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Medical Eligibility File Submission

Vermont



Name:Medical Eligibility File Submission
State:Vermont
Definition:Not Provided
VersionOctober 2008

File Specification for Medical Eligibility File Submission

Data Element ID Data Element Description Type Format Length
HD001 Record Type HD Text 2
HD002 Payer Payer submitting payments; Text 8
HD003 National Plan Id CMS National Plan ID; This is not yet available. Code as null Text 30
HD004 Type of File ME 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 the file Integer 10
HD008 Comments Payer comments Text 80
ME001 Payer Payer submitting payments; Text 8
ME002 National Plan ID CMS National Plan ID; This is not yet available. Code as null Text 30
ME003 Insurance Type Code/Product Type of Insurance Product Text 2
ME004 Year Paid year of submission Integer 4
ME005 Month Paid month of submission Integer 2
ME006 Insured Group or Policy Number Group number or Policy Number Text 30
ME007 Coverage Level Code Level of coverage for the benefit Text 3
ME008 Encrypted Subscriber Unique Identification Number Subscriber's social security number; used to create unique member ID Text 128
ME009 Plan Specific Contract Number Do not include values in this field that will distinguish one member of the family from another. If submitted, this should be the contract or certificate number for the subscriber and all of his/her dependents Text 128
ME010 Member Suffix or Sequence Number The unique number of the member within the contract. Integer 20
ME011 Member Identification Code Member's social security number; used to create unique member ID Text 128
ME012 Individual Relationship Code Member's relationship to insured Integer 2
ME013 Member Gender Member's gender Text 1
ME014 Member Date of Birth Not provided Date CCYYMMDD 8
ME015 Member City Name The city location of the 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. Text 11
ME018 Medical Coverage Not provided Text 1
ME019 Prescription Drug Coverage Not provided Text 1
ME020 Dental Coverage Placeholder N/A at this time Text 1
ME021 Race 1 Placeholder N/A at this time Text 6
ME022 Race 2 Placeholder N/A at this time Text 6
ME023 Other Race Placeholder N/A at this time Text 15
ME024 Hispanic Indicator Placeholder N/A at this time Text 1
ME025 Ethnicity 1 Placeholder N/A at this time Text 6
ME026 Ethnicity 2 Placeholder N/A at this time Text 6
ME027 Other Ethnicity Placeholder N/A at this time Text 20
ME028 Primary Insurance Indicator Is insurance policy primary Text 1
ME029 Coverage Type Type of Cov Text 3
ME030 Market Category Code Category of Insurance Policy Text 4
ME031 Special Coverage Special Insurance Coverage (e.g. Catamount) Text 3
ME101 Encrypted Subscriber Last Name Encrypted subscriber last name, used to create unique member ID Text 128
ME102 Encrypted Subscriber First Name Encrypted subscriber first name, used to create unique member ID Text 128
ME103 Encrypted Subscriber Middle Initial Encrypted subscriber middle initial, used to create unique member ID Text 1
ME104 Encrypted Member Last Name Encrypted member last name, used to create unique member ID Text 128
ME105 Encrypted Member First Name Encrypted member first name, used to create unique member ID Text 128
ME106 Encrypted Member Middle Initial Encrypted member middle initial, used to create unique member ID Text 1
ME899 Record Type Value ME Text 2
TR001 Record Type Value TR Text 2
TR002 Payer Payer Code Text 8
TR003 National Plan ID CMS National Plan ID; This is not yet available. Code as null Text 30
TR004 Type of File ME Text 2
TR005 Period Beginning Date Beginning of paid period for Claims Beginning of month covered for Eligibility Integer YYYYMM 6
TR006 Period Ending Date End of paid period for Claims End of month covered for Eligibility Integer YYYYMM 6
TR007 Date Processed Not provided Date 8

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Data Element ID Data Element Code Value
HD001 Record Type HD
HD004 Type of File ME Medical Eligibility
ME003 Insurance Type Code/Product * Indicates that code is not to be included in Vermont submissions. Included in data set for harmonization with other New England states data collection rules.
*AP Auto Insurance Policy
*D Disability
*DB Disability Benefits
*LC Long Term Care
*LD Long Term Policy
*LI Life Insurance
*LT Litigation
*WC Workers Compensation
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 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
CP Medicare Conditionally Primary
EP Exclusive Provider Organization
HM Health Maintenance Organization (HMO)
HN Health Maintenance Organization (HMO) Medicare Advantage
HS Special Low Income Medicare Beneficiary
IN Indemnity
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
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 - must be mutually exclusive with MC019.
ME019 Prescription Drug Coverage N No
Y Yes - must be mutually exclusive with MC018.
ME028 Primary Insurance Indicator 1 Yes, primary insurance
2 No, secondary or tertiary 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. Insurers using this code shall obtain prior approval from BISHCA
STN for short-term non-renewable health insurance.
UND for plans underwritten by the insurer
ME030 Market Category Code FCH or policies sold and issued directly to individuals on a franchise basis.
GCV for policies sold and issued directly to individuals as group conversion policies.
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. (Non-group)
OTH For policies sold to other types of entities. Insurers using this market code shall obtain prior approval from BISHCA
ME031 Special Coverage 0 N/A
1 NH HealthFirst
2 VT Catamount
ME899 Record Type ME
TR001 Record Type TR
TR004 Type of File ME Medical Eligibility
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