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Medical Eligibility File Submission

Colorado

Versions: Medical Eligibility File Submission• Medical Eligibility File Submission• Medical Eligibility File SubmissionCompare Versions


Name:Medical Eligibility File Submission
State:Colorado
Definition:Not Provided
VersionAugust 2011 - v3

File Specification for Medical Eligibility File Submission

Data Element ID Data Element Description Type Format Length
Multiple versionsHD001 Record Type Not Provided char 2
Multiple versionsHD002 Payer Code NAIC code (example: 12345); leave blank if not applicable varchar 8
Multiple versionsHD003 Payer Name Not Provided varchar 75
Multiple versionsHD004 Beginning Month Not Provided date CCYYMM 6
Multiple versionsHD005 Ending Month Not Provided date CCYYMM 6
Multiple versionsHD006 Record count Total number of records submitted in the medical eligibility file, excluding header and trailer records int 10
Multiple versionsME001 Payer Name/Code Payer submitting payments-assigned by CIVHC (may be multiple to support different platforms, or as required) varchar 8
Multiple versionsME002 National Plan ID CMS National Plan ID or NAIC varchar 30
Multiple versionsME003 Insurance Type Code/Product Not Provided char 2
Multiple versionsME004 Year 4 digit Year for which eligibility is reported in this submission int 4
Multiple versionsME005 Month Month for which eligibility is reported in this submission expressed numerical from 01 to 12. char 2
Multiple versionsME006 Insured Group or Policy Number Group or policy number - not the number that uniquely identifies the subscriber varchar 30
Multiple versionsME007 Coverage Level Code Benefit coverage level char 3
Multiple versionsME008 Subscriber Social Security Number Subscriber's social security number; Set as null if unavailable varchar 9
Multiple versionsME009 Plan Specific Contract Number Plan assigned subscriber's contract number; Set as null if contract number = subscriber's social security number or use an alternate unique identifier such as Medicaid ID. Must be an identifier that is unique to the subscriber. varchar 128
Multiple versionsME010 Member Suffix or Sequence Number Unique number of the member within the contract. Must be an identifier that is unique to the member. varchar 128
Multiple versionsME011 Member Identification Code Member's social security number; Set as null if contract number = subscriber's social security number or use an alternate unique identifier such as Medicaid ID. Must be an identifier that is unique to the member. varchar 9
Multiple versionsME012 Individual Relationship Code Member's relationship to insured char 2
Multiple versionsME013 Member Gender Not Provided char 1
Multiple versionsME014 Member Date of Birth Not Provided char CCYYMMDD 8
Multiple versionsME015 Member City Name City location of member varchar 30
Multiple versionsME016 Member State or Province As defined by the US Postal Service char 2
Multiple versionsME017 Member ZIP Code ZIP Code of member - may include non-US codes. Do not include dash. Plus 4 optional but desired. varchar 11
Multiple versionsME018 Medical Coverage Not Provided char 1
Multiple versionsME019 Prescription Drug Coverage Not Provided char 1
Multiple versionsME020 Dental Coverage Not Provided char 1
Multiple versionsME021 Race 1 Not Provided varchar 6
Multiple versionsME022 Race 2 Not Provided varchar 6
Multiple versionsME023 Other Race List race if MC021 or MC022 are coded as R9. varchar 15
Multiple versionsME024 Hispanic Indicator Not Provided char 1
Multiple versionsME025 Ethnicity 1 Not Provided varchar 6
Multiple versionsME026 Ethnicity 2 Not Provided varchar 6
Multiple versionsME027 Other Ethnicity List ethnicity if MC025 or MC026 are coded as OTHER. varchar 20
Multiple versionsME028 Primary Insurance Indicator Not Provided char 1
Multiple versionsME029 Coverage Type Insurers using this code shall obtain prior approval. char 3
Multiple versionsME030 Market Category Code Not Provided varchar 4
Multiple versionsME032 Group Name Group name or IND for individual policies varchar 128
Multiple versionsME043 Member Street Address Street address of member varchar 50
Multiple versionsME044 Employer Name Name of the Employer, or if same as Group Name, null varchar 50
Multiple versionsME101 Subscriber Last Name The subscriber last name varchar 128
Multiple versionsME102 Subscriber First Name The subscriber first name varchar 128
Multiple versionsME103 Subscriber Middle Initial The subscriber middle initial char 1
Multiple versionsME104 Member Last Name The member last name varchar 128
Multiple versionsME105 Member First Name The member first name varchar 128
Multiple versionsME897 Plan Effective Date Date eligibility started for this member under this plan type. The purpose of this data element is to maintain eligibility span for each member. char CCYYMMDD 8
Multiple versionsME899 Record Type Not Provided char 2
Multiple versionsTR001 Record Type Not Provided char 2
Multiple versionsTR002 Payer Code NAIC code (example: 12345); leave blank if not applicable varchar 8
Multiple versionsTR003 Payer Name Not Provided varchar 75
Multiple versionsTR004 Beginning Month Not Provided date CCYYMM 6
Multiple versionsTR005 Ending Month Not Provided date CCYYMM 6
Multiple versionsTR006 Extraction Date Not Provided date CCYYMMDD 8

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Data Element ID Data Element Code Value
HD001 Record Type ME
ME003 Insurance Type Code/Product 12 Preferred Provider Organization (PPO)
13 Point of Service (POS)
15 Indemnity Insurance
16 Health Maintenance Organization (HMO) Medicare Advantage
99 Other
CI Commercial Insurance Company
HM Health Maintenance Organization
HN HMO Medicare Risk/ Medicare Part C
MA Medicare Part A
MB Medicare Part B
MC Medicaid
MD Medicare Part D
MP Medicare Primary
QM Qualified Medicare Beneficiary
SP Supplemental Policy
TV Title V
ME007 Coverage Level Code CHD Children Only
DEP Dependents Only
ECH Employee and Children
ELF Employee and Life Partner
EMP Employee Only
EPN Employee plus N where N equals the number of other covered dependents
ESP Employee and Spouse
FAM Family
IND Individual
SPC Spouse and Children
SPO Spouse Only
ME012 Individual Relationship Code 01 Spouse
04 Grandfather or Grandmother
05 Grandson or Granddaughter
07 Nephew or Niece
10 Foster Child
15 Ward
17 Stepson or Stepdaughter
19 Child
20 Employee/Self
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
76 Dependent
ME013 Member Gender F Female
M Male
U UNKNOWN
ME018 Medical Coverage N NO
Y YES
ME019 Prescription Drug Coverage N NO
Y YES
ME020 Dental Coverage 3 UNKNOWN
N NO
Y YES
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 N Patient is not Hispanic/Latino/Spanish
U Unknown
Y Patient is Hispanic/Latino/Spanish
ME025 Ethnicity 1 2028-9 Asian
2029-7 Asian Indian
2033-9 Cambodian
2034-7 Chinese
2036-2 Filipino
2039-6 Japanese
2040-4 Korean
2041-2 Laotian
2047-9 Vietnamese
2058-6 African American
2060-2 African
2071-9 Haitian
2108-9 European
2118-8 Middle Eastern
2148-5 Mexican, Mexican American, Chicano
2155-0 Central American (not otherwise specified)
2157-6 Guatemalan
2158-4 Honduran
2161-8 Salvadoran
2165-9 South American (not otherwise specified)
2169-1 Columbian
2180-8 Puerto Rican
2182-4 Cuban
2184-0 Dominican
AMERCN American
BRAZIL Brazilian
CARIBI Caribbean Island
CVERDN Cape Verdean
EASTEU Eastern European
OTHER Other Ethnicity
PORTUG Portuguese
RUSSIA Russian
UNKNOW Unknown/Not Specified
ME026 Ethnicity 2 2028-9 Asian
2029-7 Asian Indian
2033-9 Cambodian
2034-7 Chinese
2036-2 Filipino
2039-6 Japanese
2040-4 Korean
2041-2 Laotian
2047-9 Vietnamese
2058-6 African American
2060-2 African
2071-9 Haitian
2108-9 European
2118-8 Middle Eastern
2148-5 Mexican, Mexican American, Chicano
2155-0 Central American (not otherwise specified)
2157-6 Guatemalan
2158-4 Honduran
2161-8 Salvadoran
2165-9 South American (not otherwise specified)
2169-1 Columbian
2180-8 Puerto Rican
2182-4 Cuban
2184-0 Dominican
AMERCN American
BRAZIL Brazilian
CARIBI Caribbean Island
CVERDN Cape Verdean
EASTEU Eastern European
OTHER Other Ethnicity
PORTUG Portuguese
RUSSIA Russian
UNKNOW Unknown/Not Specified
ME028 Primary Insurance Indicator N No, secondary or tertiary insurance
Y Yes, primary insurance
ME029 Coverage Type OTH any other plan
STN short-term, non-renewable health insurance (ie COBRA)
UND plans underwritten by the insurer
ME030 Market Category Code FCH policies sold and issued directly to individuals on a franchise basis
GS3 policies sold and issued directly to employers having 50 or more employees
GSA policies sold and issued directly to small employers through a qualified association trust
IND policies sold and issued directly to individuals (non-group)
OTH policies sold to other types of entities. Insurers using this market code shall obtain prior approval.
ME899 Record Type ME
TR001 Record Type ME
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