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Medical Eligibility File Submission

Maryland

Versions: Medical Eligibility File Submission• Medical Eligibility File Submission• Medical Eligibility File SubmissionCompare Versions


Name:Medical Eligibility File Submission
State:Maryland
Definition:Not provided
VersionSeptember 13, 2013

File Specification for Medical Eligibility File Submission

Data Element ID Data Element Description Type Format Length
Multiple versions1 Record Identifier The value is 5 numeric 1
Multiple versions2 Encrypted Enrollee IdentifierP (payor encrypted) Enrollee's unique identification number assigned by payor and encrypted. alphanumeric 12
Multiple versions3 Encrypted Enrollee IdentifierU (UUID encrypted) Enrollee's universally unique identification (UUID) number generated using an encryption algorithm provided by MHCC. alphanumeric 12
Multiple versions4 Enrollee Year and Month of Birth Date of enrollee's birth using 00 instead of day. numeric CCYYMM00 8
Multiple versions5 Enrollee Sex Sex of the enrollee. numeric 1
Multiple versions6 Enrollee Zip Code of Residence +4-digit add-on Zip code of enrollee's residence. numeric 10
Multiple versions7 Enrollee County of Residence County of enrollee's residence. If known, please provide. If not known, MHCC will arbitrarily assign using Zip code of residence. numeric 3
Multiple versions8 Source of Enrollee Race/Ethnicity Information Race/ethnicity of enrollee gathered from enrollee or other source. numeric 1
Multiple versions9 Enrollee OMB Race 1 Race of enrollee. numeric 1
Multiple versions10 Enrollee OMB Race 2 Race of enrollee. numeric 1
Multiple versions11 Enrollee OMB Race 3 for future use numeric 1
Multiple versions12 Enrollee OMB Hispanic Ethnicity 1 (Hispanic Indicator) Ethnicity of enrollee. numeric 1
Multiple versions13 Enrollee Other Ethnicity 2 for future use numeric 1
Multiple versions14 Enrollee Preferred Spoken Language A locally relevant list of languages will be developed by the Commission in consort with the Racial, Ethnic and Language Disparities Work Group (for future use) . numeric 2
Multiple versions15 Coverage Type Enrollee's type of insurance coverage. alphanumeric 1
Multiple versions16 Source Company Defines the payor company that holds the beneficiary's contract; for use in characterizing contract requirements under Maryland law. alphanumeric 1
Multiple versions17 Product Type Classifies the benefit plan by key product characteristics (scope of coverage, size of network, coverage for out-of-network benefits).(Please code based on how the product is primarily marketed, and most importantly be consistent from year to year. If not sure, send an e-mail describing the product to Larry Monroe at larry.monroe@maryland.gov) numeric 1
Multiple versions18 Policy Type Type of policy. numeric 1
Multiple versions19 Encrypted Contract or Group Number Payor assigned contract or group number for the plan sponsor using an encryption algorithm generated by the payor. alphanumeric 20
Multiple versions20 Employer Federal Tax ID Number Employer Federal Tax ID number will be encrypted by the database contractor in such a way that an employer will have the same encrypted ID across all payor records and the same employer has the same encrypted number from year to year. alphanumeric 9
Multiple versions21 Medical Services Indicator Medical Coverage numeric 1
Multiple versions22 Pharmacy Services Indicator Prescription Drug Coverage numeric 1
Multiple versions23 Behavioral Health Services Indicator Behavioral Health Services Coverage numeric 1
Multiple versions24 Dental Services Indicator Dental Coverage numeric 1
Multiple versions25 Plan Liability Indicates if insurer is at risk for the patient's service use or the insurer is simply paying claims as an ASO. numeric 1
Multiple versions26 Consumer Directed Health Plan (CDHP) with HSA or HRA Indicator Consumer Directed Health Plan (CDHP)with Health Savings Account (HSA) or Health Resources Account (HRA). numeric 1
Multiple versions27 Start Date of Coverage The start date for benefits in the month(for example, if the enrollee was insured at the start of the month of January in 2013, the start date is 20130101) numeric CCYYMMDD 8
Multiple versions28 End Date of Coverage The end date for benefits in the month (for example, if the enrollee was insured for the entire month of January in 2013, the end date is 20130131) numeric CCYYMMDD 8
Multiple versions29 Date of FIRST Enrollment The date of that the patient was initially enrolled with your organization. numeric CCYYMMDD 8
Multiple versions30 Date of Disenrollment The end date of enrollment for the patient in this delivery system (in this data submission time period).(see Source Company on page 99) numeric CCYYMMDD 8
Multiple versions31 Relationship to Policyholder Member's relationship to subscriber/insured. numeric 1
Multiple versions32 Payor ID Number Payor assigned submission identification number. alphanumeric 4
Multiple versions33 Source System Identify the source system (platforms or business units) from which the data was obtained by using an alphabet letter (A, B, C, D, etc...) (Note: In your documentation on page 14, please be sure to list the source system that corresponds with the letter assigned.) For payors with all data coming from one system only, leave the field blank. alphanumeric 1

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Data Element ID Data Element Code Value
1 Record Identifier 5 Eligibility
5 Enrollee Sex 1 Male
2 Female
3 Unknown
7 Enrollee County of Residence 001 Allegany
003 Anne Arundel
005 Baltimore County
009 Calvert
011 Caroline
013 Carroll
015 Cecil
017 Charles
019 Dorchester
021 Frederick
023 Garrett
025 Harford
027 Howard
029 Kent
031 Montgomery
033 Prince George's
035 Queen Anne's
037 St. Mary's
039 Somerset
041 Talbot
043 Washington
045 Wicomico
047 Worcester
510 Baltimore City
999 Unknown
8 Source of Enrollee Race/Ethnicity Information 0 Enrollee not asked
1 Enrollee asked and reported
2 Enrollee asked but refused
3 Obtained from other source
9 Enrollee OMB Race 1 1 American Indian or Alaska Native
2 Asian
3 Black or African American
4 Native Hawaiian or Other Pacific Islander
5 White/Caucasian
6 Some Other Race
9 Missing/Unknown/Not specified
10 Enrollee OMB Race 2 1 American Indian or Alaska Native
2 Asian
3 Black or African American
4 Native Hawaiian or Other Pacific Islander
5 White/Caucasian
6 Some Other Race
9 Missing/Unknown/Not specified
12 Enrollee OMB Hispanic Ethnicity 1 (Hispanic Indicator) 1 Hispanic or Latino or Spanish origin
2 Not Hispanic or Latino or Not of Spanish origin
9 Missing/Unknown/Not specified
15 Coverage Type 1 Medicare Supplemental (i.e., Individual, Group, WRAP)
2 Medicare Advantage Plan
3 Individual Market (not MHIP)
4 Maryland Health Insurance Plan (MHIP)
5 Private Employer Sponsored or Other Group (i.e. union or association plans)
6 Public Employee - Federal (FEHBP)
7 Public Employee - Other (state, county, local/municipal government and public school systems)
8 Comprehensive Standard Health Benefit Plan [a self employed individual or small businesses (public or private employers) with 2-50 eligible employees]
9 Health Insurance Partnership (HIP)
A Student Health Plan
Z Unknown
16 Source Company 1 Health Maintenance Organization
2 Life & Health Insurance Company or Not-for-Profit Health Benefit Plan
3 Third-Party Administrator (TPA) Unit
17 Product Type 1 Exclusive Provider Organization (in any form)
2 Health Maintenance Organization
3 Indemnity
4 Point of Service (POS)
5 Preferred Provider Organization (PPO)
6 Limited Benefit Plan (Mini-Meds)
7 Student Health Plan
8 Catastrophic
18 Policy Type 1 Individual
2 Any combination of two or more persons
21 Medical Services Indicator 0 No
1 Yes
22 Pharmacy Services Indicator 0 No
1 Yes
23 Behavioral Health Services Indicator 0 No
1 Yes
24 Dental Services Indicator 0 No
1 Yes
25 Plan Liability 1 Risk (under Maryland contract)
2 Risk (under non-Maryland contract)
3 ASO (employer self-insured)
26 Consumer Directed Health Plan (CDHP) with HSA or HRA Indicator 0 No
1 Yes
31 Relationship to Policyholder 1 Self/employee
2 Spouse
3 Child
4 Other Dependent
5 Other Adult
9 Unknown
32 Payor ID Number P020 Aetna Life Insurance Co.
P030 Aetna Health, Inc.
P130 CareFirst BlueChoice, Inc.
P131 CareFirst of Maryland, Inc.
P132 Group Hospitalization & Medical Services, Inc. (GHMSI)
P160 Cigna Health and Life Insurance Co., Inc.
P180 Connecticut General Life Insurance Co.
P220 Corporate Health Insurance Co.
P280 Assurant Health/Time Insurance Co.
P320 Golden Rule Insurance Co.
P480 Kaiser Permanente Mid-Atlantic States
P500 MAMSI Life and Health Insurance Co.
P520 MD-Individual Practice Association, Inc.
P530 MEGA Life and Health Insurance Co.
P620 Optimum Choice, Inc.
P680 Coventry Healthcare of Delaware, Inc.
P760 State Farm Mutual Automobile Insurance Co.
P820 United Healthcare Insurance Co.
P870 United Healthcare of the Mid-Atlantic, Inc.
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