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Dental Eligibility File Submission

Maine

Versions: Dental Eligibility File Submission• Dental Eligibility File SubmissionCompare Versions


Name:Dental Eligibility File Submission
State:Maine
Definition:Not Provided
Versionv1.1

File Specification for Dental Eligibility File Submission

Data Element ID Data Element Description Type Format Length
Multiple versionsDE001 Payer This field contains the MHDO submitter code for the payer submitting payments. The first character of the submitter code indicates the type of submitter. This field is primarily used for tracking compliance by payer. CHAR 6
Multiple versionsDE002 National Plan ID CMS National Plan ID CHAR 30
Multiple versionsDE003 Insurance Type/Product Code This field contains the insurance type or product code that indicates the type of insurance coverage the individual has. CHAR 2
Multiple versionsDE004 Year The year during which the member is eligible for services. This field is generally used in conjunction with Month to determine a specific period of eligibility. NUMBER 4
Multiple versionsDE005 Month Month indicates the month during which the member is eligible for services. This field is generally used in conjunction with Year to determine a specific period of eligibility. NUMBER 2
Multiple versionsDE006 Insured Group or Policy Number The group or policy number is associated with the entity that has purchased the insurance. For self insured individuals this relates to the purchaser. For the majority of eligibility and claims data the group relates to the employer. CHAR 31
Multiple versionsDE007 Coverage Level Code This field indicates the type of coverage or type of contract. CHAR 3
Multiple versionsDE008 Encrypted Subscriber Social Security Number This field contains the encrypted social security number for the subscriber. If the social security number was not available from the payer this field will be null and the Contract field will be populated.This field has been encrypted using the same algorithm across all payers. If this field is populated, it forms the core of the unique member identification code(Memberid). CHAR 32
Multiple versionsDE009 Plan Specific Contract Number This field contains the payer assigned contract number for the subscriber. If the Encrypted Social Security Number is null, this field forms the core of the unique member number (Memberid). CHAR 64
Multiple versionsDE010 Member Suffix or Sequence Number This payer supplied code uniquely identifies the member within the context of the subscriber Encrypted Social Security Number or the Contract. CHAR 20
Multiple versionsDE011 Member Identification Code This field is used to record the member's social security number when available. If the member is the subscriber, this field should contain the same value as the Encrypted Social Security Number. If the member is not the subscriber, this field will not equal the Encrypted Social Security Number. CHAR 64
Multiple versionsDE012 Individual Relationship Code This field contains the member's relationship to the subscriber or the insured. CHAR 2
Multiple versionsDE013 Member Gender This field contains the gender of the member. CHAR 1
Multiple versionsDE014 Member Date of Birth This field contains the member's data of birth with a format of CCYYMMDD. This field is used to calculate age as of the first day of the membership month. DATE CCYYMMDD 8
Multiple versionsDE015 Member City Name This field contains the member's city of residence and was not required reporting until 2004. CHAR 30
Multiple versionsDE016 Member State or Province The Member State or Province contains the 2 character abbreviation code used by the US Postal Service and was not required reporting until 2004. Since this database has been built for Maine residents the code will generally be ME for Maine. CHAR 2
Multiple versionsDE017 Member ZIP Code This field contains ZIP Code of the member. Payers are encouraged to provide a full 9 character zip code. CHAR 11
Multiple versionsDE018 Medical Coverage The medical coverage flag indicates whether this member is covered for medical expenses or not. CHAR 1
Multiple versionsDE019 Prescription Drug Coverage The prescription drug coverage flag indicates whether this member is covered for prescription drug expenses or not. CHAR 1
Multiple versionsDE020 Dental Coverage The dental coverage flag indicates whether this member is covered for dental expenses or not. CHAR 1
Multiple versionsDE021 Record Type This field indicates the type of record. CHAR 2
Multiple versionsDE901 Member Age This field contains the age of the member in years as of the last day of the previous eligibility month. Children under the age of 1 have an age of zero. If no date of birth is available, this field is null. NUMBER 3
Multiple versionsDE902 Record ID # This field contains a Data Processing Center assigned record number that is unique across all data types. This field is used for tracking purposes. NUMBER 12
Multiple versionsDE903 MHDO Extract Date This is the date the record was extracted by the Data Processing Center for inclusion in the MHDO Data Warehouse. The format is CCYYMMDD. DATE CCYYMMDD 8
Multiple versionsDE904 Unique Member ID The MEMBERID is a combination of fields which generally represent a unique individual. For those members with a value in the Encrypted Subscriber Social Security Number, the Memberid is comprised of Encrypted Subscriber Social Security Number + Year and Month of Birth + Gender + Individual Relationship Code. If the Encrypted Subscriber Social Security Number is blank, the Memberid is comprised of the Plan Specific Contract Number + Year and Month of Birth + Gender + Individual Relationship Code. CHAR 71
Multiple versionsDE905 Medicare Coverage This field is used to flag all Medical Eligibility records associated with supplemental Medicare Coverage. Medicare eligibility does not apply to dental data. CHAR 1
Multiple versionsDE906 Submission ID # This field contains a unique submission number assigned by the Data Processing Center for tracking purposes. Each payer submission receives a submission number that is unique across all data types. NUMBER 12
Multiple versionsDE907 Double Encrypted Social Security Number This field contains an encryption of the information originally submitted by the payer in field DC007 - the Encrypted Social Security Number for the subscriber. If the social security number was not available from the payer this field will be null and the CONTRACT field will be populated. This field has been encrypted using the same algorithm across all payers. If this field is populated, it forms the core of the unique member identification code(MHDO_MEMBERID). CHAR 64
Multiple versionsDE908 Double Encrypted Contract Number This field contains an encryption of the information originally submitted by the payer in field DC008 - the payer assigned contract number for the subscriber. If the Encrypted Subscriber Social Security Number is null, this field forms the core of the unique member number (MHDO_MEMBERID). This field has been encrypted using the same algorithm across all payers. CHAR 128
Multiple versionsDE909 Double Encrypted Member Identification Code This field is used to record the member's social security number when available. If the member is the subscriber, this field should contain the same value as the Double Encrypted Social Security Number. If the member is not the subscriber, this field will not equal the Double Encrypted Social Security Number. CHAR 128
Multiple versionsDE910 Double Encrypted Member ID The Double Encrypted Member ID is a combination of fields which generally represent a unique individual. For those members with a value in the Encrypted Subscriber Social Security Number, the Double Encrypted MemberID is comprised of Double Encrypted Subscriber Social Security Number + Year and Month of birth + Gender + Individual Relationship Code. If the Double Encrypted Subscriber Social Security Number is blank, the Double Encrypted Memberid is comprised of the Encrypted Plan Specific Contract Number + Year and Month of birth + Gender + Individual Relationship Code. This field contains the member's relationship to the CHAR 135
Multiple versionsDE911 Standardized Relationship Code Subscriber or the insured. INTEGER 2
Multiple versionsDE912 Standardized Insurance Type/Product Code The insurance type or product code indicates the type of insurance coverage the individual has. CHAR 2
Multiple versionsDE913 Duplicate Member Flag This field flags duplicate eligibility records that should not be released. INTEGER 1
Multiple versionsDE914 Eligibility Year and Month This field combines YEAR (DE004) and MONTH (DE005) into a single field with a format of YYYYMM. NUMBER YYYYMM 6

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Data Element ID Data Element Code Value
DE001 Payer C Commercial carrier
T Third Party Administrator
U Unlicensed entity
DE003 Insurance Type/Product Code 12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
13 Medicare Secondary End-Stage Renal Disease Beneficiary in the 12 month coordination period with an employer's group health plan
14 Medicare Secondary, No-fault insurance including Auto is primary
15 Medicare Secondary Worker's Compensation
16 Medicare Secondary Public Health Service or Other Federal Agency
41 Medicare Secondary Black Lung
42 Medicare Secondary Veteran's Administration
43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
47 Medicare Secondary, Other Liability Insurance is Primary
AP Auto Insurance Policy
CP Medicare Conditionally Primary
D Disability
DB Disability Benefits
EP Exclusive Provider Organization
HM Health Maintenance Organization (HMO)
HN Health Maintenance Organization (HMO) Medicare Risk
HS Special Low Income Medicare Beneficiary
IN Indemnity
LC Long Term Care
LD Long Term Policy
LI Life Insurance
LT Litigation
MA Medicare Part A
MB Medicare Part B
MC Medicaid
MH Medigap Part A
MI Medigap Part B
MP Medicare Primary
DE007 Coverage Level Code CHD Children Only
DEP Dependents Only
ECH Employee and Children
EMP Employee Only
ESP Employee and Spouse
FAM Family
IND Individual
SPC Spouse and Children
SPO Spouse Only
DE012 Individual Relationship Code 01 Spouse
18 Self/Employee
19 Child
21 Unknown
34 Other Adult
DE013 Member Gender F Female
M Male
U Unknown
DE018 Medical Coverage N No
Y Yes
DE019 Prescription Drug Coverage N No
Y Yes
DE020 Dental Coverage N No
Y Yes
DE021 Record Type DE Dental Eligibility
DE905 Medicare Coverage N No supplemental Medicare Coverage
Y Yes supplemental Medicare Coverage
DE911 Standardized 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
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
DE912 Standardized Insurance Type/Product Code 11 Other non Federal program
12 Medicare secondary working aged beneficiary or spouse with employer group health plan
13 Medicare secondary end-stage renal disease beneficiary in the 12 month coordination period with an employer's group health plan
14 Medicare secondary, no-fault insurance including auto is primary
15 Medicare secondary worker's compensation
15 Medicare secondary public health service (PHS) or other federal agency
41 Medicare secondary black lung
42 Medicare secondary veteran's administration
43 Medicare secondary disabled beneficiary under age 65 with large group health plan (LGHP)
47 Medicare secondary, other liability insurance is primary
AM Auto insurance policy
CP Medicare conditionally primary
DB Disability benefits
DS Disability
EP Exclusive Provider Organization (EPO)
HM Health Maintenance Organization (HMO)
HN Health Maintenance Organization (HMO) Medicare risk
HS Special low income Medicare beneficiary
IN Indemnity Insurance
LC Long term care
LD Long term policy
LI Life insurance
LM Liability medical
LT Litigation
MA Medicare part A
MB Medicare part B
MC Medicaid
MH Medigap part A
MI Medigap part B
MP Medicare primary
OF Other federal program (e.g. black lung)
OT Other
PE Property Insurance - Personal
PR Preferred Provider Organization (PPO)
PS Point of Service (POS)
QM Qualified Medicare beneficiary
SP Supplemental policy
TV Title V
VA Veteran administration plan
WC Workers' compensation
DE913 Duplicate Member Flag 1 Same member, same month, same payer
2 Same member, same month, administrative relationship between payers
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