California Code of Regulations
Title 22 - Social Security
Division 7 - Health Planning and Facility Construction
Chapter 11 - Health Care Payments Data Program
Article 5 - Monthly Data File Submission
Section 97342 - Data File Contents

Universal Citation: 22 CA Code of Regs 97342

Current through Register 2024 Notice Reg. No. 38, September 20, 2024

(a) The following files, as specified in the Data Submission Guide in conjunction with the APCD-CDLT, shall be submitted.

(1) Member Eligibility File (ME)--contains demographic information for each individual member residing in California, regardless of whether the member utilized services during the reporting period.

(2) Medical Claims File (MC)--contains service-level medical claims and encounter data processed during the reporting period, that were not fully denied, except as prohibited by federal or state law.

(3) Pharmacy Claims File (PC)--contains detailed pharmacy claims and encounter data processed during the reporting period, that were not fully denied, except as prohibited by federal or state law.

(4) Dental Claims File (DC)--contains service-level dental claims and encounter data processed during the reporting period, that were not fully denied, except as prohibited by federal or state law.

(5) Provider File (PV)--contains demographic-type data on every provider included on the ME, MC, PC, or DC files during the reporting period.

(b) Files shall exclude data for any members who are exclusively enrolled in Medi-Cal or one of the following types of coverage:

(1) Supplemental (including Medicare supplemental).

(2) Student health.

(3) Chiropractic-only.

(4) Acupuncture-only.

(5) Vision-only.

Note: Authority cited: Section 127673, Health and Safety Code. Reference: Sections 127671.1, 127673 and 127673.1, Health and Safety Code.

Note: Authority cited: Section 127673, Health and Safety Code. Reference: Sections 127671.1, 127673 and 127673.1, Health and Safety Code.

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