Revision History Date Version Description Author 12/1/2012 3.0 Administrative Bulletin 12-01; issued 11/8/2012 M. Prettenhofer 1/4/2013 3.1 New Data Elements section: ME045 (MA Exchange Flag); ME055 (Business Type Code); ME072 (Family Size); ME078 (Employer Zip) H. 5/31/2013 3.1 Updated ‘Non-Massachusetts Resident’ section Updated HD009 Elements ME119 changed to Filler Revised ME045, ME120, ME121, ME124-ME132 ME121 (Metal Level): Added option (5) Catastrophic ME134 (APCD Id Code): Added option (6) ICO – Integrated Care Organization H. 5/31/13 3.1 Updated reference wording ME035 – ME039 K. Hines 10/2014 4.0 Administrative Bulletin 14-08 K. Hines Table of Contents
Health care data and information submitted by Health Care Payers and TPAs to CHIA is not a public record. No public disclosure of any health plan information or data shall be made unless specifically authorized under957 CMR 5.00. Acronyms Frequently Used APCD – Claims Database CHIA – Center for Health Information and Analysis CSO – Computer Services Organization DBA – Delegated Benefit Administrator DBM – Dental Benefit Manager DOI – Division of Insurance GIC – Group Insurance Commission ID – Identification; Identifier MA APCD – Massachusetts’ All-Payer Claims Database NPI – National Provider Identifier PBM – Pharmacy Benefit Manager QA – Quality Assurance RA – Risk Adjustment; Risk Adjuster TME / RP – Total Medical Expense / Relative Pricing TPA – Third Party Administrator The File Types: DC – Dental Claims MC – Medical Claims ME – Member Eligibility PC – Pharmacy Claims PR – Product File PV – Provider File BP – Benefit Plan Control File The MA APCD Monthly Member Eligibility File
ME 6 Insured Group or Policy Number 6/24/10 Text ID Group varchar[30] Group / Policy Number Report the number that defines the insured or policy. Do not report the number that uniquely identifies the subscriber or member All 99% A2 ME 7 Coverage Level Code 11/8/12 Lookup Table - Text char[3] Benefit Coverage Level Code Report the code that defines the dependent coverage All 99% A1 Code Description CHD Children Only DEP Dependents Only ECH Employee and Children ELF Employee and Life Partner EMP Employee Only ESP Employee and Spouse FAM Family IND Individual SPC Spouse and Children SPO Spouse Only UNK Unknown ME 8 Subscriber SSN 11/8/12 ID Tax char[9] Subscriber's Social Security Number Report the Subscriber's SSN here; used to create Unique Member ID; will not be passed into analytic file. Do not use hyphen. If not available do not report any value here All 85% A0 ME 9 Plan Specific Contract Number 11/8/12 Text ID Contract varchar[30] Contract Number Report the Plan assigned contract number. Do not include values in this element that will distinguish one member of the family from another. This should be the contract or certificate number for the subscriber and all of the dependents. All 95% A2 ME 10 Member Suffix or Sequence Number 6/24/10 Text ID Sequence varchar[20] Member's Contract Sequence Number Report the unique number / identifier of the member within the contract All 99% B
3 Unknown Other 5 Not Applicable ME 19 Prescription Drug Coverage 11/8/12 Lookup Table - Integer int[1] Indicator - Pharmacy Option Report the value that defines the element. EXAMPLE: 1 = Yes there is Prescription Coverage. All 100% A2 Value Description 1 Yes 2 No 3 Unknown Other 5 Not Applicable ME 20 Dental Coverage 11/8/12 Lookup Table - Integer int[1] Indicator - Dental Option Report the value that defines the element. EXAMPLE: 1 = Yes there is Dental Coverage. All 100% A2 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable ME 21 Race 1 11/8/12 Lookup Table - Text tlkpRace varchar[6] Member's self-disclosed Primary Race Report the Member-identified primary race here. The code value “UNKNOW” (Unknown/not specified), should be used ONLY when Member answers unknown, or refuses to answer. Do not report any value here if data has not been collected. Report only collected data. EXAMPLE: R9 = Other Race All 3% B Code Description R1 American Indian/Alaska Native R2 Asian R3 American
3 Unknown 4 Other 5 Not Applicable ME 25 Ethnicity 1 11/8/12 Lookup Table - OR - Code Source 17 - Text External Code Source 17 - Ethnicity char[6] Member's Primary Ethnicity Report the Member-identified primary ethnicity from either the External Code Source or here, whichever provides the best detail as obtained from the Member / Subscriber. The value “UNKNOW” should be used ONLY when the Member answers unknown, or refuses to answer. Do not report any value here if data has not been collected. Report only collected data. All 3% B Code Description AMERCN American BRAZIL Brazilian CVERDN Cape Verdean CARIBI Caribbean Island (see CDC Code PORTUG Portuguese RUSSIA Russian EASTEU Eastern European OTHER Other Ethnicity UNKNOW Unknown / not specified ME 26 Ethnicity 2 11/8/12 Lookup Table - OR - Code Source 17 - Text External Code Source 17 - Ethnicity char[6] Member's Secondary Ethnicity Report the Member-identified secondary ethnicity from either the External Code Source or here, whichever provides the best detail as obtained from the Member / Subscriber. The “UNKNOW” should be used ONLY when the Member answers unknown, or refuses to answer. Do not report any value here if data has not been collected. Report only collected data. All 2% C Code Description AMERCN American BRAZIL Brazilian
CVERDN Cape Verdean CARIBI Caribbean Island (see CDC Code PORTUG Portuguese RUSSIA Russian EASTEU Eastern European OTHER Ethnicity UNKNOW Unknown / not specified ME 27 Other Ethnicity 6/24/10 Text Free Text Field varchar[20] Member's Other Ethnicity Report the member's self-disclosed ethnicity when ME025 or ME026 is entered as OTHER; if not applicable, do not report any value here Required when ME025 or MC026 = OTHER 99% C ME 28 Primary Insurance Indicator 11/8/12 Lookup Table - Integer int[1] Indicator - Primary Insurance Coverage Report the value that defines the element. EXAMPLE: 1 = Yes, Insurance is Primary (Products, Plans or Benefits that only cover Copays, Coinsurance and Deductibles [Gap Coverage] will answer 2 = No here). All 100% A0 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable ME 29 Coverage Type 11/8/12 Lookup Table - Text char[3] Type of Coverage Code Report the code that defines the type of insurance policy by the enrollee is covered. EXAMPLE: UND = Plan underwritten by the insurer All 98% A0 Code Description ASW Self-funded that are administered by a third-party administrator, where the employer has purchased stop-loss, or group excess, insurance coverage 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
STN Short-term, non-renewable health insurance UND Plans underwritten by the insurer OTH Any other plan. Insurers using this code shall obtain prior approval. ME 30 Market Category Code 11/8/12 Lookup Table - Text varchar[4] Market Category Code Report the code that defines the market, by size and or association, to which the policy is directly sold and issued All 99% A0 Code Description IND Individuals (non-group) ISCO Individuals as a Senior Care Option FCH Individuals on a franchise basis GCV Individuals as group conversion Policies GS1 Employers having exactly 1 employee GS2 Employers having 2 thru 9 employees GS3 Employers having 10 thru 25 employees GS4 Employers having 26 thru 50 employees GLG1 Employers having 51 thru 100 employees GLG2 Employers having 101 thru 250 employees GLG3 Employers having 251 thru 500 employees GLG4 Employers having more than 500 employees GSA Small employers through a qualified association trust OTH Other types of entities. Insurers using this market code shall obtain prior approval. ME 31 Special Coverage 11/8/12 Lookup Table - Text varchar[3] Special Coverage Code Report the code that defines the product coverage as related to a health exchange or Report N/A if neither apply. EXAMPLE: N/A = Not Applicable All 98% A2 Code Description CC Commonwealth Care
HSN Health Safety Net N/A Not Applicable ME 32 Group Name 11/8/12 Text Name Group varchar[50] name Report the group name that the policy is attached to. Report IND for individual policies. Do not report any value here if the data is not available All 80% A2 ME 33 Member language preference 11/8/12 Code Source 7 - Integer External Code Source 7 - Languages int[3] Member's self-disclosed verbal language preference Report the code that defines the spoken language preference of the member. The code value 999 (Unknown/ Not Specified), should only be used when patient/client answers unknown or refuses to answer. Do not report any value here if the submitter does not have the data. Report only collected data. All 3% B ME 34 Member language preference -Other 6/24/10 Text Free Text Field varchar[20] Member's Language Preference Report the other language the member / subscriber has identified. Do not report any value If no other language identified Required when = 997 99% C ME 35 Health Care Home (PCMH) Assigned Flag 11/8/12 Lookup Table - Integer int[1] Health Care Home Assigned indicator Report the value that defines the element. EXAMPLE: 1 = Yes, Member has an assigned approved patient centered medical home for this coverage period. All 100% A2 Value Description 1 Yes 2 No 3 Unknown 4 5 Not Applicable ME 36 Health Care Home (PCMH) Number 11/8/12 Text ID Link to PV002 varchar[30] Health Care Home ID Report the submitter assigned patient centered medical home number. It is anticipated that this will be the same data submitter number used in reporting servicing provider. Do not report any data here if not applicable. The number of the member’s healthcare home must also be in the Provider File in PV002, Provider ID. Required when ME035 = 1 90% C
ME 45 Purchased through Exchange Flag Lookup Table - Integer int[1] Indicator - MA Exchange Purchase Report the value that defines the element. EXAMPLE: 1 = Yes, policy for this eligibility was purchased through MA Health Exchange. Required for Risk Assessment All 100% A2 Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable ME 46 Member PCP ID Text ID Link to varchar[30] Member's PCP ID Report the identifier of the members PCP. The value in this element must have a corresponding Provider ID (PV002) in the Provider File. Report a value of ‘999999999U’ when PCP is unknown or '999999999NA' if the eligibility does not require a PCP. All 98% A2 ME 47 Member PCP Effective Date 6/24/10 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] PCP Effective Date with Member Report the Member enrollment begin date with the PCP in CCYYMMDD Format. Required when PCP ID is not = 999999999U or 98% B ME 48 Member PCP Termination Date 6/24/10 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] PCP Termination Date with Member Report the Member termination date from the PCP in CCYYMMDD Format. If the member is still active with their PCP at the end of the current month, then do not fill with any value Required when PCP ID is not = 999999999U or 98% B
3 Unknown 4 Other 5 Not Applicable ME 53 Disease Enrollee Flag 11/8/12 Lookup - Integer int[1] Chronic Illness Management indicator Report the value that defines the element. EXAMPLE: 1 = Yes, Member's chronic illness is being managed by plan or vendor of plan. All 100% A2 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable ME 54 Eligibility Date 11/8/12 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Eligibility date Report the date the member eligibility was determined in CCYYMMDD Format. All 98% B ME 55 Business Type Code 11/8/12 Lookup - Integer int[1] Business Type Report the value that defines the submitter's line of business for this line of eligibility. EXAMPLE: 1 = Risk Holder of this line of eligibility All 100% A2 Value Description 1 Risk Holder 2 TPA - Third Party Administrator 3 DBA - Delegated Business Administrator 4 PBM - Pharmacy Benefit Manger 5 DBM - Dental Benefit Manager 6 CSO - Computer Service Organization 7 Other 0 Unknown / Not Applicable ME 56 Last Activity Date 11/8/12 Full Date - Integer Century Year Day - CCYYMMDD int[8] Activity Date Report the date of last activity / change on member enrollment file for this line of eligibility in CCYYMMDD Format. This All 98% A2
2 No 3 Unknown 4 Other 5 Not Applicable ME 62 Marital Status 11/8/12 Lookup Table - Text char[1] Marital Status Code Report the member's marital status here All 100% B Code Description C Common Law Married D Divorced M Married P Domestic Partnership S Married W Widowed X Legally Separated U Unknown ME 63 Benefit Status 11/8/12 Lookup Table - Text char[1] Benefit Status Code Report the code that defines status of benefits for the subscriber All 100% A2 Code Description A Active C COBRA P Pending S Surviving Insured T TEFRA U Unknown ME 64 Employee Type 11/8/12 Lookup Table - Text char[1] Employee Type Code Report the code that defines the subscribers employment Required when ME063 = A 100% C Code Description H Hourly Q Seasonal
here. EXAMPLE: 1 = Regular State Employee and Retirees Value Description 1 Regular State Employees and Retirees, plus local authorities 2 Elderly Governmental Retirees (EGR) and Retired Municipal Teachers (RMTs) ME 72 Family Size 11/8/12 Integer Counter varchar[2] Family Size Contracted Report the number of individuals covered the policy/contract (ME009) of the subscriber. This is required for Risk Assessment and Division of Insurance reporting. No alpha or special characters All 100% A2 ME 73 Fully Insured member 11/8/12 Lookup - Integer int[1] Insured identifier Report the that defines the element. EXAMPLE: 1 = Yes, Member is fully insured. All 100% A0 Value Description 1 Yes 2 No 3 Unknown 4 5 Not Applicable ME 74 Interpreter 11/8/12 Lookup Table - Integer int[1] Indicator - Interpreter Need Report the value that defines the element. EXAMPLE: 1 = Yes, Member requires an interpreter. All 100% A2 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable ME 75 NewMMIS ID 6/24/10 Text ID MassHealth char[12] Member ID Report the unique ID that NewMMIS uses to identify a member. This ID must be on all lines of eligibility for MassHealth and Medicaid MCOs Required when ME134 = 4 98% B
ME 76 Member rating category 6/24/10 Carrier - Text Carrier Defined Table - MCO Rating Category char[5] Member Rating Category Code Report the rating category of the member here. Required when ME134 = 4 90% B ME 77 Members NAICS Code 11/8/12 Code Source 6 - External Code Source 6 - Standard Industry Class varchar[6] Member Standard or SIC Code Report the standard code that describes the industry of the subscriber / member. This can be from either the 6-digit list or the SIC 4-digit list All 2% C ME 78 Employer Zip Code (Situs) 11/8/12 Code Source 2 - Text External Code Source 2 - Zip Codes char[5] Zip code of the Employer Report the 5 Zip Code of the Employer of the Subscriber/Member as defined by the United States Postal Service. Required for GIC and Division of Insurance Reporting. (Situs) All 90% A2 ME 79 Recipient Number only) 11/8/12 Text ID MassHealth varchar[15] Member ID Report the previous MassHealth identification number here. This element is for MassHealth or Medicaid MCOs only and should only be populated when reporting older lines of eligibility Required when ME134 = 4 98% B ME 80 Recipient Historical Number only) 6/24/10 Text ID MassHealth varchar[15] Member ID Report the permanent MassHealth identification number here. This element is for MassHealth or Medicaid MCOs only and should only be populated when reporting older lines of eligibility. Required when ME134 = 4 98% B ME 81 Medicare Code 11/8/12 Lookup Table - Integer int[1] Medicare Plan Indicator Code Report the value that defines if and what type of Medicare coverage that applies to this line of eligibility. EXAMPLE: 1 = Part A Only All 100% B Value Description 1 Part A Only 2 Part B Only 3 Part A and B 4 Part C Only 5 Advantage 6 Part D Only 9 Not Applicable
ME 99 Vision Deductible 11/8/12 Integer Currency varchar[10] Maximum out of pocket amount of member's deductible applied to vision services Report the maximum amount of the member / subscriber’s deductible that is applied to vision services before certain vision services are covered. If deductible does not apply when vision benefits are available, submit as zero. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when ME118 = 1 98% A2 ME Carrier Specific Unique Subscriber ID 11/8/12 Text ID Link to MC141, PC108, DC057 varchar[50] Subscriber's Unique ID Report the identifier the carrier / submitter uses internally to uniquely identify the subscriber. Used to create Unique Member ID and link across carrier's / submitter's files for reporting and aggregation All 100% A0 ME Vision Benefit 11/8/12 Lookup Table - Integer int[1] Indicator - Vision Option Report the value that defines the element. EXAMPLE: 1 = Yes, Vision is a covered benefit. All 100% A0 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable ME Filler 4/5/13 Filler Filler char[0] Filler The APCD reserves this field for future use. Do not populate with any data. All 0% Z ME Actuarial - Percent as 0.0000 varchar[6] The actuarial value of the risk adjustment covered plan the member is enrolled in Calculate using the Federal AV Calculator for the risk adjustment covered plan the member is enrolled in. Report the Actuarial Value of this member as of the 15th of the month. Format to be used is 0.0000. For example, an AV of 88.27689% should be reported as 0.8828. Required when ME126 = 1 or 3 100% A0 ME Metal Level Lookup - Integer int[1] Standardized plan level in metal reference Report the Level benefits that the member is associated to in this line of eligibility. Required for Risk Assessment. EXAMPLE: 1 = Bronze Level Required when ME126 = 1 or 3 100% A0 116 117 118
ME Benefit Plan Contract ID Text Benefit Plan ID varchar [30] Identifier for the benefit plan the member is enrolled in as of 15th of the The Benefit Plan Contract ID is the issuer-generated unique ID number for each benefit plan for the issuer sets a premium in the Massachusetts merged (non-group/small group) market. Report the carrier/submitter-assigned identifier as it appears in in the Benefit Plan File. This element is used to understand Benefit Plan and Eligibility attributes of the member / subscriber as applied to this record for the Massachusetts Alternative Risk Adjustment Methodology. Required when ME126 = 1 or 3 100% A0 ME Member Benefit Plan Contract Enrollment Start Date Date CCYYMMDD Int(8) Date the member is enrolled in the benefit plan Report the date the member was enrolled in the Benefit Plan in CCYYMMDD format. Required when = 1 or 3 100% A0 ME Member Benefit Plan Contract Enrollment End Date Date CCYYMMDD Int(8) Date the member’s enrollment ends with the benefit plan Report the date the member disenrolled in the Benefit Plan in CCYYMMDD format. When member is still active in the Benefit Plan, do not report any date in this element. Required when ME126 = 1 or 3 and member is disenrolled 100% B ME TME Global Indicator 4/5/13 Integer Int[1] TME Global Indicator Required when Submitter is identified as a TME / RP Submitter. Report whether the member’s contract was assigned under a global budget/payment contract. EXAMPLE: 1 = Yes, the member’s contract was assigned under a global/budget/payment contract. Assigned Submitters only. 100% A2 Description 1 Yes 2 No
1 Record Type 6/24/10 Text ID Record char[2] Trailer Record Identifier Report TR here. Indicates the end of the data file Mandatory 100% TM 2 Submitter 11/8/12 Integer ID Submitter varchar[6] Trailer Submitter / Carrier ID defined by CHIA Report the Unique Submitter ID as defined by CHIA here. This must the Submitter ID reported in HD002 Mandatory 100% TM 3 National Plan ID 11/8/12 Integer ID Nat'l PlanID int[10] CMS National Plan Identification Number (PlanID) Do not report any value here until National PlanID is fully implemented. This is a unique identifier as outlined by Centers for Medicare and Medicaid Services (CMS) for Plans or Sub plans Situational 0% TS 4 Type of File 6/24/10 Text ID File char[2] Validates the file type defined in HD004. Report ME here. This must match the File Type reported in HD004 Mandatory 100% TM 5 Period Beginning Date 6/24/10 Date Period - Integer Century Year Month - CCYYMM int[6] Trailer Period Start Date Report the Year and Month of the reported submission period in CCYYMM format. This date period must match the date period reported in HD005, HD006 and TR006 Mandatory 100% TM 6 Period Ending Date 6/24/10 Date Period - Integer Century Year Month - CCYYMM int[6] Trailer Period Ending Date Report the Year and Month of the reporting submission period in CCYYMM format. This date period must match the date period reported in TR005 and HD005 and HD006 Mandatory 100% TM 7 Date Processed 6/24/10 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Trailer Processed Date Report the full date that the submission was compiled by the submitter in CCYYMMDD Format. Mandatory 100% TM Appendix – External Code Sources 2. States, Zip Codes and Other Areas of the US U.S. Postal Service