Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 590 - MAINE HEALTH DATA ORGANIZATION › Chapter 243 - UNIFORM REPORTING SYSTEM FOR HEALTH CARE CLAIMS DATA SETS › Appendix 590-243-C-1 - Maine Health Data Organization Member eligibility File Specifications

Current through 2024-29, July 17, 2024
Data Element
								#
Data Element
								Name
Date
								Effective
Type
Maximum
								Length
Description/Codes/Sources
ME001
Submitter
1/1/2003
Text
8
MHDO-assigned identifier of payor submitting claims
								data. Do not leave blank.
ME002
Payor
7/1/2012
Text
8
MHDO-assigned code of the insurer/underwriter in
								the case of premiums-based coverage, or of the administrator in the case of
								self-funded coverage. Do not leave blank.
ME003
Insurance Type/Product
								Code
1/1/2003
Text
2
Code identifying the type of insurance policy
								within a specific insurance program. Refer to Appendix A
HN Medicare Part C
MD Medicare Part D
ME004
Year
1/1/2003
Number
4
Year for which eligibility is reported in this
								submission
ME005
Month
1/1/2003
Text
2
Month for which eligibility is reported in this
								submission
ME006
Insured Group or Policy
								Number
1/1/2003
Text
30
Group or policy number - not the number that
								uniquely identifies the subscriber
ME007
Coverage Level Code
1/1/2003
Text
3
Benefit coverage level Refer to Appendix
								A
ME008
Subscriber Social Security
								Number
1/1/2003
Text
9
Subscriber's social security number Leave blank if
								unavailable
ME009
Plan Specific Contract
								Number
1/1/2003
Text
80
Plan-assigned subscriber's contract number Leave
								blank if contract number = subscriber's social security number
ME010
Member Suffix or Sequence
								Number
1/1/2003
Text
20
Unique number of the member within the
								contract
ME011
Member Identification
								Code
1/1/2003
Text
50
Member's social security number Leave blank if
								unavailable
ME012
Individual Relationship
								Code
1/1/2003
Text
2
Member's relationship to insured Refer to Appendix
								A
ME013
Member Gender
1/1/2003
Text
1
Refer to Appendix A
ME014
Member Date of Birth
1/1/2003
Text
8
CCYYMMDD
ME015
Member City Name
4/1/2004
Text
30
City name of member Refer to Appendix A
ME016
Member State or
								Province
4/1/2004
Text
2
As defined by the US Postal Service and Canada Post
								Refer to Appendix A
ME017
Member ZIP Code
1/1/2003
Text
11
ZIP Code of member - may include non-US codes. Do
								not include dash Refer to Appendix A
ME018
Medical Coverage
1/1/2003
Text
1
N No
Y Yes
ME019
Prescription Drug
								Coverage
1/1/2003
Text
1
N No
Y Yes
ME020
Dental Coverage
1/1/2003
Text
1
N No
Y Yes
ME021
Race 1
1/1/2021
Text
2
Report the Member-identified race using the first
								two characters of the CDC Hierarchical Code. The code value "UN" (Unknown/not
								specified) should be used ONLY when Member answers unknown or refuses to
								answer. Report only collected data. If not available, leave blank. Refer to
								Appendix A.
For quick reference, the two-character subset of
								the CDC race list is:
R1 American Indian/Alaska Native
R2 Asian
R3 Black/African American
R4 Native Hawaiian or Other Pacific Islander
R5 White
R9 Other Race
UN Unknown/Not Specified
ME022
Race 2
1/1/2021
Text
2
Report the Member-identified race using the first
								two characters of the CDC Hierarchical Code. The code value "UN" (Unknown/not
								specified) should be used ONLY when Member answers unknown or refuses to
								answer. Report only collected data. If not available, leave blank. Refer to
								Appendix A.
ME023
Race 3
1/1/2021
Text
2
Report the Member-identified race using the first
								two characters of the CDC Hierarchical Code. The code value "UN" (Unknown/not
								specified) should be used ONLY when Member answers unknown or refuses to
								answer. Report only collected data. If not available, leave blank. Refer to
								Appendix A.
ME024
Hispanic Indicator
1/1/2021
Text
1
Report the value that defines the element. The code
								value "U" for unknown should be used ONLY when member answers unknown or
								refuses to answer. Report only collected data. If not available, leave
								blank.
Y Member is Hispanic/Latino/Spanish
N Member is not Hispanic/Latino/Spanish
U Unknown/not specified.
ME025
Ethnicity 1
1/1/2021
Text
6
Report the Member-identified ethnicity from the
								External Code Source that best describes the information obtained from the
								Member / Subscriber. The value "UNKNOW" should be used ONLY when the Member
								answers unknown or refuses to answer. Report only collected data. If not
								available, leave blank. Refer to Appendix A. Report the CDC Unique Identifiers
								(format NNNN-N; 6 characters).
ME026
Ethnicity 2
1/1/2021
Text
6
Report the Member-identified ethnicity from the
								External Code Source that best describes the information obtained from the
								Member / Subscriber. The value "UNKNOW" should be used ONLY when the Member
								answers unknown or refuses to answer. Report only collected data. If not
								available, leave blank. Refer to Appendix A. Report the CDC Unique Identifiers
								(format NNNN-N; 6 characters).
ME027
Ethnicity 3
1/1/2021
Text
6
Report the Member-identified ethnicity from the
								External Code Source that best describes the information obtained from the
								Member / Subscriber. The value "UNKNOW" should be used ONLY when the Member
								answers unknown or refuses to answer. Report only collected data. If not
								available, leave blank. Refer to Appendix A. Report the CDC Unique Identifiers
								(format NNNN-N; 6 characters).
ME028
Primary Insurance
								Indicator
1/1/2010
Number
1
1 Yes - primary insurance
2 No - secondary, or tertiary insurance
ME029
Coverage Type
1/1/2010
Text
3
ASO - 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 - self-funded plans that are administered by a
								third-party administrator, where the employer has purchased stop-loss, or group
								excess, insurance coverage
OTH - any other plan. Insurers using this code
								shall obtain prior approval.
STN - short-term, non-renewable health
								insurance
UND - plans underwritten by the insurer
ME030
Market Category Code
1/1/2010
Text
4
IND - coverage sold and issued directly to
								individuals (non-group)
FCH - coverage sold and issued directly to
								individuals on a franchise basis
GCV - coverage sold and issued directly to
								individuals as group conversion policies
GS1 - coverage sold and issued directly to
								employers having exactly one employee
GS2 - coverage sold and issued directly to
								employers having between two and nine employees
GS3 - coverage sold and issued directly to
								employers having between 10 and 25 employees
GS4 - coverage sold and issued directly to
								employers having between 26 and 50 employees
GLG1 - coverage sold and issued directly to
								employers having between 51 and 99 employees
GLG2 - coverage sold and issued directly to
								employers having 100 or more employees
GSA - coverage sold and issued directly to small
								employers through a qualified association trust
OTH - coverage sold to other types of entities.
								Insurers using this market code shall obtain prior approval.
ME031
Special Coverage
N/A
Number
3
State-specific assignment. Default value for Maine
								is "0".
ME032
Group Name
1/1/2010
Text
128
Group name or IND for individual policies, and
								BLANK if data is not available
ME101
Subscriber Last Name
1/1/2010
Text
60
The subscriber last name
ME102
Subscriber First Name
1/1/2010
Text
35
The subscriber first name
ME103
Subscriber Middle Name
1/1/2010
Text
25
The subscriber middle name or initial
ME104
Member Last Name
1/1/2010
Text
60
The member last name
ME105
Member First Name
1/1/2010
Text
35
The member first name
ME106
Member Middle Name
1/1/2010
Text
25
The member middle name or initial
ME107
Member Address Line 1
2/1/2019
Text
55
ME108
Member Address Line 2
2/1/2019
Text
55
ME109
Member Country Code
2/1/2019
Text
2
Use ISO 3166-1 alpha-2 country codes. Refer to
								Appendix A.
ME110
Placeholder
2/1/2021
N/A
0
Subscriber's Health Insurance Claim Number retired.
								Leave blank.
ME111
Subscriber MBI
2/1/2019
Text
11
Subscriber's Medicare Beneficiary Identifier. May
								be populated starting February 1, 2019 or as soon as MBI is available for
								reporting. Required starting January 1, 2020 or if ME110 is not
								present.
ME112
Placeholder
2/1/2021
N/A
0
Member's Health Insurance Claim Number retired.
								Leave blank.
ME113
Member MBI
2/1/2019
Text
11
Member's Medicare Beneficiary Identifier. Required
								only for Medicare Supplemental/Companion Plans for which 1) the subscriber and
								the member are not the same person, 2) the payor is primary and 3) ME112 is not
								present. Otherwise, leave blank. If not the same as ME111, may be populated
								starting February 1, 2019; however, only required starting January 1,
								2020.
ME114
Plan Begin Date (Member Effective
								Date)
2/1/2020
Text
8
CCYYMMDD. Effective date of coverage. Date
								eligibility started for this member under this plan type.
ME115
Plan End Date (Member Cancellation
								Date)
2/1/2020
Text
8
CCYYMMDD. Last continuous day of coverage (date
								eligibility ended) for this member under this plan. For open contracts, leave
								blank.
ME116
Grandfathered Plan
								Indicator
2/1/2025
Text
1
Indicates if a plan qualifies as a "Grandfathered"
								or "Transitional Plan" under the Affordable Care Act (ACA). Please see
								definition for "grandfathered" and "transitional" in HHS rules 45-CFR-147.140:
https://www.federalregister.gov/select-citation/2013/06/03/45-CFR-147
.
								The values of the indicator are as follows:
1=Grandfathered;
2=Non-Grandfathered;
3=Transitional;
4=Not Applicable.
ME117
Metal Tier
2/1/2025
Text
1
For Non-Grandfathered health plans for the
								Individual and Small Group markets (under ACA) ONLY. Health benefit plan metal
								tier for qualified health plans (QHPs) and catastrophic plans as defined in the
								Patient Protection and Affordable Care Act,  Public Law 111-148, Section
								1302 :
Essential Health Benefits Requirements:
0=Not a QHP or catastrophic plan;
1=Catastrophic;
2=Bronze;
3=Silver;
4=Gold;
5=Platinum.
If not applicable, leave blank.
ME118
Enrolled Through a Public Health Insurance
								Exchange
2/1/2025
Text
1
For Non-Grandfathered health plans for the
								Individual and Small Group markets (under ACA) ONLY. Use this field to report
								whether the policy for this eligibility record was enrolled through a Public
								Health Insurance Exchange.
Valid codes include:
1=Yes;
2=No;
3=Unknown/not applicable.
ME119
Cost-Sharing Reduction
								Indicator
2/1/2025
Text
1
For Non-Grandfathered health plans for the
								Individual and Small Group markets (under ACA) ONLY. Indicates cost-sharing
								reduction under the Affordable Care Act (ACA). This is a person- level
								indicator in which enrollees who qualify for cost-sharing reduction are
								assigned cost- sharing indicator values of 1-8. Non-Cost-Sharing recipients are
								assigned a costsharing indicator value of zero. Valid codes include:
								1=Enrollees in 94% Actuarial Value (AV) Silver Plan Variation;
2=Enrollees in 87% AV Silver Plan Variation;
3=Enrollees in 73% AV Silver Plan Variation;
4=Enrollees in Zero Cost Sharing Plan Variation of
								Platinum Level QHP (Qualified Health Plan);
5=Enrollee in Zero Cost Sharing Plan Variation of
								Gold Level QHP;
6=Enrollee in Zero Cost Sharing Plan Variation of
								Silver Level QHP;
7=Enrollee in Zero Cost Sharing Plan Variation of
								Bronze Level QHP;
8=Enrollee in Limited Cost Sharing Plan
								Variation;
0=Non-CSR recipient, and enrollees with unknown
								CSR.
ME899
Record Type
1/1/2003
Text
2
ME