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Medical Eligibility File Submission

Pennsylvania



Name:Medical Eligibility File Submission
State:Pennsylvania
Definition:Not provided
VersionJune 2011

File Specification for Medical Eligibility File Submission

Data Element ID Data Element Description Type Format Length
1 Payer Payer submitting payments. Alphanumeric 128
2 National Plan ID CMS National Plan Identification Number Alphanumeric 30
3 Insurance Type Code/Product These codes differ from the codes for this data element in the Medical Claims file. Alphanumeric 2
4 Year Year for which eligibility is reported in this submission Use CCYY as year format. Numeric CCYY 4
5 Month Month for which eligibility is reported in this submission Use MM as month format. Numeric MM 2
6 Insured Group or Policy Number Group or policy number, not the number that uniquely identifies the subscriber. Alphanumeric 30
7 Coverage Level Code Benefit coverage level Alphanumeric 3
8 Subscriber Social Security Number Subscriber's Social Security Number Numeric 9
9 Plan Specific Contract Number Plan assigned subscriber's contract number Alphanumeric 30
10 Member Suffix or Sequence Number Uniquely numbers the member within the contract. Numeric 20
11 Member Identification Code Member's SSN. Numeric 9
12 Individual Relationship Code Member's relationship to insured. Numeric 2
13 Member Gender Member Gender Alphanumeric 1
14 Member Date of Birth Not Provided Numeric MMDDCCYY 8
15 Member City Name City name associated with member Alphanumeric 30
16 Member State or Province As defined by the US Postal Service Alphanumeric 2
17 Member ZIP Code Zip code of member Numeric 9
18 Medical Coverage Does the member have medical coverage? Alphanumeric 1
19 Prescription Drug Coverage Does the member have prescription drug coverage? Alphanumeric 1
20a Patient Race Patient's/Member's racial background. Alphanumeric 1
20b Patient Hispanic/Latino Origin or Descent Hispanic/Latino origin refers to people whose origins are from Spain, Mexico, or the Spanish speaking countries of Central or South America. Origin can be viewed as the ancestry, nationality lineage, or country in which the person or his/her ancestors were born before their arrival in the United States. Alphanumeric 1
21 Primary Insurance Indicator Indicates whether coverage under member's plan or policy is primary. Alphanumeric 1
22 Coverage Type Not Provided Alphanumeric 3
23 Market Category Code The market the policy is sold into. Alphanumeric 4
24 Special Coverage Future element reserved for assignment. character field 3
25 Group Name Group name. Alphanumeric 128
26 Health Care Home Assigned Flag Future element reserved for assignment. Alphanumeric 1
27 Health Care Home Number Future element reserved for assignment. Alphanumeric 10
28 Health Care Home Tax ID Number Future element reserved for assignment. Alphanumeric 20
29 Health Care Home National Provider ID Future element reserved for assignment. Alphanumeric 60
30 Health Care Home Name Future element reserved for assignment. Alphanumeric 128
31 Subscriber Last Name Not Provided Alphanumeric 128
32 Subscriber First Name Not Provided Alphanumeric 128
33 Subscriber Middle Initial Not Provided Alphanumeric 1
34 Member Last Name Not Provided Alphanumeric 128
35 Member First Name Not Provided Alphanumeric 128
36 Member Middle Initial Not Provided Alphanumeric 1
37 Record Type Indicates the type of record being submitted, in this case, Member Eligibility. Alphanumeric 2

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Data Element ID Data Element Code Value
3 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's group health plan
14 Medicare Secondary, No-fault insurance including insurance in which 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 (for self-insured risks)
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
7 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
12 Individual Relationship Code 01 Spouse
18 Self
19 Child
21 Unknown
34 Other Adult
13 Member Gender F Female
M Male
U Unknown
18 Medical Coverage N no
Y yes
19 Prescription Drug Coverage N no
Y yes
20a Patient Race A Asian Alone
B Black Alone
I American Indian and Alaskan Native Alone
M Two or More Race Groups
N Other
P Native Hawaiian or Other Pacific Islander
U Unknown
W White Alone
20b Patient Hispanic/Latino Origin or Descent 1 Yes, the patient is of Hispanic origin or descent.
2 No, the patient is not of Hispanic origin or descent.
21 Primary Insurance Indicator N No, secondary or tertiary insurance.
Y Yes, this is primary insurance
22 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
STN short-term, non-renewable health insurance
UND plans underwritten by the insurer
23 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 100 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.
37 Record Type ME
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