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-G-1 - Maine Health Data Organization Capitated Payments File Specification

Current through 2024-29, July 17, 2024
Data Element
								#
Data Element Name
Date
								Effective
Type
Maximum
								Length
Description/Codes/Sources
CF001
Submitter
2/1/2025
Text
8
MHDO-assigned identifier of payor submitting
								payment data. Do not leave blank.
CF002
Payor
2/1/2025
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.
CF003
Insurance Type/Product
								Code
2/1/2025
Text
2
Code identifying the type of insurance policy
								within a specific insurance program. Refer to Appendix A
CF004
Subscriber Social Security
								Number
2/1/2025
Text
9
Subscriber's social security number Leave blank if
								unavailable. Shall be left blank when the payor indicates the record contains
								42 CFR Part 2 SUD-related data by setting the values of CF035 = 'Y' and MC333 =
								'Y' on any 42 CFR Part 2 SUD-related service records for this member in the
								medical claims file.
CF005
Member Identification
								Code
2/1/2025
Text
10
Member's social security number Leave blank if
								unavailable. Shall be left blank when the payor indicates the record contains
								42 CFR Part 2 SUD-related data by setting the values of CF035 = 'Y' and MC333 =
								'Y' on any 42 CFR Part 2 SUD-related service records for this member in the
								medical claims file.
CF006
Plan Specific Contract
								Number
2/1/2025
Text
80
Plan-assigned contract number Leave blank if
								contract number = subscriber's social security number. Shall be left blank when
								the payor indicates the record contains 42 CFR Part 2 SUD-related data by
								setting the values of CF035 = 'Y' and MC333 = 'Y' on any 42 CFR Part 2
								SUD-related service records for this member in the medical claims
								file.
CF007
Member Suffix or Sequence
								Number
2/1/2025
Text
20
Uniquely numbers the member within the contract.
								Shall be left blank when the payor indicates the record contains 42 CFR Part 2
								SUD-related data by setting the values of CF035 = 'Y' and MC333 = 'Y' on any 42
								CFR Part 2 SUD-related service records for this member in the medical claims
								file.
CF008
Carrier Specific Unique Member (CSUM)
								ID
2/1/2025
Text
50
This ID should uniquely and consistently identify a
								member in both the medical claims and the capitated payments files. It shall be
								used when the payor indicates that related records in the medical and
								capitation files contain 42 CFR Part 2 SUD-related data (CF035 = 'Y' and MC333
								= 'Y' on the related service records), and other inter-file identifiers shall
								be left blank. For fully identified data records that do not contain 42 CFR
								Part 2-related data (CF035 = 'N' and MC333 = 'N' on the related service
								records), the CSUM ID shall be left blank, and all other inter-file identifiers
								shall be populated, when available. This ID must differ from any of the other
								identifiers on the record and may not be derived from any of these in a manner
								that the original values could be determined.
CF009
Insured Group or Policy
								Number
2/1/2025
Text
30
Group or policy number - not the number that
								uniquely identifies the subscriber. Shall be left blank when the payor
								indicates the record contains 42 CFR Part 2 SUD-related data by setting the
								values of CF035 = 'Y' and MC333 = 'Y' on any 42 CFR Part 2 SUD-related service
								records for this member in the medical claims file.
CF010
Monetary Amount/Provider
								Adjustment
Amount
2/1/2025
Number
10
This is the per member per month amount paid to the
								provider.
Excludes any withhold amounts.
Do not code decimal point. Two decimal places
								implied.
CF011
Payment Subcategory
2/1/2025
Text
2
D1 = Primary care capitation
D2 = Professional capitation
D3 = Facility Capitation
D4 = Behavioral health capitation
D5 = Global capitation
D6 = Payment to integrated, comprehensive payment
								and delivery systems
CF012
Performance Period
								Year
2/1/2025
Number
4
Year of the performance period covered by the
								payment on this record.
CF013
Performance Period
								Month
2/1/2025
Text
2
Month of the performance period covered by the
								payment on this record.
CF014
Withhold Amount
2/1/2025
Number
10
The amount that is deducted from the payment to the
								physician group/physician that may or may not be returned depending on specific
								predetermined factors. This could be an amount being withheld until an agreed
								upon quality goal is met. This may be part of an ACO agreement.
Do not code decimal point. Two decimal places
								implied.
CF015
Member Gender
2/1/2025
Text
1
Refer to Appendix A
Shall be left blank when the payor indicates the
								record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 =
								'Y' and MC333 = 'Y' on any 42 CFR Part 2 SUD-related service records for this
								member in the medical claims file.
CF016
Member Date of Birth
2/1/2025
Text
8
CCYYMMDD Shall be left blank when the payor
								indicates the record contains 42 CFR Part 2 SUD-related data by setting the
								values of CF035 = 'Y' and MC333 = 'Y' on any 42 CFR Part 2 SUD-related service
								records for this member in the medical claims file.
CF017
Rendering Provider
								Specialty
2/1/2025
Text
10
Refer to Appendix A If defined by payor, then
								dictionary for specialty code values must be supplied during testing. Shall be
								left blank when the payor indicates the record contains 42 CFR Part 2
								SUD-related data by setting the values of CF035 = 'Y' and MC333 = 'Y' on any 42
								CFR Part 2 SUD-related service records for this member in the medical claims
								file.
CF018
Rendering Provider
								Number
2/1/2025
Text
30
Payor-assigned rendering provider number Shall be
								left blank when the payor indicates the record contains 42 CFR Part 2
								SUD-related data by setting the values of CF035 = 'Y' and MC333 = 'Y' on any 42
								CFR Part 2 SUD-related service records for this member in the medical claims
								file.
CF019
Rendering Provider Tax
								ID
2/1/2025
Text
10
Federal taxpayer's identification number Shall be
								left blank when the payor indicates the record contains 42 CFR Part 2
								SUD-related data by setting the values of CF035 = 'Y' and MC333 = 'Y' on any 42
								CFR Part 2 SUD-related service records for this member in the medical claims
								file.
CF020
National Provider ID - Rendering
								Provider
2/1/2025
Text
20
National Provider ID for Rendering Provider This
								data element pertains to the entity or individual directly providing the
								service.
Refer to Appendix A Shall be left blank when the
								payor indicates the record contains 42 CFR Part 2 SUD-related data by setting
								the values of CF035 = 'Y' and MC333 = 'Y' on any 42 CFR Part 2 SUD-related
								service records for this member in the medical claims file.
CF021
Rendering Provider Last Name or Organization
								Name
2/1/2025
Text
60
Full name of provider organization or last name of
								individual Provider Shall be left blank when the payor indicates the record
								contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = 'Y'
								and MC333 = 'Y' on any 42 CFR Part 2 SUD-related service records for this
								member in the medical claims file.
CF022
Rendering Provider First
								Name
2/1/2025
Text
40
Individual first name Leave blank if provider is a
								facility or organization. Shall be left blank when the payor indicates the
								record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 =
								'Y' and MC333 = 'Y' on any 42 CFR Part 2 SUD-related service records for this
								member in the medical claims file.
CF023
Billing Provider
								Number
2/1/2025
Text
30
Payor-assigned billing provider number. This number
								should be the identifier used by the payor for internal identification
								purposes, and does not routinely change.
Shall be left blank when the payor indicates the
								record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 =
								'Y' and MC333 = 'Y' on any 42 CFR Part 2 SUD-related service records for this
								member in the medical claims file.
CF024
Billing Provider Tax
								ID
2/1/2025
Text
10
Federal taxpayer's identification number Shall be
								left blank when the payor indicates the record contains 42 CFR Part 2
								SUD-related data by setting the values of CF035 = 'Y' and MC333 = 'Y' on any 42
								CFR Part 2 SUD-related service records for this member in the medical claims
								file.
CF025
National Provider ID - Billing
								Provider
2/1/2025
Text
20
National Provider ID for billing provider Refer to
								Appendix A
Shall be left blank when the payor indicates the
								record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 =
								'Y' and MC333 = 'Y' on any 42 CFR Part 2 SUD-related service records for this
								member in the medical claims file.
CF026
Billing Provider Last Name or Organization
								Name
2/1/2025
Text
60
Full name of provider billing organization or last
								name of individual billing provider.
Shall be left blank when the payor indicates the
								record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 =
								'Y' and MC333 = 'Y' on any 42 CFR Part 2 SUD-related service records for this
								member in the medical claims file.
CF027
Member First Name
2/1/2025
Text
35
The member first name Shall be left blank when the
								payor indicates the record contains 42 CFR Part 2 SUD-related data by setting
								the values of CF035 = 'Y' and MC333 = 'Y' on any 42 CFR Part 2 SUD-related
								service records for this member in the medical claims file.
CF028
Member Middle Name
2/1/2025
Text
25
The member middle name or initial Shall be left
								blank when the payor indicates the record contains 42 CFR Part 2 SUD-related
								data by setting the values of CF035 = 'Y' and MC333 = 'Y' on any 42 CFR Part 2
								SUD-related service records for this member in the medical claims
								file.
CF029
Member Last Name
2/1/2025
Text
60
The member last name Shall be left blank when the
								payor indicates the record contains 42 CFR Part 2 SUD-related data by setting
								the values of CF035 = 'Y' and MC333 = 'Y' on any 42 CFR Part 2 SUD-related
								service records for this member in the medical claims file.
CF030
Member Address Line 1
2/1/2025
Text
55
Shall be left blank when the payor indicates the
								record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 =
								'Y' and MC333 = 'Y' on any 42 CFR Part 2 SUD-related service records for this
								member in the medical claims file.
CF031
Member Address Line 2
2/1/2025
Text
55
Shall be left blank when the payor indicates the
								record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 =
								'Y' and MC333 = 'Y' on any 42 CFR Part 2 SUD-related service records for this
								member in the medical claims file.
CF032
Member City Name
2/1/2025
Text
30
City name of member Refer to Appendix A Shall be
								left blank when the payor indicates the record contains 42 CFR Part 2
								SUD-related data by setting the values of CF035 = 'Y' and MC333 = 'Y' on any 42
								CFR Part 2 SUD-related service records for this member in the medical claims
								file.
CF033
Member State or
								Province
2/1/2025
Text
2
As defined by the US Postal Service and Canada Post
								Refer to Appendix A Shall be left blank when the payor indicates the record
								contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = 'Y'
								and MC333 = 'Y' on any 42 CFR Part 2 SUD-related service records for this
								member in the medical claims file.
CF034
Member ZIP Code
2/1/2025
Text
11
ZIP Code of member - may include non-US codes Refer
								to Appendix A Shall be left blank when the payor indicates the record contains
								42 CFR Part 2 SUD-related data by setting the values of CF035 = 'Y' and MC333 =
								'Y' on any 42 CFR Part 2 SUD-related service records for this member in the
								medical claims file.
CF035
Substance Use Disorder (SUD)
								Indicator
2/1/2025
Text
1
Indicates whether a record contains 42 CFR Part 2
								SUD-related data or not. Valid values are:
N = Record does not contain 42 CFR Part 2
								SUD-related data. Send all available values of all requested fields.
Y = Record contains 42 CFR Part 2 SUD-related data.
								The following fields shall be left blank: CF004-CF007; CF009;
								CF015-CF034.
NOTE: only 42 CFR Part 2 SUD-related payment
								records shall be marked with 'Y'; other payment records that are not 42 CFR
								Part 2 SUD-related shall be marked with 'N'.
CF899
Record Type
2/1/2025
Text
2
Value = CF
To ensure the security of personally identifiable
								information and personal health information that is submitted to the MHDO Data
								Warehouse and to reduce file transmission times, MHDO requires submitters to
								compress and encrypt all files before uploading to the warehouse. This
								file-level encryption will ensure the confidentiality of all data that are
								submitted to the warehouse, not just individual fields.