||
ME003 | Product code | CHP | Special Childrens Health Insurance Program (SCHIP) |
EPO | Commercial EPO | ||
HMO | Commercial HMO | ||
IN | Commercial indemnity | ||
MC | Medicare Cost | ||
MD | Medicaid disabled HMO | ||
MDE | Medicaid dual eligible HMO | ||
MDF | Medicaid fee-for-service | ||
MLI | Medicaid low income HMO | ||
MP | Medicare Advantage PPO | ||
MPD | Medicare Part D only | ||
MR | Medicare Advantage HMO | ||
MRB | Medicaid restricted benefit HMO | ||
PH | Pharmacy benefits only | ||
POS | Commercial POS | ||
PPO | Commercial PPO | ||
SIF | Self insured POS | ||
SIH | Self insured HMO | ||
SIP | Self insured PPO | ||
SL | Commercial stop loss | ||
SN1 | Special needs plan - chronic condition | ||
SN2 | Special needs plan - institutionalized | ||
SN3 | Special needs plan - dual eligible | ||
ZZ | Unknown | ||
ME009A | PEBB flag | 0 | otherwise |
1 | PEBB group | ||
ME009B | OEBB flag | 0 | otherwise |
1 | OEBB group | ||
ME009C | Medical home flag | 0 | otherwise |
1 | medical home plan | ||
ME012 | 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 | ||
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 | ||
36 | Emancipated Minor | ||
39 | Organ Donor | ||
40 | Cadaver Donor | ||
41 | Injured Plaintiff | ||
43 | Child Where Insured Has No Financial Responsibility | ||
53 | Life Partner | ||
ME013 | Member gender | F | female |
M | male | ||
U | unknown | ||
ME018 | Medical coverage flag | N | |
Y | |||
ME019 | Prescription drug coverage flag | N | |
Y | |||
QC013 | ChemDep Benefit - Inpatient | N | |
Y | |||
QC014 | ChemDep Benefit - Day/Night | N | |
Y | |||
QC015 | ChemDep Benefit - Ambulatory | N | |
Y | |||
QC016 | Dental benefit | N | |
Y | |||
QC018 | Mental Health Benefit - Inpatient | N | |
Y | |||
QC019 | Mental Health Benefit - Day/ Night | N | |
Y | |||
QC020 | Mental Health Benefit - Ambulatory | N | |
Y | |||
RE1 | Member race | A | Asian |
B | Black or African American | ||
I | American Indian or Alaska Native | ||
O | Other (or multiple races) | ||
P | Native Hawaiian or Pacific Islander | ||
R | Refused | ||
U | Unknown | ||
W | White | ||
RE2 | Member ethnicity | H | Hispanic |
O | Not Hispanic | ||
R | Refused | ||
U | Unknown | ||
OHLC3 | Oregon HVMH flag | N | |
Y | |||
ME009D | OMIP flag | 0 | otherwise |
1 | OMIP member | ||
ME009E | HKC flag | 0 | otherwise |
1 | Healthy Kids Connect plan | ||
ME201 | Medicare coverage flag | A | Part A |
B | Part B | ||
C | Part C only | ||
CD | Part C and Part D | ||
D | Part D only | ||
X | other | ||
Z | none |