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Medical Eligibility File Submission

Oregon

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


Name:Medical Eligibility File Submission
State:Oregon
Definition:Eligibility files capture patient demographic information such as date of birth, gender, geography, and race/ethnicity. These also serve as the starting point for identifying claims and providers to be included in the data submissions. Criteria for inclusion are members living in Oregon, and members enrolled in a plan for which the state is a payer (such as PEBB, OEBB, or OMIP), regardless of residence.
Version2015.0.1

File Specification for Medical Eligibility File Submission

Data Element ID Data Element Description Type Format Length
Multiple versionsME001 Payer type Not Provided Text 8
Multiple versionsME003 Product code Not Provided Text 3
Multiple versionsME004A Eligibility date example: 20100402. Dates before the submission date range are not valid. See Schedule A for submission data range. Date CCYYMMDD 8
Multiple versionsME005A Termination date example: 20100702. Use 99991231 if termination date is open-ended. Dates over one year past submission due date are not valid (exception: the date of a dependent's 26th birthday is a valid value). Date CCYYMMDD 8
Multiple versionsME007 Subscriber ID Plan-specific unique identifier for subscriber Text 30
Multiple versionsME009 Plan specific contract number Plan-specific contract number (aka group number) Text 30
Multiple versionsME009A PEBB flag Not Provided Numeric 1
Multiple versionsME009B OEBB flag Not Provided Numeric 1
Multiple versionsME009C Medical home flag Not Provided Numeric 1
Multiple versionsME010 Member ID Plan-specific unique identifier for member Text 30
Multiple versionsME012 Relationship code Not Provided Numeric 2
Multiple versionsME013 Member gender Not Provided Text 1
Multiple versionsME014 Member date of birth example: 19570402)\ Date CCYYMMDD 8
Multiple versionsME015A Member's street address Member's primary street address. If member's address is missing then default to subscriber's address. Example: 123 Main Street Text 50
Multiple versionsME015 Member city Example: Grants Pass Text 30
Multiple versionsME016 Member state Example: OR Text 4
Multiple versionsME017 Member ZIP Example: 97209-1234 or 97209 Text 10
Multiple versionsME018 Medical coverage flag Not Provided Text 1
Multiple versionsME019 Prescription drug coverage flag Not Provided Text 1
Multiple versionsME101 Subscriber last name Not Provided Text 35
Multiple versionsME102 Subscriber first name Not Provided Text 25
Multiple versionsME103 Subscriber middle name Not Provided Text 25
Multiple versionsME104 Member last name Not Provided Text 35
Multiple versionsME105 Member first name Not Provided Text 25
Multiple versionsME106 Member middle name Not Provided Text 25
Multiple versionsQC013 ChemDep Benefit - Inpatient Required for HEDIS processing for participants in Q- Corp initiative. Text 1
Multiple versionsQC014 ChemDep Benefit - Day/Night Required for HEDIS processing for participants in Q- Corp initiative. Text 1
Multiple versionsQC015 ChemDep Benefit - Ambulatory Required for HEDIS processing for participants in Q- Corp initiative. Text 1
Multiple versionsQC016 Dental benefit Required for HEDIS processing for participants in Q- Corp initiative. Text 1
Multiple versionsQC018 Mental Health Benefit - Inpatient Required for HEDIS processing for participants in Q- Corp initiative. Text 1
Multiple versionsQC019 Mental Health Benefit - Day/ Night Required for HEDIS processing for participants in Q- Corp initiative. Text 1
Multiple versionsQC020 Mental Health Benefit - Ambulatory Required for HEDIS processing for participants in Q- Corp initiative. Text 1
Multiple versionsRE1 Member race Not Provided Text 1
Multiple versionsRE2 Member ethnicity Not Provided Text 1
Multiple versionsRE3 Primary spoken language This field contains the ANSI/NISO three-character string identifying the member's primary spoken language. Please refer to most recent version of ANSI/NISO Z39.53 (Codes for the Representation of Languages for Information Interchange); the 2001 version is freely available here: http://www.niso.org/topics/ccm/ccmstandards/ Text 3
Multiple versionsOHLC3 Oregon HVMH flag Required for participants in OHLC high value medical home initiative. Text 1
Multiple versionsOHLC4 Oregon HVMH clinic Required for participants in OHLC high value medical home initiative. Text 3
Multiple versionsOHLC5 Oregon HVMH eligibility segment effective date Required for participants in OHLC high value medical home initiative. example: 20090603 Date CCYYMMDD 8
Multiple versionsOHLC6 Oregon HVMH eligibility segment termination date Required for participants in OHLC high value medical home initiative. example: 20090603) Date CCYYMMDD 8
Multiple versionsOHLC7 Prepaid amount/ PMPM Required for participants in OHLC high value medical home initiative. Two explicit decimal places. Example: 402.73 Numeric 12
Multiple versionsME009D OMIP flag Not Provided Numeric 1
Multiple versionsME009E HKC flag Not Provided Numeric 1
Multiple versionsME201 Medicare coverage flag Type of Medicare coverage. Text 2
Multiple versionsME202 Not Provided For future implementation Not Supplied Not Supplied Not Supplied
Multiple versionsME203 Not Provided For future implementation Not Supplied Not Supplied Not Supplied
Multiple versionsME204 Not Provided For future implementation Not Supplied Not Supplied Not Supplied
Multiple versionsME205 Not Provided For future implementation Not Supplied Not Supplied Not Supplied
Multiple versionsME206 Not Provided For future implementation Not Supplied Not Supplied Not Supplied
Multiple versionsME207 Not Provided For future implementation Not Supplied Not Supplied Not Supplied
Multiple versionsME208 Not Provided For future implementation Not Supplied Not Supplied Not Supplied
Multiple versionsME209 Not Provided For future implementation Not Supplied Not Supplied Not Supplied
Multiple versionsME210 Not Provided For future implementation Not Supplied Not Supplied Not Supplied

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Data Element ID Data Element Code Value
ME001 Payer type C Carrier
D Medicaid
G Other government agency
P Pharmacy benefits manager
T Third-party administrator
U Unlicensed entity
ME003 Product code CHP Special Childrens Health Insurance Program (SCHIP)
EPO Commercial EPO
HMO Commercial HMO
IN Commercial indemnity
MC Medicare Cost
MD Medicaid disabled HMO
MDE Medicaid dual eligible HMO
MDF Medicaid fee-for-service
MLI Medicaid low income HMO
MP Medicare Advantage PPO
MPD Medicare Part D only
MR Medicare Advantage HMO
MRB Medicaid restricted benefit HMO
PH Pharmacy benefits only
POS Commercial POS
PPO Commercial PPO
SIF Self insured POS
SIH Self insured HMO
SIP Self insured PPO
SL Commercial stop loss
SN1 Special needs plan - chronic condition
SN2 Special needs plan - institutionalized
SN3 Special needs plan - dual eligible
ZZ Unknown
ME009A PEBB flag 0 otherwise
1 PEBB group
ME009B OEBB flag 0 otherwise
1 OEBB group
ME009C Medical home flag 0 otherwise
1 medical home plan
ME012 Relationship code 1 Spouse
4 Grandfather or Grandmother
5 Grandson or Granddaughter
7 Nephew or Niece
10 Foster Child
15 Ward
17 Stepson or Stepdaughter
18 Self
19 Child
20 Employee
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
ME013 Member gender F female
M male
U unknown
ME018 Medical coverage flag N
Y
ME019 Prescription drug coverage flag N
Y
QC013 ChemDep Benefit - Inpatient N
Y
QC014 ChemDep Benefit - Day/Night N
Y
QC015 ChemDep Benefit - Ambulatory N
Y
QC016 Dental benefit N
Y
QC018 Mental Health Benefit - Inpatient N
Y
QC019 Mental Health Benefit - Day/ Night N
Y
QC020 Mental Health Benefit - Ambulatory N
Y
RE1 Member race A Asian
B Black or African American
I American Indian or Alaska Native
O Other (or multiple races)
P Native Hawaiian or Pacific Islander
R Refused
U Unknown
W White
RE2 Member ethnicity H Hispanic
O Not Hispanic
R Refused
U Unknown
OHLC3 Oregon HVMH flag N
Y
ME009D OMIP flag 0 otherwise
1 OMIP member
ME009E HKC flag 0 otherwise
1 Healthy Kids Connect plan
ME201 Medicare coverage flag A Part A
B Part B
C Part C only
CD Part C and Part D
D Part D only
X other
Z none
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