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Medical Eligibility File Submission

Tennessee



Name:Medical Eligibility File Submission
State:Tennessee
Definition:Not Provided
VersionMarch 18, 2010

File Specification for Medical Eligibility File Submission

Data Element ID Data Element Description Type Format Length
HD001 Record Type Must be coded HD to indicate Header record. Text 2
HD002 Payer Payer or submitter code assigned by Onpoint CDM Text 8
HD003 National Plan ID Code according to CMS National Plan ID Text 30
HD004 Type of File Must be coded ME to indicate submission of eligibility data. Text 2
HD005 Period Beginning Date Code the earliest eligibility year/month included in the submission in CCYYMM format. Submissions with records containing an eligibility period (ME004, ME005) before this date will fail. Integer CCYYMM 6
HD006 Period Ending Date Code the latest eligibility year/month included in the submission in CCYYMM format. Submissions with records containing an eligibility period (ME004, ME005) after this date will fail. Integer CCYYMM 6
HD007 Record Count Report the total number of records in the submission, excluding the header and trailer records. If the number of records within the submission does not equal the number reported in this field, the submission will fail. Integer 10
HD008 Comments Submitter comments Text 80
ME001 Payer This field contains the Onpoint CDM-assigned submitter code for the data submitter. The first two characters of the submitter code indicate Tennessee and the third character designates the type of submitter: A single data submitter may have multiple submitter codes because the data submitter is submitting from more than one system or from more than one location. All submitter codes associated with a single data submitter will have the same first 7 characters. A suffix will be used to distinguish the location and/or system variations. This field contains a constant value and is used primarily for tracking compliance by data submitters. Text 8
ME002 National Plan ID Code according to CMS National Plan ID Text 30
ME003 Insurance Type / Product Code This field contains the insurance type or product code that indicates the type of insurance coverage the individual has: Text 6
ME004 Year The year during which the member is eligible for services. This field generally is used in conjunction with the month (ME005) to determine a specific period of eligibility. Integer 4
ME005 Month Month indicates the month during which the member is eligible for services. This field generally is used with the year field (ME004) to determine a specific period of eligibility. Integer 2
ME006 Insured Group Or Policy Number Group number or policy number. If submitting an individual policy, use IND. Text 30
ME007 Coverage Level Code Benefits coverage level: Text 3
ME008 Encrypted Subscriber Index Number Carriers, healthcare claims processors, and pharmacy benefit managers shall input subscriber's Social Security number. During transformation and encryption: All but one digit of the Social Security number shall be combined with a seed value. This modified subscriber index number then is encrypted by an application on the processor's desktop The original input Social Security number is deleted and carriers, healthcare claims processors, and pharmacy benefit managers shall set the input field null if unavailable. This or ME009 must be populated. Text 128
ME009 Encrypted Plan Specific Contract Index Number Carriers and healthcare claims processors shall input a plan-assigned subscriber index number that uniquely identifies members in a contract. This must not be the original contract number, but must be consistent in all fields requiring the plan-specific contract index number and it must be consistent in all file submission types (eligibility, medical, and pharmacy claims) submitted by the submitter. This plan-assigned contract index number shall be combined with a seed value and then encrypted. Carriers and healthcare claims processors shall set as null if unavailable. This or ME008 must be populated. Text 128
ME010 Member Suffix Number Code a number to designate a member within the contract. Integer 20
ME011 Encrypted Member Index Number Carriers, healthcare claims processors, and pharmacy benefit managers shall input member's Social Security number. During transformation and encryption: All but one digit of the Social Security number shall be combined with a seed value This modified member index number then is encrypted by an application on the processor's desktop The original input Social Security number is deleted and replaced with the modified and encrypted output Carriers, healthcare claims processors, and pharmacy benefit managers shall set the input field null if unavailable. Text 128
ME012 Individual Relationship Code This field contains the member's relationship to the subscriber or the insured: Integer 2
ME013 Member Gender Member's gender: Text 1
ME014 Member Year of Birth Carriers, healthcare claims processors and pharmacy benefit managers shall input member's date of birth as CCYYMMDD. During transformation: Age in months will be calculated for member using first day of the month for the eligibility file The age in months value will be added to the end of the record by an application on the processor's desktop The original input date of birth is deleted and replaced with the year of birth only in the output Date CCYYMMDD 8
ME015 Member City Name This field contains the member's city of residence. Text 30
ME016 Member State or Province The member state or province contains the two-character abbreviation code used by the U.S. Postal Service. Text 2
ME017 Member ZIP Code This field contains the ZIP code of the member. Text 5
ME018 Medical Coverage The medical coverage flag indicates whether this member is covered for medical expenses. This is an administrative field required by Onpoint CDM and derived from the eligibility data maintained by the data submitter: Text 1
ME019 Prescription Drug Coverage The prescription drug coverage flag indicates whether this member is covered for prescription drug expenses. This is an administrative field required by Onpoint CDM and derived from the eligibility data maintained by the data submitter: Text 1
ME020 Placeholder Placeholder N/A N/A
ME021 Placeholder Placeholder N/A N/A
ME022 Placeholder Placeholder N/A N/A
ME023 Placeholder Placeholder N/A N/A
ME024 Placeholder Placeholder N/A N/A
ME025 Placeholder Placeholder N/A N/A
ME026 Placeholder Placeholder N/A N/A
ME027 Placeholder Placeholder N/A N/A
ME028 Primary Insurance Indicator Is insurance primary? Text 1
ME029 Coverage Type Type of coverage: Text 3
ME030 Market Category Category of Insurance Policy Text 4
ME031 Special Coverage Form of special coverage: Text 3
ME032 Group Name Name of the group which the member is covered by: Text 128
ME033 Placeholder Placeholder N/A N/A
ME034 Placeholder Placeholder N/A N/A
ME035 Placeholder Placeholder N/A N/A
ME036 Placeholder Placeholder N/A N/A
ME037 Placeholder Placeholder N/A N/A
ME101 Placeholder Placeholder N/A N/A
ME102 Placeholder Placeholder N/A N/A
ME103 Placeholder Placeholder N/A N/A
ME104 Encrypted Index Number, Member Last Name Carriers, healthcare claims processors, and pharmacy benefit managers shall input member's last name. During transformation and encryption: The first character of the last name is combined with a numeric name ID This modified member last name field then is encrypted by an application on the processor's desktop The original input member last name is deleted and replaced with the modified and encrypted output Text 128
ME105 Encrypted Index Number, Member First Name Carriers, healthcare claims processors and pharmacy benefit managers shall input member's first initial. During transformation and encryption: o This first character of the first name is combined with a seed value o This modified member first initial is then encrypted by an application on the processors desktop o The original input member first initial is deleted and replaced with the modified and encrypted output Text 128
ME106 Placeholder Placeholder N/A N/A
ME899 Record Type This field indicates the type of record: This is an administrative field required by Onpoint CDM and populated with a constant value. Text 2
TR001 Record Type Must be coded TR to indicate the Trailer record Text 2
TR002 Payer Payer or submitter code assigned by Onpoint CDM Text 8
TR003 National Plan ID Code according to CMS National Plan ID Text 30
TR004 Type of File Must be coded ME to indicate submission of eligibility data. Text 2
TR005 Period Beginning Date Code the earliest eligibility year/month included in the submission in CCYYMM format. Submissions with records containing an eligibility period (ME004, ME005) before this date will fail. Integer CCYYMM 6
TR006 Period Ending Date Code the latest eligibility year/month included in the submission in CCYYMM format. Submissions with records containing an eligibility period (ME004, ME005) after this date will fail. Integer CCYYMM 6
TR007 Date Processed Date that the file was created in CCYYMMDD format Date CCYYMMDD 8

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Data Element ID Data Element Code Value
HD001 Record Type HD Header Record
HD004 Type of File ME eligibility data
ME001 Payer TNC Commercial Carrier
TNG Governmental Agency
TNT Third-Party Administrator
TNU Unlicensed Entity
ME003 Insurance Type / Product Code 12 Medicare Secondary, Working Aged Beneficiary or Spouse with an Employer's 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, 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
47 Medicare Secondary, Other Liability Insurance is Primary
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 / Medicare Part C
HS Special Low Income Medicare Beneficiary
IN Indemnity
MA Medicare Part A
MB Medicare Part B
MCTNCR Tennessee Medicaid (TennCare)
MD Medicare Part D
MH Medigap Part A
MI Medigap Part B
MP Medicare Primary
PR Preferred Provider Organization (PPO)
PS Point of Service (POS)
QM Qualified Medicare Beneficiary
SP Supplemental Policy
WC Workers' Compensation
XXTNAC AccessTN
XXTNCV CoverTN
XXTNKD CoverKids
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
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
ME028 Primary Insurance Indicator N No, secondary or tertiary insurance
Y Yes, primary insurance
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
STN For short-term non-renewable health insurance
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 TCA § 56-26-101(3)
GCV For policies sold and issued directly to individuals as group conversion policies as required pursuant to TCA § 56-7-2312
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 two and nine 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 TCA § 56-26-101(3), or as group conversion policies as defined pursuant to TCA § 56-7-2312
OTH For policies sold to other types of entities
ME031 Special Coverage 0 Not applicable
41 Yes, member is enrolled in a TennCare plan
ME032 Group Name IND If the member is part of a group of one
Null If this is non-group
ME899 Record Type ME Eligibility
TR001 Record Type TR Trailer Record
TR004 Type of File ME eligibility data
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