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Medical Eligibility File Submission

Utah

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Name:Medical Eligibility File Submission
State:Utah
Definition:Not Provided
VersionDecember 5, 2013 - v2.0

File Specification for Medical Eligibility File Submission

Data Element ID Data Element Description Type Format Length
ME001 Payer Code Distributed by OHCS varchar 8
ME002 Payer Name Distributed by OHCS varchar 30
ME003 Insurance Type Code/Product Not Provided char 2
ME004 Year 4 digit Year for which eligibility is reported in this submission int 4
ME005 Month Month for which eligibility is reported in this submission expressed numerical from 01 to 12. char 2
ME006 Insured Group or Policy Number Group or policy number - not the number that uniquely identifies the subscriber varchar 30
ME007 Coverage Level Code Benefit coverage level char 3
ME008 Subscriber Social Security Number Subscriber's social security number; Set as blank if unavailable varchar 9
ME009 Plan Specific Contract Number Plan assigned subscriber's contract number; Set as null if contract number = subscriber's social security number or use an alternate unique identifier such as Medicaid ID. Must be an identifier that is unique to the subscriber. varchar 128
ME010 Member Suffix or Sequence Number Unique number of the member. This column is the unique identifying column for membership and related medical and pharmacy claims. Only one record per eligibility month. Must match MC009 and PC009. varchar 128
ME011 Member Identification Code Member's social security number; Set as blank if unavailable. varchar 9
ME012 Individual Relationship Code Member's relationship to insured char 2
ME013 Member Gender Not Provided char 1
ME014 Member Date of Birth Not Provided char YYYYMMDD 8
ME015 Member City Name City location of member varchar 30
ME016 Member State or Province As defined by the US Postal Service char 2
ME017 Member ZIP Code ZIP Code of member - may include non-US codes. Do not include dash. Plus 4 optional but desired. varchar 11
ME018 Medical Coverage Not Provided char 1
ME019 Prescription Drug Coverage Not Provided char 1
ME020 Dental Coverage Not Provided char 1
ME021 Race 1 Not Provided varchar 6
ME022 Race 2 Not Provided varchar 6
ME023 Other Race List race if MC021or MC022 are coded as R9. varchar 15
ME024 Hispanic Indicator Not Provided char 1
ME025 Ethnicity 1 Not Provided varchar 6
ME026 Ethnicity 2 Not Provided varchar 6
ME027 Other Ethnicity List ethnicity if MC025 or MC026 are coded as OTHER. varchar 20
ME028 Primary Insurance Indicator Not Provided char 1
ME029 Coverage Type Not Provided char 3
ME030 Market Category Code Not Provided varchar 4
ME032 Group Name Group name or IND for individual policies varchar 128
ME043 Member Street Address Street address of member varchar 50
ME044 Employer Name Name of the Employer, or if same as Group Name, null varchar 50
ME101 Subscriber Last Name The subscriber last name varchar 128
ME102 Subscriber First Name The subscriber first name varchar 128
ME103 Subscriber Middle Initial The subscriber middle initial char 1
ME104 Member Last Name The member last name varchar 128
ME105 Member First Name The member first name varchar 128
ME897 Plan Effective Date Date eligibility started for this member under this plan type. The purpose of this data element is to maintain eligibility span for each member. char YYYYMMDD 8
ME045 Exchange Offering Identifies whether or not a policy was purchased through the Utah Health Benefits Exchange (UBHE). char 1
ME106 Group Size Code indicating Group Size consistent with Utah Insurance Law and Regulation Required only for plans sold in the commercial large, small and non-group markets. The following plan/products do not need to report this value: Student plans Medicare supplemental Medicaid-funded plans Stand-alone behavioral health, dental and vision char 2
ME107 Risk Basis Not Provided char 1
ME108 High Deductible/ Health Savings Account Plan Not Provided char 1
ME120 Actuarial Value Report value as calculated in the most recent version of the HHS Actuarial Value Calculator available at http://cciio.cms.gov/resources/regulations/index.html Size includes decimal point. Required as of January 1, 2014 for small group and non-group (individual) plans sold inside or outside the Exchange. decimal 6
ME121 Metallic Value Metal Level (percentage of Actuarial Value) per federal regulations. Required as of January 1, 2014 for small group and non group (individual) plans sold inside or outside the Exchange. Use values provided in the most recent version of the HHS Actuarial Value Calculator available at : http://cciio.cms.gov/resources/regulations/index.html int 1
ME122 Grandfather Status See definition of "grandfathered plans" in HHS rules CFR 147.140 Required as of January 1, 2014 for small group and non group (individual) plans sold inside or outside the Exchange. Char 1
ME899 Record Type Not Provided char 2

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Data Element ID Data Element Code Value
ME003 Insurance Type Code/Product 12 Preferred Provider Organization (PPO)
13 Point of Service (POS)
15 Indemnity Insurance
16 Health Maintenance Organization (HMO) Medicare Advantage
17 Dental Maintenance Organization (DMO)
99 Other
CI Commercial Insurance Company
DN Dental
HM Health Maintenance Organization
HN HMO Medicare Risk/ Medicare Part C
MA Medicare Part A
MB Medicare Part B
MC Medicaid
MD Medicare Part D
MP Medicare Primary
QM Qualified Medicare Beneficiary
SP Supplemental Policy
SP Medicare Supplemental (Medi-gap) plan
TV Title V
ME007 Coverage Level Code CHD Children Only
DEP Dependents Only
ECH Employee and Children
ELF Employee and Life Partner
EMP Employee Only
EPN Employee plus N where N equals the number of other covered dependents
ESP Employee and Spouse
FAM Family
IND Individual
SPC Spouse and Children
SPO Spouse Only
ME012 Individual Relationship Code 01 Spouse
04 Grandfather or Grandmother
05 Grandson or Granddaughter
07 Nephew or Niece
10 Foster Child
15 Ward
17 Stepson or Stepdaughter
19 Child
20 Employee/Self
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
U UNKNOWN
ME018 Medical Coverage 3 UNKNOWN
N NO
Y YES
ME019 Prescription Drug Coverage 3 UNKNOWN
N NO
Y YES
ME020 Dental Coverage 3 UNKNOWN
N NO
Y YES
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 N Patient is not Hispanic/Latino/Spanish
U Unknown
Y Patient is Hispanic/Latino/Spanish
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 N No, secondary or tertiary insurance
Y Yes, primary insurance
ME029 Coverage Type AWS Self-funded
OTH any other plan. Insurers using this code shall obtain prior approval.
STN short-term, non-renewable health insurance (ie COBRA)
UND plans underwritten by the insurer
ME030 Market Category Code FCH policies sold and issued directly to individuals on a franchise basis
GS3 policies sold and issued directly to employers having 50 or more 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.
ME045 Exchange Offering N Commercial small or non-group QHP purchased outside the Exchange
U Not applicable (plan/product is not offered in the commercial small or nongroup market)
Y Commercial small or non-group QHP purchased through the Exchange
ME106 Group Size A 1
B 2 to 50
C 51 - 100
D 100+
ME107 Risk Basis F Fully insured
S Self-insured
ME108 High Deductible/ Health Savings Account Plan N Plan is not High Deductible/HSA eligible
Y Plan is High Deductible/HSA eligible
ME121 Metallic Value 0 Not Applicable
1 Platinum
2 Gold
3 Silver
4 Bronze
ME122 Grandfather Status N No
Y Yes
ME899 Record Type ME
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