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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
VersionMarch 2014 - v6

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 Distributed by CIVHC varchar 8
Multiple versionsHD003 Payer Name Distributed by CIVHC 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 Code Distributed by CIVHC varchar 8
Multiple versionsME002 Payer Name Distributed by CIVHC varchar 30
Multiple versionsME003 Insurance Type Code/Product changes: Required field; codes added to Lookup Table. 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. This column is the unique identifying column for membership and related medical and pharmacy claims. Only one record per eligibility month. 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 YYYYMMDD 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 MC021or 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 Employer Tax ID Employer tax ID varchar 50
Multiple versionsME043 Member Street Address Street address of member varchar 50
Multiple versionsME044 Employer Group Name Employer Group Name or IND for individual Policies varchar 128
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 YYYYMMDD 8
Multiple versionsME045 Exchange Offering Identifies whether or not a policy was purchased through the Colorado Health Benefits Exchange (COBHE). char 1
Multiple versionsME106 Group Size Code indicating Group Size consistent with Colorado Insurance Law and Regulation Required only for plans sold in the commercial large, small and non-group markets. The following plan/products do not need to report this value: Student plans Medicare supplemental Medicaid-funded plans Stand-alone behavioral health, dental and vision char 2
Multiple versionsME107 Risk Basis Default to "F" for grandfathered Plans char 1
Multiple versionsME108 High Deductible/ Health Savings Account Plan Default to "N" for grandfathered Plans char 1
Multiple versionsME120 Actuarial Value Report value as calculated in the most recent version of the HHS Actuarial Value Calculator available at http://cciio.cms.gov/resources/regulations/index.html Size includes decimal point. Required as of January 1, 2014 for small group and non-group (individual) plans sold inside or outside the Exchange. Default to "0" for Grandfathered plans decimal 6
Multiple versionsME121 Metallic Value Metal Level (percentage of Actuarial Value) per federal regulations... Required as of January 1, 2014 for small group and non-group (individual) plans sold inside or outside the Exchange. Use values provided in the most recent version of the HHS Actuarial Value Calculator available at : http://cciio.cms.gov/resources/regulations/index.html Default to "0" for Grandfathered plans int 1
Multiple versionsME122 Grandfather Status See definition of "grandfathered plans" in HHS rules CFR 147.140 Required as of January 1, 2014 for small group and non-group (individual) plans sold inside or outside the Exchange. Default to "0" for  Grandfathered plans Char 1
Multiple versionsME899 Record Type Not Provided char 2
Multiple versionsTR001 Record Type Not Provided char 2
Multiple versionsTR002 Payer Code Distributed by CIVHC varchar 8
Multiple versionsTR003 Payer Name Distributed by CIVHC 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 YYYYMMDD 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
17 Dental Maintenance Organization (DMO)
99 Other
CI Commercial Insurance Company
DN Dental
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
SP Medicare Supplemental (Medi-gap) plan
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 3 UNKNOWN
N NO
Y YES
ME019 Prescription Drug Coverage 3 UNKNOWN
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. Insurers using this code shall obtain prior approval.
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)
MED Medicare and Retiree products.
OTH policies sold to other types of entities. Insurers using this market code shall obtain prior approval.
SMG Policies sold and issued to employers having less than 50 employees
ME045 Exchange Offering N Commercial small or non-group QHP purchased outside the Exchange
U Not applicable (plan/product is not offered in the commercial small or non-group market or grandfathered )
Y Commercial small or non-group QHP purchased through the Exchange
ME106 Group Size A 1
B 2 to 50
C 51 - 100
D 100+
ME107 Risk Basis F Fully insured
S Self-insured
ME108 High Deductible/ Health Savings Account Plan N Plan is not High Deductible/HSA eligible
Y Plan is High Deductible/HSA eligible
ME121 Metallic Value 0 Not Applicable
1 Platinum
2 Gold
3 Silver
4 Bronze
ME122 Grandfather Status N No
Y Yes
ME899 Record Type ME
TR001 Record Type ME
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