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Member Eligibility File Submission

Massachusetts

Versions: Member Eligibility File Submission• Member Eligibility File Submission• Member Eligibility File SubmissionCompare 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.
VersionDecember 1, 2010 - v2.1

File Specification for Member Eligibility File Submission

Data Element ID Data Element Description Type Format Length
Multiple versionsHD001 Record Type Header Record Identifier Text HD 2
Multiple versionsHD002 Payer Header Submitter/Carrier ID Text 8
Multiple versionsHD003 National Plan ID Header CMS National Plan Identification Number (PlanID) Text 30
Multiple versionsHD004 Type of File Header Type of File Text ME 2
Multiple versionsHD005 Period Beginning Date Header Period Start Date Date Period CCYYMM 6
Multiple versionsHD006 Period Ending Date Header Period Ending Date Date Period CCYYMM 6
Multiple versionsHD007 Record Count Header Record Count Integer ####### 10
Multiple versionsHD008 Comments Header Carrier Comments Text Free Text Comments 80
Multiple versionsME001 Payer Carrier Specific Submitter Code as defined by APCD. This must match the Submitter Code reported in HD002 Text 8
Multiple versionsME002 National Plan ID CMS National Plan Identification Number (PlanID) Text 30
Multiple versionsME003 Insurance Type Code/Product Type / Product Identification Code Text tlkpInsuranceTypeCode 2
Multiple versionsME004 Year Eligibility year reported in this submission. Date Period CCYY 4
Multiple versionsME005 Month Reporting Month of Eligibility Date Period Month MM 2
Multiple versionsME006 Insured Group or Policy Number Carriers group or policy number Text 30
Multiple versionsME007 Coverage Level Code Benefit Coverage Level Code Text tlkpCoverageLevel 3
Multiple versionsME008 Subscriber Unique Identification Number Subscriber's Social Security Number Text ######### 9
Multiple versionsME009 Plan Specific Contract Number Contract Number Text 30
Multiple versionsME010 Member Suffix or Sequence Number Member's Contract Sequence Number Text 20
Multiple versionsME011 Member Identification Code Member's Social Security Number Text ######### 9
Multiple versionsME012 Individual Relationship Code Member/Patient to Subscriber Relationship Code Integer tlkpIndividualRelathionshipCode 2
Multiple versionsME013 Member Gender The Member's Gender Text tlkpGender 1
Multiple versionsME014 Member Date of Birth Member's date of birth Date CCYYMMDD 8
Multiple versionsME015 Member City Name City name of the Member Text Free Text Address 30
Multiple versionsME016 Member State or Province State of the Member Text External Code Source 2 2
Multiple versionsME017 Member ZIP Code Zip Code of the Member Text External Code Source 3 11
Multiple versionsME018 Medical Coverage Indicator to refine Product or define Benefit within a Product. Text tlkpFlagIndicators 1
Multiple versionsME019 Prescription Drug Coverage Indicator to refine Product or define Benefit within a Product. Text tlkpFlagIndicators 1
Multiple versionsME020 Dental Coverage Indicator to refine Product or define Benefit within a Product. Text tlkpFlagIndicators 1
Multiple versionsME021 Race 1 Member's self disclosed Primary Race Text tlkpRace 6
Multiple versionsME022 Race 2 Member's self disclosed Secondary Race Text tlkpRace 6
Multiple versionsME023 Other Race Member's self disclosed Other Race Text Free Text Other Race 15
Multiple versionsME024 Hispanic Indicator Indicator to define Hispanic status Text tlkpFlagIndicators 1
Multiple versionsME025 Ethnicity 1 Member's self disclosed Primary Ethnicity Text tlkpEthnicity 6
Multiple versionsME026 Ethnicity 2 Member's self disclosed Secondary Ethnicity Text tlkpEthnicity 6
Multiple versionsME027 Other Ethnicity Member's self disclosed Other Ethnicity Text Free Text Ethnicity 20
Multiple versionsME028 Primary Insurance Indicator Indicator to define if Insurance is Primary Text tlkpFlagIndicators 1
Multiple versionsME029 Coverage Type Type of Coverage Code Text tlkpCoverageType 3
Multiple versionsME030 Market Category Code Market Category Code Text tlkpMarketCategoryCode 4
Multiple versionsME031 Special Coverage Special Coverage Code Text tlkpSpecialCoverageCode 3
Multiple versionsME032 Group Name Group name Text Free Text Name 50
Multiple versionsME033 Member language preference Member's self disclosed verbal language preference Text tlkpLanguagePreference 3
Multiple versionsME034 Member language preference -Other Member's self disclosed verbal language secondary preference Text Free Text Language 20
Multiple versionsME035 Health Care Home Assigned Flag Health Care Home Assigned indicator Text tlkpFlagIndicators 1
Multiple versionsME036 Health Care Home Number Health Care Home Number Text 28
Multiple versionsME037 Health Care Home Tax ID Number Health Care Home EIN Text ######### 20
Multiple versionsME038 Health Care Home National Provider ID National Provider Identification (NPI) of the Health Care Home Provider Text External Code Source 4 28
Multiple versionsME039 Health Care Home Name Name of Health Care Home Text Free Text Name 60
Multiple versionsME040 Product ID Number Product Identification Number Text ID PR001 20
Multiple versionsME041 Product Enrollment Start Date the date the member was enrolled in the product Date CCYYMMDD 8
Multiple versionsME042 Product Enrollment End Date Enrollment Date Date CCYYMMDD 8
Multiple versionsME043 Member Street Address Street address of the Member Text Free Text Address 50
Multiple versionsME044 Member Address 2 Secondary Street Address of the Member Text Free Text Address 50
Multiple versionsME045 Filler The APCD will reserve this field for possible future use. Please fill with null values in the format described. Filler Filler 30
Multiple versionsME046 Member PCP ID Member's PCP Identification Number Text 25
Multiple versionsME047 Member PCP Effective Date PCP Effective Date with Member Date CCYYMMDD 8
Multiple versionsME048 Member PCP Termination Date PCP Termination Date with Member Date CCYYMMDD 8
Multiple versionsME049 Member Deductible Annual maximum out of pocket Member Deductible across all benefit types Integer DDDDCC 10
Multiple versionsME050 Member Deductible Used Member deductible amount incurred Integer DDDDCC 10
Multiple versionsME051 Behavioral Health Benefit Flag Indicates if Behavioral / Mental Health is a covered benefit in the member's eligibility Integer tlkpFlagIndicators 1
Multiple versionsME052 Laboratory Benefit Flag Laboratory Benefits indicator Text tlkpFlagIndicators 1
Multiple versionsME053 Disease Management Enrollee Flag Chronic Illness Management indicator Integer tlkpFlagIndicators 1
Multiple versionsME054 Eligibility Determination Date Eligibility date Date CCYYMMDD 8
Multiple versionsME055 Filler The APCD will reserve this field for possible future use. Please fill with null values in the format described. Filler Filler 2
Multiple versionsME056 Last Activity Date Activity Date Date CCYYMMDD 8
Multiple versionsME057 Date of Death Member's Date of Death Date CCYYMMDD 8
Multiple versionsME058 Subscriber Street Address Street address of the Subscriber Text Free Text Address 50
Multiple versionsME059 Disability Indicator Flag Disability Identifier Integer tlkpFlagIndicators 1
Multiple versionsME060 Employment Status Employment Status Code Text tlkpEmploymentStatus 1
Multiple versionsME061 Student Status Student Status Indicator Text tlkpFlagIndicators 1
Multiple versionsME062 Marital Status Marital Status Code Text tlkpMaritalStatus 1
Multiple versionsME063 Benefit Status Benefit Status Code Text tlkpBenefitStatus 1
Multiple versionsME064 Employee Type Employee Type Code Text tlkpEmployeeType 1
Multiple versionsME065 Date of Retirement Member's date of Retirement Date CCYYMMDD 8
Multiple versionsME066 COBRA Status COBRA usage indicator Integer tlkpFlagIndicators 1
Multiple versionsME067 Spouse Plan Type Spouse Plan Type Code Text Carrier Defined Reference Table 2
Multiple versionsME068 Spouse Plan Spouse Plan Medicare Code Text Carrier Defined Reference Table 2
Multiple versionsME069 Spouse Medical Coverage Spouse Medical Medicare Coverage Code Text Carrier Defined Reference Table 2
Multiple versionsME070 Spouse Medicare Indicator Spouse Medicare Selected Code Text Carrier Defined Reference Table 2
Multiple versionsME071 Pool Indicator Pool Indicator Code Text tlkpPoolIndicator 2
Multiple versionsME072 Filler The APCD will reserve this field for possible future use. Please fill with null values in the format described. Text Filler 20
Multiple versionsME073 Fully insured member Fully Insured identifier Text tlkpFlagIndicators 1
Multiple versionsME074 Interpreter Interpreter Required indicator Text tlkpFlagIndicators 1
Multiple versionsME075 NewMMISID NewMMIS Identification Number Text 12
Multiple versionsME076 Member rating category Member Rating Category Code Text Carrier Defined Reference Table 2
Multiple versionsME077 Members SIC Code Member Standard SIC Code Text External Code Source 15 10
Multiple versionsME078 Filler The APCD will reserve this field for possible future use. Please fill with null values in the format described. Filler Filler 2
Multiple versionsME079 Recipient Identification Number (MassHealth only) MassHealth RID Number Text 15
Multiple versionsME080 Recipient Historical Number (MassHealth only) MassHealth RHN Number Text 15
Multiple versionsME081 Medicare Code Medicare Plan Indicator Code Text tlkpMedicareCode 1
Multiple versionsME082 Employer Name Member's Employer Name Text Free Text Name 60
Multiple versionsME083 Employer EIN Member's Employer EIN Text ######### 9
Multiple versionsME101 Subscriber Last Name Last name of Subscriber Text Free Text Name 60
Multiple versionsME102 Subscriber First Name First name of the Subscriber Text Free Text Name 25
Multiple versionsME103 Subscriber Middle Initial Middle initial of Subscriber Text Free Text Name 1
Multiple versionsME104 Member Last Name Last name of Member Text Free Text Name 60
Multiple versionsME105 Member First Name First name of Member Text Free Text Name 25
Multiple versionsME106 Member Middle Initial Middle initial of Member Text Free Text Name 1
Multiple versionsME107 CarrierSpecificUniqueMemberID Member/Patient Carrier Unique Identification Text 20
Multiple versionsME108 Subscriber City Name City name of the Subscriber Text Free Text Address 30
Multiple versionsME109 Subscriber State or Province State of the Subscriber Text External Code Source 2 2
Multiple versionsME110 Subscriber ZIP Code Zip Code of the Subscriber Text External Code Source 3 11
Multiple versionsME111 Medical Deductible Maximum out of pocket amount of applied member's deductible Integer DDDDCC 10
Multiple versionsME112 Pharmacy Deductible Maximum out of pocket amount of member's deductible applied to pharmacy Integer DDDDCC 10
Multiple versionsME113 Medical and Pharmacy Deductible Maximum out of pocket amount of member's deductible applied to services Integer DDDDCC 10
Multiple versionsME114 Behavioral Health Deductible Maximum out of pocket amount of member's deductible applied to behavioral health Integer DDDDCC 10
Multiple versionsME115 Dental Deductible Maximum out of pocket amount of member's deductible applied to dental services Integer DDDDCC 10
Multiple versionsME116 Vision Deductible Maximum out of pocket amount of member's deductible applied to vision services Integer DDDDCC 10
Multiple versionsME117 CarrierSpecificUniqueSubscriberID Subscriber Carrier Unique Identification Text 20
Multiple versionsME118 Vision Benefit Indicates if Vision Services are a covered benefit in the member's eligibility Integer tlkpFlagIndicators 1
Multiple versionsME899 Record Type File Type Identifier Text ME 2
Multiple versionsTR001 Record Type Trailer Record Identifier Text TR 2
Multiple versionsTR002 Payer Carrier Specific Submitter Code as defined by APCD. This must match the Submitter Code reported in HD002 Text 8
Multiple versionsTR003 National Plan ID CMS National Plan Identification Number (PlanID) Text 30
Multiple versionsTR004 Type of File This is an indicator that defines the type of file and the data contained within the file. This must match the File Type reported in HD004. Text ME 2
Multiple versionsTR005 Period Beginning Date Trailer Period Start Date Date Period CCYYMM 6
Multiple versionsTR006 Period Ending Date Trailer Period Ending Date Date Period CCYYMM 6
Multiple versionsTR007 Date Processed Trailer Processed Date Date CCYYMMDD 8

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Data Element ID Data Element Code Value
HD001 Record Type HD
HD004 Type of File ME
ME003 Insurance Type Code/Product 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)
AM Automobile Medical
DS Disability
HM Health Maintenance Organization
HN HMO Medicare Risk/Medicare Part C
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
OF Other Federal Program (e.g. Black Lung)
QM Qualified Medicare Beneficiary
SC Senior Care Option
SP Supplemental Policy
TV Title V
VA Veterans Administration Plan
WC Workers' Compensation
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
ME012 Individual 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
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 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 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 Policies sold and issued directly to individuals on a franchise basis
GCV Policies sold and issued directly to individuals as group conversion Policies
GLG1 Policies sold and issued directly to employers having between 51 and 99 employees
GLG2 Policies sold and issued directly to employers having between 100 and 249 employees
GLG3 Policies sold and issued directly to employers having between 250 and 499 employees
GLG4 Policies sold and issued directly to employers having 500 or more employees
GS1 Policies sold and issued directly to employers having exactly one employee
GS2 Policies sold and issued directly to employers having between two and nine employees
GS3 Policies sold and issued directly to employers having between 10 and 25 employees
GS4 Policies sold and issued directly to employers having between 26 and 50 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.
ME031 Special Coverage CC Commonwealth Care
HSN Health Safety Net
N/A Not Applicable
ME033 Member language preference 600 English
601 Cape Verdean Creole
607 German
619 Italian
620 French
623 Haitian Creole
625 Spanish
629 Portuguese
637 Greek
639 Russian
645 Polish
656 Persian
663 Hindi
671 Urdu
708 Chinese (Please specify in ME034)
723 Japanese
724 Korean
728 Vietnamese
742 Tagalog
777 Arabic
778 Hebrew
799 African (Please specify in ME034)
997 Other Language (Please specify in ME034)
999 Unknown / not specified
ME035 Health Care Home Assigned 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
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 D Divorced
M Married
S Never Married
U Unknown
W Widowed
X Legally Separated
ME063 Benefit Status A Active
C COBRA
S Surviving Insured
T TEFRA
U Unknown
ME064 Employee Type H Hourly
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
ME118 Vision Benefit 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
ME899 Record Type ME
TR001 Record Type TR
TR004 Type of File ME
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