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Member Eligibility File Submission

Massachusetts

Versions: December 1, 2010 - v2.1 • June 7, 2013 - v3.1• October 1, 2014 - v4.0Compare Versions


Name:Member Eligibility File Submission
State:Massachusetts
Definition:A file that includes data about a person who receives health care coverage from a payer, including but not limited to subscriber and member identifiers; member demographics; race, ethnicity and language information; plan type; benefit codes; enrollment start and end dates; and behavioral and mental health, substance abuse and chemical dependency and prescription drug benefit indicators.
VersionOctober 1, 2014 - v4.0

File Specification for Member Eligibility File Submission

Data Element ID Data Element Description Type Format Length
Multiple versionsHD001 Record Type Header Record Identifier Text char[2] 2
Multiple versionsHD002 Submitter Header Submitter / Carrier ID defined by CHIA Integer varchar[6] 6
Multiple versionsHD003 National Plan ID Header CMS National Plan Identification Number (PlanID) Integer int[10] 10
Multiple versionsHD004 Type of File Defines the file type and data expected. Text char[2] 2
Multiple versionsHD005 Period Beginning Date Header Period Start Date Date Period - Integer int[6] CCYYMM 6
Multiple versionsHD006 Period Ending Date Header Period Ending Date Date Period - Integer int[6] CCYYMM 6
Multiple versionsHD007 Record Count Header Record Count Integer varchar[10] 10
Multiple versionsHD008 Comments Header Carrier Comments Text varchar[80] 80
Multiple versionsHD009 APCD Version Number Submission Guide Version Decimal - Numeric char[3] 3
Multiple versionsME001 Submitter CHIA defined and maintained unique identifier Integer varchar[6] 6
Multiple versionsME002 National Plan ID CMS National Plan Identification Number (PlanID) Integer int[10] 10
Multiple versionsME003 Insurance Type Code/Product Type / Product Identification Code Lookup Table - Text char[2] 2
Multiple versionsME004 Year Eligibility year reported in this submission. Date Period - Integer int[4] CCYY 4
Multiple versionsME005 Month Reporting Month of Eligibility Date Period - Numeric char[2] MM 2
Multiple versionsME006 Insured Group or Policy Number Group / Policy Number Text varchar[30] 30
Multiple versionsME007 Coverage Level Code Benefit Coverage Level Code Lookup Table - Text char[3] 3
Multiple versionsME008 Subscriber SSN Subscriber's Social Security Number Numeric char[9] 9
Multiple versionsME009 Plan Specific Contract Number Contract Number Text varchar[30] 30
Multiple versionsME010 Member Suffix or Sequence Number Member's Contract Sequence Number Text varchar[20] 20
Multiple versionsME011 Member SSN Member's Social Security Number Numeric char[9] 9
Multiple versionsME012 Individual Relationship Code Member to Subscriber Relationship Code Lookup Table - Numeric varchar[2] 2
Multiple versionsME013 Member Gender Member's Gender Lookup Table - Text char[1] 1
Multiple versionsME014 Member Date of Birth Member's date of birth Full Date - Integer int[8] CCYYMMDD 8
Multiple versionsME015 Member City Name City name of the Member Text varchar[30] 30
Multiple versionsME016 Member State State / Province of the Member External Code Source 2 - Text char[2] 2
Multiple versionsME017 Member ZIP Code Zip Code of the Member External Code Source 2 - Text varchar[9] 9
Multiple versionsME018 Medical Coverage Indicator - Medical Option Lookup Table - Integer int[1] 1
Multiple versionsME019 Prescription Drug Coverage Indicator - Pharmacy Option Lookup Table - Integer int[1] 1
Multiple versionsME020 Dental Coverage Indicator - Dental Option Lookup Table - Integer int[1] 1
Multiple versionsME021 Race 1 Member's self-disclosed Primary Race Lookup Table - Text varchar[6] 6
Multiple versionsME022 Race 2 Member's self-disclosed Secondary Race Lookup Table - Text varchar[6] 6
Multiple versionsME023 Filler Filler Text varchar[15] 15
Multiple versionsME024 Hispanic Indicator Indicator - Hispanic Status Lookup Table - Integer int[1] 1
Multiple versionsME025 Ethnicity 1 Member's Primary Ethnicity Lookup Table - OR - External Code Source 17 - Text char[6] 6
Multiple versionsME026 Ethnicity 2 Member's Secondary Ethnicity Lookup Table - OR - External Code Source 17 - Text char[6] 6
Multiple versionsME027 Other Ethnicity Member's Other Ethnicity Text varchar[20] 20
Multiple versionsME028 Primary Insurance Indicator Indicator - Primary Insurance Coverage Lookup Table - Integer int[1] 1
Multiple versionsME029 Coverage Type Type of Coverage Code Lookup Table - Text char[3] 3
Multiple versionsME030 Market Category Code Market Category Code Lookup Table - Text varchar[4] 4
Multiple versionsME031 Special Coverage Special Coverage Code Lookup Table - Text varchar[3] 3
Multiple versionsME032 Group Name Group name Text varchar[50] 50
Multiple versionsME033 Member language preference Member's self-disclosed verbal language preference External Code Source 7 - Integer int[3] 3
Multiple versionsME034 Member language preference -Other Member's Other Language Preference Text varchar[20] 20
Multiple versionsME035 Health Care Home (PCMH) Assigned Flag Health Care Home Assigned indicator Lookup Table - Integer int[1] 1
Multiple versionsME036 Health Care Home (PCMH) Number Health Care Home ID Text varchar[30] 30
Multiple versionsME037 Health Care Home (PCMH) Tax ID Number Health Care Home EIN Numeric char[9] 9
Multiple versionsME038 National Provider ID - Health Care Home (PCMH) National Provider Identification (NPI) of the Health Care Home Provider External Code Source 3 - Integer int[10] 10
Multiple versionsME039 Health Care Home Name (PCMH) Name of Health Care Home Text varchar[60] 60
Multiple versionsME040 Product ID Number Product Identification Text varchar[30] 30
Multiple versionsME041 Product Enrollment Start Date Member Enrollment Date Full Date - Integer int[8] CCYYMMDD 8
Multiple versionsME042 Product Enrollment End Date Enrollment Date Full Date - Integer int[8] CCYYMMDD 8
Multiple versionsME043 Member Street Address Street address of the Member Text varchar[50] 50
Multiple versionsME044 Member Street Address 2 Secondary Street Address of the Member Text varchar[50] 50
Multiple versionsME045 Purchased through Massachusetts Exchange Flag Indicator - MA Exchange Purchase Lookup Table - Integer int[1] 1
Multiple versionsME046 Member PCP ID Member's PCP ID Text varchar[30] 30
Multiple versionsME047 Member PCP Effective Date PCP Effective Date with Member Full Date - Integer int[8] CCYYMMDD 8
Multiple versionsME048 Member PCP Termination Date PCP Termination Date with Member Full Date - Integer int[8] CCYYMMDD 8
Multiple versionsME049 Member Deductible Annual maximum out of pocket Member Deductible across all benefit types Integer varchar[10] 10
Multiple versionsME050 Member Deductible Used Member deductible amount incurred Integer varchar[10] 10
Multiple versionsME051 Behavioral Health Benefit Flag Indicator - Behavioral Health Option Lookup Table - Integer int[1] 1
Multiple versionsME052 Laboratory Benefit Flag Indicator - Laboratory Option Lookup Table - Integer int[1] 1
Multiple versionsME053 Disease Management Enrollee Flag Chronic Illness Management indicator Lookup Table - Integer int[1] 1
Multiple versionsME054 Eligibility Determination Date Eligibility date Full Date - Integer int[8] CCYYMMDD 8
Multiple versionsME055 Business Type Code Business Type Lookup Table - Integer int[1] 1
Multiple versionsME056 Last Activity Date Activity Date Full Date - Integer int[8] CCYYMMDD 8
Multiple versionsME057 Date of Death Member's Date of Death Full Date - Integer int[8] CCYYMMDD 8
Multiple versionsME058 Subscriber Street Address Street address of the Subscriber Text varchar[50] 50
Multiple versionsME059 Disability Indicator Flag Indicator - Disability Status Lookup Table - Integer int[1] 1
Multiple versionsME060 Employment Status Employment Status Code Lookup Table - Text char[1] 1
Multiple versionsME061 Student Status Indicator - Student Status Lookup Table - Integer int[1] 1
Multiple versionsME062 Marital Status Marital Status Code Lookup Table - Text char[1] 1
Multiple versionsME063 Benefit Status Benefit Status Code Lookup Table - Text char[1] 1
Multiple versionsME064 Employee Type Employee Type Code Lookup Table - Text char[1] 1
Multiple versionsME065 Date of Retirement Member's date of Retirement Full Date - Integer int[8] CCYYMMDD 8
Multiple versionsME066 COBRA Status COBRA usage indicator Lookup Table - Integer int[1] 1
Multiple versionsME067 Spouse Plan Type Spouse Plan Type Code Carrier Defined Table - Text char[2] 2
Multiple versionsME068 Spouse Plan Spouse Plan Medicare Code Carrier Defined Table - Text char[2] 2
Multiple versionsME069 Spouse Medical Coverage Spouse Medical Medicare Coverage Code Carrier Defined Table - Text char[2] 2
Multiple versionsME070 Spouse Medicare Indicator Spouse Medicare Selected Code Carrier Defined Table - Text char[2] 2
Multiple versionsME071 Pool Indicator Pool Indicator Code Lookup Table - Integer int[1] 1
Multiple versionsME072 Family Size Family Size Contracted Integer varchar[2] 2
Multiple versionsME073 Fully Insured member Fully Insured identifier Lookup Table - Integer int[1] 1
Multiple versionsME074 Interpreter Indicator - Interpreter Need Lookup Table - Integer int[1] 1
Multiple versionsME075 NewMMIS ID MassHealth-assigned Member ID Text char[12] 12
Multiple versionsME076 Member rating category Member Rating Category Code Carrier Defined Table - Text char[5] 5
Multiple versionsME077 Members NAICS Code Member Standard NAICS or SIC Code External Code Source 6 - Numeric varchar[6] 6
Multiple versionsME078 Employer Zip Code (Situs) Zip code of the Employer External Code Source 2 - Text char[5] 5
Multiple versionsME079 Recipient Identification Number (MassHealth only) MassHealth-assigned Member ID Text varchar[15] 15
Multiple versionsME080 Recipient Historical Number (MassHealth only) MassHealth-assigned Member ID Text varchar[15] 15
Multiple versionsME081 Medicare Code Medicare Plan Indicator Code Lookup Table - Integer int[1] 1
Multiple versionsME082 Employer Name Member's Employer Name Text varchar[60] 60
Multiple versionsME083 Employer EIN Member's Employer EIN Numeric char[9] 9
Multiple versionsME101 Subscriber Last Name Last name of Subscriber Text varchar[60] 60
Multiple versionsME102 Subscriber First Name First name of Subscriber Text varchar[25] 25
Multiple versionsME103 Subscriber Middle Initial Middle initial of Subscriber Text char[1] 1
Multiple versionsME104 Member Last Name Last name of Member Text varchar[60] 60
Multiple versionsME105 Member First Name First name of Member Text varchar[25] 25
Multiple versionsME106 Member Middle Initial Middle initial of Member Text char[1] 1
Multiple versionsME107 Carrier Specific Unique Member ID Member's Unique ID Text varchar[50] 50
Multiple versionsME108 Subscriber City Name City name of the Subscriber Text varchar[30] 30
Multiple versionsME109 Subscriber State or Province State of the Subscriber External Code Source 2 - Text char[2] 2
Multiple versionsME110 Subscriber ZIP Code Zip Code of the Subscriber External Code Source 2 - Text varchar[9] 9
Multiple versionsME111 Medical Deductible Maximum out of pocket amount of applied member's deductible Integer varchar[10] 10
Multiple versionsME112 Pharmacy Deductible Maximum out of pocket amount of member's deductible applied to pharmacy Integer varchar[10] 10
Multiple versionsME113 Medical and Pharmacy Deductible Maximum out of pocket amount of member's deductible applied to services Integer varchar[10] 10
Multiple versionsME114 Behavioral Health Deductible Maximum out of pocket amount of member's deductible applied to behavioral health Integer varchar[10] 10
Multiple versionsME115 Dental Deductible Maximum out of pocket amount of member's deductible applied to dental services Integer varchar[10] 10
Multiple versionsME116 Vision Deductible Maximum out of pocket amount of member's deductible applied to vision services Integer varchar[10] 10
Multiple versionsME117 Carrier Specific Unique Subscriber ID Subscriber's Unique ID Text varchar[50] 50
Multiple versionsME118 Vision Benefit Indicator - Vision Option Lookup Table - Integer int[1] 1
Multiple versionsME119 Filler Filler Filler char[0] 0
Multiple versionsME120 Actuarial Value The actuarial value of the risk adjustment covered plan the member is enrolled in Decimal - Numeric varchar[6] 6
Multiple versionsME121 Metal Level Standardized plan level in metal reference Lookup Table - Integer int[1] 1
Multiple versionsME122 Coinsurance Maximum % Maximum coinsurance percentage contract of the member Lookup Table - Integer int[1] 1
Multiple versionsME123 Monthly Premium Expected Monthly Premium Integer varchar[10] 10
Multiple versionsME124 Attributed PCP Provider ID PV002 for PCP attributed to the patient for prior year. Text varchar[30] 30
Multiple versionsME125 TME OrgID - Physician Group of the Member's PCP TME Provider OrgID Integer varchar[6] 6
Multiple versionsME126 Risk Adjustment Covered Plan (RACP) Member Enrolled in RACP Indicator Lookup table - Integer Int(1) 1
Multiple versionsME127 Billable Member Billable Member Indicator Lookup table - Integer Int(1) 1
Multiple versionsME128 Benefit Plan Contract ID Identifier for the benefit plan the member is enrolled in as of 15th of the month Text varchar [30] 30
Multiple versionsME129 Member Benefit Plan Contract Enrollment Start Date Date the member is enrolled in the benefit plan Date int[8] CCYYMMDD 8
Multiple versionsME130 Member Benefit Plan Contract Enrollment End Date Date the member's enrollment ends with the benefit plan Date int[8] CCYYMMDD 8
Multiple versionsME131 TME Global Budget/Payment Indicator TME Global Budget/Payment Indicator Integer Int[1] 1
Multiple versionsME132 Total Monthly Premium Employer + Subscriber's total contribution to monthly premium Integer varchar[10] 10
Multiple versionsME133 GIC ID GIC Member ID Text varchar[9] 9
Multiple versionsME134 APCD ID Code Member Enrollment Type Lookup Table - Integer int[1] 1
ME135 Aid Category MassHealth Aid Category Lookup Table - Aid Category Varchar[4] 4
Multiple versionsME899 Record Type File Type Identifier Text char[2] 2
Multiple versionsTR001 Record Type Trailer Record Identifier Text char[2] 2
Multiple versionsTR002 Submitter Trailer Submitter / Carrier ID defined by CHIA Integer varchar[6] 6
Multiple versionsTR003 National Plan ID CMS National Plan Identification Number (PlanID) Integer int[10] 10
Multiple versionsTR004 Type of File Validates the file type defined in HD004. Text char[2] 2
Multiple versionsTR005 Period Beginning Date Trailer Period Start Date Date Period - Integer int[6] CCYYMM 6
Multiple versionsTR006 Period Ending Date Trailer Period Ending Date Date Period - Integer int[6] CCYYMM 6
Multiple versionsTR007 Date Processed Trailer Processed Date Full Date - Integer int[8] CCYYMMDD 8

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Data Element ID Data Element Code Value
HD001 Record Type HD Header Elements
HD004 Type of File ME ELIGIBILITY
HD009 APCD Version Number 2.1 Prior Version; valid only for reporting periods prior to October 2013
3.0 Version 3.0; required for reporting periods as of October 2013: No longer VALID as of May 2015
4.0 Version 4.0: required for reporting periods October 2013 onward as of May 2015
ME003 Insurance Type Code/Product 09 Self-pay
10 Central Certification
11 Other Non-Federal Programs
12 Preferred Provider Organization (PPO)
13 Point of Service (POS)
14 Exclusive Provider Organization (EPO)
15 Indemnity Insurance
16 Health Maintenance Organization (HMO) Medicare Advantage
17 Dental Maintenance Organization (DMO)
20 Medicare Advantage PPO
21 Medicare Advantage Private Fee for Service
AM Automobile Medical
BL Blue Cross / Blue Shield
CC Commonwealth Care
CE Commonwealth Choice
CH CHAMPUS
CI Commercial Insurance
DS Disability
HM Health Maintenance Organization
HN HMO Medicare Risk/Medicare Part C
IC Integrated Care Organization
LI Liability
LM Liability Medical
MA Medicare Part A
MB Medicare Part B
MC Medicaid
MD Medicare Part D
MO Medicaid Managed Care Organization
MP Medicare Primary
MS Medicare Secondary Plan
OF Other Federal Program (e.g. Black Lung)
QM Qualified Medicare Beneficiary
SC Senior Care Option
SP Supplemental Policy
TF HSN Trust Fund
TV Title V
VA Veterans Administration Plan
WC Workers' Compensation
ZZ Other
ME007 Coverage Level Code CHD Children Only
DEP Dependents Only
ECH Employee and Children
ELF Employee and Life Partner
EMP Employee Only
ESP Employee and Spouse
FAM Family
IND Individual
SPC Spouse and Children
SPO Spouse Only
UNK Unknown
ME012 Individual Relationship Code 01 Spouse
04 Grandfather or Grandmother
05 Grandson or Granddaughter
07 Nephew or Niece
10 Foster Child
12 Other Adult
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
ME013 Member Gender F Female
M Male
O Other
U Unknown
ME018 Medical Coverage 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
ME019 Prescription Drug Coverage 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
ME020 Dental Coverage 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
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 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
ME025 Ethnicity 1 AMERCN American
BRAZIL Brazilian
CARIBI Caribbean Island (see CDC Code 2075-0)
CVERDN Cape Verdean
EASTEU Eastern European
OTHER Other Ethnicity
PORTUG Portuguese
RUSSIA Russian
UNKNOW Unknown / not specified
ME026 Ethnicity 2 AMERCN American
BRAZIL Brazilian
CARIBI Caribbean Island (see CDC Code 2075-0)
CVERDN Cape Verdean
EASTEU Eastern European
OTHER Other Ethnicity
PORTUG Portuguese
RUSSIA Russian
UNKNOW Unknown / not specified
ME028 Primary Insurance Indicator 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
ME029 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. Insurers using this code shall obtain prior approval.
STN Short-term, non-renewable health insurance
UND Plans underwritten by the insurer
ME030 Market Category Code FCH Individuals on a franchise basis
GCV Individuals as group conversion Policies
GLG1 Employers having 51 thru 100 employees
GLG2 Employers having 101 thru 250 employees
GLG3 Employers having 251 thru 500 employees
GLG4 Employers having more than 500 employees
GS1 Employers having exactly 1 employee
GS2 Employers having 2 thru 9 employees
GS3 Employers having 10 thru 25 employees
GS4 Employers having 26 thru 50 employees
GSA Small employers through a qualified association trust
IND Individuals (non-group)
ISCO Individuals as a Senior Care Option
OTH Other types of entities. Insurers using this market code shall obtain prior approval.
ME031 Special Coverage CC Commonwealth Care
HSN Health Safety Net
N/A Not Applicable
ME035 Health Care Home (PCMH) Assigned Flag 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
ME045 Purchased through Massachusetts Exchange Flag 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
ME051 Behavioral Health Benefit Flag 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
ME052 Laboratory Benefit Flag 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
ME053 Disease Management Enrollee Flag 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
ME055 Business Type Code 0 Unknown / Not Applicable
1 Risk Holder
2 TPA - Third Party Administrator
3 DBA - Delegated Business Administrator
4 PBM - Pharmacy Benefit Manger
5 DBM - Dental Benefit Manager
6 CSO - Computer Service Organization
7 Other
ME059 Disability Indicator Flag 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
ME060 Employment Status A Active
I Involuntary Leave
O Orphan
P Pending
R Retiree
U Unknown
Z Unemployed
ME061 Student Status 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
ME062 Marital Status C Common Law Married
D Divorced
M Married
P Domestic Partnership
S Never Married
U Unknown
W Widowed
X Legally Separated
ME063 Benefit Status A Active
C COBRA
P Pending
S Surviving Insured
T TEFRA
U Unknown
ME064 Employee Type H Hourly
Q Seasonal
S Salaried
T Temporary
U Unknown
ME066 COBRA Status 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
ME071 Pool Indicator 1 Regular State Employees and Retirees, plus local authorities
2 Elderly Governmental Retirees (EGR) and Retired Municipal Teachers (RMTs)
ME073 Fully Insured member 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
ME074 Interpreter 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
ME081 Medicare Code 0 No Medicare Coverage
1 Part A Only
2 Part B Only
3 Part A and B
4 Part C Only
5 Advantage
6 Part D Only
9 Not Applicable
ME118 Vision Benefit 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
ME121 Metal Level 0 Unknown / Not Applicable
1 Bronze
2 Silver
3 Gold
4 Platinum
5 Catastrophic
ME122 Coinsurance Maximum % 0 Unknown / Not Applicable
1 10% Maximum Coinsurance
2 20% Maximum Coinsurance
3 30% Maximum Coinsurance
4 40% Maximum Coinsurance
5 50% Maximum Coinsurance
6 75% Maximum Coinsurance
7 80% Maximum Coinsurance
8 90% Maximum Coinsurance
ME126 Risk Adjustment Covered Plan (RACP) 1 Yes
2 No
3 Mock - Provided for Simulation Purposes Only
ME127 Billable Member 1 Yes, the member is billable
2 No, the member is not billable
ME131 TME Global Budget/Payment Indicator 1 Yes
2 No
ME134 APCD ID Code 0 Unknown / Not Applicable
1 FIG - Fully-Insured Commercial Group Enrollee
2 SIG - Self-Insured Group Enrollee
3 GIC - Group Insurance Commission Enrollee
4 MCO - MassHealth Managed Care Organization Enrollee
5 Supplemental Policy Enrollee
6 ICO - Integrated Care Organization or SCO - Senior Care Option
ME899 Record Type ME
TR001 Record Type TR
TR004 Type of File ME
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