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Medical Eligibility File Submission

New Hampshire



Name:Medical Eligibility File Submission
State:New Hampshire
Definition:"Member eligibility file" means a data file containing demographic information for each individual member eligible for medical or pharmacy benefits for one or more days of coverage at any time during the reporting month.
VersionSeptember 10, 2012

File Specification for Medical Eligibility File Submission

Data Element ID Data Element Description Type Format Length
HD001 Record Type Not provided Text 2
HD002 Payer Payer submitting payments NHID Submitter Code Text 8
HD003 National Plan ID CMS National Plan ID Text 30
HD004 Type of File Not provided Text 2
HD005 Period Beginning Date Beginning of paid period for claims Beginning of month covered for eligibility Integer CCYYMM 6
HD006 Period Ending Date End of paid period for claims End of month covered for eligibility Integer CCYYMM 6
HD007 Record Count Total number of records submitted in this file Integer 10
HD008 Comments Submitted may use to document this submission by assigning a filename, system source, etc. Text 80
ME001 Payer Payer submitting payments NHID Submitter Code Text 8
ME002 National Plan ID CMS National Plan ID Text 30
ME003 Insurance Type Code/Product Not provided Text 2
ME004 Year Year for which eligibility is reported in this submission Integer 4
ME005 Month Month for which eligibility is reported in this submission Integer 2
ME006 Insured Group or Policy Number Group or policy number (not the number that uniquely identifies the subscriber) Text 50
ME007 Coverage Level Code Benefit Coverage Level Text 3
ME008 Subscriber Social Security Number Subscriber's social security number (set as null if unavailable) (this data element will be de-identified by the NHpreprocessor application) Text 128
ME009 Plan Specific Contract Number Plan assigned contract number (set as null if contract number = subscriber's social security number) (this data element will be de-identified by the NHpreprocessor application) Text 128
ME010 Member Suffice or Sequence Number Uniquely numbers the member within the contract Integer 2
ME011 Member Identification Code Member's social security number (set as null if unavailable) (this data element will be de-identified by the NHpreprocessor application) Text 128
ME012 Individual Relationship Code Member's relationship to insured Integer 2
ME013 Member Gender Not provided Text 1
ME014 Member Date of Birth Not provided Date CCYYMMDD 8
ME015 Member City Name City name of member Text 30
ME016 Member State or Province As defined by the US Postal Service Text 2
ME017 Member ZIP Code ZIP Code of member - may include non-US codes. (Do not include dash) Text 11
ME018 Medical Coverage Not provided Text 1
ME019 Prescription Drug Coverage Not provided Text 1
ME020 Dental Coverage Not provided Text 1
ME021 Race 1 Not provided Text 6
ME022 Race 2 Not provided Text 6
ME023 Placeholder Not provided Not Supplied Not Supplied Not Supplied
ME024 Hispanic Indicator Not provided Text 1
ME025 Ethnicity 1 Not provided Text 6
ME026 Ethnicity 2 Not provided Text 6
ME027 Place holder Not provided 20
ME028 Primary Insurance Indicator Not provided Text 1
ME029 Coverage Type Not provided Text 3
ME030 Market Category Not provided Text 4
ME031 Special Coverage Not provided Text 3
ME032 Group Name Name of the group which the member is covered by. If the member is part of a group of one or non-group then this field shall be set as null Text 128
ME101 Subscriber Last Name (this data element will be de-identified by the NHpreprocessor application) Not provided Text 128
ME102 Subscriber First Name (this data element will be de-identified by the NHpreprocessor application) Not provided Text 128
ME103 Subscriber Middle Initial (this data element will be de- identified by the NHpreprocessor application) Not provided Text 1
ME104 Member Last Name (this data element will be de-identified by the NHpreprocessor application) Not provided Text 128
ME105 Member First Name (this data element will be de-identified by the NHpreprocessor application) Not provided Text 128
ME106 Member Middle Initial (this data element will be de-identified by the NHpreprocessor application) Not provided Text 1
ME899 Record Type Not provided Text 2
TR001 Record Type Not provided Text 2
TR002 Payer Payer submitting payments NHID Submitter Code Text 8
TR003 National Plan ID CMS National Plan ID Text 30
TR004 Type of File Not provided Text 2
TR005 Period Beginning Date Beginning of paid period for claims Beginning of month covered for eligibility Integer CCYYMM 6
TR006 Period Ending Date End of paid period for claims End of month covered for eligibility Integer CCYYMM 6
TR007 Date Processed Not provided Date CCYYMMDD 8

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Data Element ID Data Element Code Value
HD001 Record Type HD
HD004 Type of File NH Member Eligibility
ME003 Insurance Type Code/Product 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 Group Health Plan
14 Medicare Secondary, No-fault insurance including insurance in which auto is primary
15 Medicare Secondary Workers' Compensation
16 Medicare Secondary Public Health Service or Other Federal Agency
41 Medicare Secondary Black Lung
42 Medicare Secondary Veterans 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 Advantage
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
MD Medicare Part D
MH Medigap Part A
MI Medigap Part B
MP Medicare Primary
PC Personal Care
PE Property Insurance - Personal
PR Preferred Provider Organization (PPO)
PS Point of Service (POS)
QM Qualified Medicare Beneficiary
SP Supplemental Policy
WC Workers' Compensation
ME007 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
ME012 Individual Relationship Code 01 Spouse
18 Self/Employee
19 Child
21 Unknown
34 Other Adult
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 N No
Y Yes
ME021 Race 1 R1 American Indian/Alaskan 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/Alaskan 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 No member is not Hispanic/Latino/Spanish
U Unknown
Y Yes member is Hispanic/Latino/Spanish
ME025 Ethnicity 1 2028-9 Asian
2029-7 Asian Indian
2033-9 Cambodian CVERDN Cape Verdean CARIBI Caribbean Island
2034-3 Chinese
2036-2 Filipino
2039-6 Japanese
2040-4 Korean
2041-2 Loatian
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
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 CVERDN Cape Verdean CARIBI Caribbean Island
2034-3 Chinese
2036-2 Filipino
2039-6 Japanese
2040-4 Korean
2041-2 Loatian
2047-9 Vietnamese
2058-6 African American
2060-2 African
2071-9 Haitian
2108-9 European
2118-8 Middle Eastern PORTUG Portuguese RUSSIA Russian
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
EASTEU Eastern European
OTHER Other Ethnicity
UNKNOW Unknown/Not Specified
ME028 Primary Insurance Indicator N No
Y Yes
ME029 Coverage Type ASO for 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 for self-funded plans that are administered by a third party administrator, where the employer has purchased stop-loss, or group excess insurance coverage
OTH for any other plan. Carriers using this code shall obtain prior approval from the NH Insurance Department
STN for short-term non-renewable health insurance as defined pursuant to RSA 415:4 III
UND for plans underwritten by the carrier
ME030 Market Category FCH for policies sold and issued directly to individuals on a franchise basis as defined pursuant to RSA 415:19
GCV for policies sold and issued directly to individuals as group conversion policies as required pursuant to RSA 415:18 VII (a)
GLG1 for policies sold and issued directly to employers having between 51 and 99 employees
GLG2 for policies sold and issued directly to employers having 100 or more employees
GS1 for policies sold and issued directly to employers having exactly one employee
GS2 for policies sold and issued directly to employers having between 2 and 9 employees
GS3 for policies sold and issued directly to employers having between 10 and 25 employees
GS4 for policies sold and issued directly to employers having between 26 and 50 employees
GSA for policies sold and issued directly to small employers through a qualified association trust
IND for policies sold and issued directly to individuals, other than those sold on a franchise basis, as defined pursuant to RSA 415:19, or as group conversion policies as defined pursuant to RSA 415:18 VII (a)
OTH for policies sold to other types of entities. Carriers using this market code shall obtain prior approval from the NH Insurance Department
ME031 Special Coverage 0 not applicable
1 Yes, member is enrolled in HealthFirst plan
ME899 Record Type ME
TR001 Record Type TR
TR004 Type of File NH Member Eligibility
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