Code of Vermont Rules
Agency 21 - DEPARTMENT OF FINANCIAL REGULATION
Sub-Agency 040 - DIVISION OF HEALTH CARE ADMINISTRATION
Chapter 021 - REGULATION H-2008-01 - VERMONT HEALTHCARE CLAIMS UNIFORM REPORTING AND EVALUATION SYSTEM ("VHCURES")
Section 21 040 021 - REGULATION H-2008-01 - VERMONT HEALTHCARE CLAIMS UNIFORM REPORTING AND EVALUATION SYSTEM ("VHCURES")

Universal Citation: VT Code of Rules 21 040 021

Current through August, 2024

Section 1 Purpose

The purpose of this rule is to set forth the requirements for the submission of health care claims data, member eligibility data, and other information relating to health care provided to Vermont residents or by Vermont health care providers and facilities by health insurers, managed care organizations, third party administrators, pharmacy benefit managers and others to the Department of Banking, Insurance, Securities and Health Care Administration and conditions for the use and dissemination of such claims data, all as required by and consistent with the purposes of 18 V.S.A. § 9410.

Section 2 Authority

This rule is issued pursuant to the authority vested in the Commissioner of the Department of Banking, Insurance, Securities and Health Care Administration by 18 V.S.A. § 9410, as well as 8 V.S.A. § 15 and other applicable portions of Chapter 221 of Title 18.

Section 3 Definitions

As used in this Rule

A. "BISHCA" or "Department" means the Vermont Department of Banking, Insurance, Securities and Health Care Administration.

B. "Capitated services" means services rendered by a provider through a contract in which payment are based upon a fixed dollar amount for each member on a monthly basis.

C. "Cell size" means the count of persons that share a set of characteristics contained in a statistical table.

D. "Charge" means the actual dollar amount charged on the claim.

E. "Co-insurance" means the percentage a member pays toward the cost of a covered service.

F. "Commissioner" means the commissioner of the Department of Banking, Insurance, Securities and Health Care Administration or his or her designee.

G. "Co-payment" means the fixed dollar amount a member pays to a health care provider at the time a covered service is provided or the full cost of a service when that is less than the fixed dollar amount.

H. "Current Procedural Terminology (CPT)" means a medical code set of physician and other services, maintained and copyrighted by the American Medical Association (AMA), and adopted by the U.S. Secretary of Health and Human Services as the standard for reporting physician and other services on standard transactions.

I. "Data set" means a collection of individual data records, whether in electronic or manual files.

J. "Deductible" means the total dollar amount a member pays towards the cost of covered services over an established period of time before the contracted third-party payer makes any payments.

K. "De-identified health information" means information that does not identify an individual patient, member or enrollee and with respect to which no reasonable basis exists to believe that the information can be used to identify an individual patient, member or enrollee. De-identification means that health information is not individually identifiable and requires the removal of Direct Personal Identifiers associated with patients, members or enrollees.

L. "Direct personal identifiers" is information relating to an individual patient, member or enrollee that contains primary or obvious identifiers, including:
(1) Names;

(2) Business names when that name would serve to identify a person;

(3) Postal address information other than town or city, state, and 5-digit zip code;

(4) Specific latitude and longitude or other geographic information that would be used to derive postal address;

(5) Telephone and fax numbers;

(6) Electronic mail addresses;

(7) Social security numbers;

(8) Vehicle Identifiers and serial numbers, including license plate numbers;

(9) Medical record numbers;

(10) Health plan beneficiary numbers;

(11) Certificate and license numbers;

(12) Internet protocol (IP) addresses and uniform resource locators (URL) that identify a business that would serve to identify a person;

(13) Biometric identifiers, including finger and voice prints; and

(14) Personal photographic images.

M. "Disclosure" means the release, transfer, provision of access to, or divulging in any other manner of information outside the entity holding the information.

N. "Encrypted identifier" is a code or other means of record identification to allow patients, members or enrollees to be tracked across the data set without revealing their identity. Encrypted identifiers are not direct identifiers.

O. "Encryption" means a method by which the true value of data has been disguised in order to prevent the identification of persons or groups, and which does not provide the means for recovering the true value of the data.

P. "Health benefit plan" means a policy, contract, certificate or agreement entered into, or offered by a health insurer to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services.

Q. "Healthcare claims data" means information consisting of or derived directly from member eligibility files, medical claims files, pharmacy claims files and other related data pursuant to the Vermont Healthcare Claims Uniform Reporting and Evaluation System (VHCURES) in effect at the time of the data submission. "Healthcare claims data" does not include analysis, reports, or studies containing information from health care claims data sets if those analyses, reports, or studies have already been released in response to another request for information or as part of a general distribution of public information by BISHCA.

R. "Healthcare premium" means the dollar amount charged for any policies offered by health insurers which partially or fully cover the cost of health care services.

S. "Healthcare Common Procedure Coding System (HCPCS)" means a medical code set that identifies health care procedures, equipment, and supplies for claim submission purposes. These are often known as "local codes".

T. "Health care" means care, services, or supplies related to the health of an individual. It includes but is not limited to (1) preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, and counseling, service, assessment, or procedure with respect to the physical or mental condition, or functional status, of an individual or that affects the structure or function of the body; and (2) sale or dispensing of a drug, device, equipment, or other item in accordance with a prescription [ 45 CFR § 160.103] .

U. "Health care facility" shall be defined as per 18 V.S.A § 9432, as amended from time to time.

V. "Health care provider" means a person, partnership, corporation, facility or institution, licensed or certified or authorized by law to provide professional health care service in this state to an individual during that individual's medical care, treatment or confinement, as per 18 V.S.A. § 9432.

W. "Health information" means any information, whether oral or recorded in any form or medium, that 1) is created or received by a health-care provider, health plan, public health authority, employer, life insurer, school or university, or health-care clearinghouse; and 2) relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual shall be as defined in 45 CFR § 160.103.

X. "Health insurer" means those entities defined in 18 V.S.A. §§ 9402 and 9410(j)(1), and includes any health insurance company, nonprofit hospital and medical service corporation, managed care organization, third party administrator, pharmacy benefit manager, and any entity conducting administrative services for business or possessing claims data, eligibility data, provider files, and other information relating to health care provided to Vermont residents or by Vermont health care providers and facilities. The term may also include, to the extent permitted under federal law, any administrator of an insured, self-insured, or publicly funded health care benefit plan offered by public and private entities.

Y. "HIPAA" means the federal Health Insurance Portability and Accountability Act of 1996, Public Law 104-191.

Z. "Indirect personal identifiers" means information relating to an individual patient, member or enrollee that a person with appropriate knowledge of and experience with generally accepted statistical and scientific principles and methods could apply to render such information individually identifiable by using such information alone or in combination with other reasonably available information.
Aa. "International Classification of Diseases" or "ICD" shall mean that medical code set maintained by the World Health Organization..

Ab. "Mandated Reporter" means a health insurer as defined herein and at 18 V.S.A. § 9410(j)(1) with two hundred (200) or more enrolled or covered members in each month during a calendar year, including both Vermont residents and any non-residents receiving covered services provided by Vermont health care providers and facilities.

Ac. "Medical claims file" means a data file composed of service level remittance information for all non-denied adjudicated claims for each billed service including, but not limited to member demographics, provider information, charge/payment information, and clinical diagnosis and procedure codes, and shall include all claims related to behavioral or mental health.

Ad. "Member" means the insured subscriber and any spouse and/or dependent covered by the subscriber's policy.

Ae. "Member eligibility file" means a data file containing demographic information for each individual member eligible for medical or pharmacy benefits for one or more days of coverage at any time during the reporting month.

Af. "Patient" means any person in the data set that is the subject of the activities of the claim performed by the health care provider.

Ag. "Payer" means a third-party payer or third-party administrator.

Ah. "Payment" means the actual dollar amount paid for a claim by a health insurer.

Ai. "Personal identifiers" means information relating to an individual that contains direct or indirect identifiers to which a reasonable basis exists to believe that the information can be used to identify an individual.

Aj. "Pharmacy Benefit Manager" or "PBM" means a person or entity that performs pharmacy benefit management as that term is defined at 18 V.S.A. § 9471(4). The term includes a person or entity in a contractual or employment relationship with an entity performing pharmacy benefit management for a health plan.

Ak. "Pharmacy claims file" means a data file containing service level remittance information from all non-denied adjudicated claims for each prescription including, but not limited to: member demographics; provider information; charge/payment information; and national drug codes.

Al. "Prepaid amount" means the fee for the service equivalent that would have been paid for a specific service if the service had not been capitated.

Am. "Principal Investigator" means the person in charge of a project that makes use of limited use research health care claims data sets. The principal investigator is the custodian of the data and is responsible for compliance with all restrictions, limitations and conditions of use associated with the data release.

An. "Public Use Data Set" means a publicly available data set containing only the public use data elements specified in this Rule as unrestricted data elements in Appendix J.

Ao. "Reporter" means a health insurer as defined herein and at 18 V.S.A. § 94100(j)(1), and shall include Voluntary Reporters as defined herein.

Ap. "Subscriber" means the individual responsible for payment of premiums or whose employment is the basis for eligibility for membership in a health benefit plan.

Aq. "Third-party Administrator" means any person who, on behalf of a health insurer or purchaser of health benefits, receives or collects charges, contributions or premiums for, or adjusts or settles claims on or for residents of this State or Vermont health care providers and facilities.

Ar. "Vermont Healthcare Claims Uniform Reporting and Evaluation System" or "VHCURES" means the Department's system for the collection, management and reporting of eligibility, claims and related data submitted pursuant to 18 V.S.A. § 9410.

As. "Voluntary Reporter" includes any entity other than a mandated reporter, including any health benefit plan offered or administered by or on behalf of the federal government where such plan, with the agreement of the federal government, voluntarily submits data to the BISHCA commissioner for inclusion in the database on such terms as may be appropriate.

Section 4 Reporting Requirements

Registration and Reporting Requirements

A. VHCURES Reporter Registration. On an annual basis prior to December 31, Health Insurers shall register with the Department on a form established by the Commissioner and identify whether health care claims are being paid for members who are Vermont residents and whether health care claims are being paid for non-residents receiving covered services from Vermont health care providers or facilities. Where applicable, the completed form shall identify the types of files to be submitted per Section 5. This form shall be submitted to BISHCA or its designee. See Appendix F.

B. Third Party Administrator Registration. Any person or entity that provides third party administration services, a third party administrator or "TPA" as defined in Section 3, shall register with the Department on a form established by the Commissioner, both before doing business in Vermont and on an annual basis prior to December 31 thereafter. 18 V.S.A. § 9410. See Appendix G.

C. Pharmacy Benefit Manager Registration. Any person or entity that performs pharmacy benefit management (a pharmacy benefit manager or "PBM") shall register with the Department on a form established by the Commissioner both before doing business in Vermont and on an annual basis prior to December 31. 18 V.S.A. § 9421. The registration requirement includes persons or entities in a contractual or employment relationship with a health insurer or PBM performing pharmacy benefit management for a health plan with Vermont enrollees or beneficiaries. 18 V.S.A. § 9471. See Appendix H.

D. Health Insurers shall regularly submit medical claims data, pharmacy claims data, member eligibility data, provider data, and other information relating to health care provided to Vermont residents and health care provided by Vermont health care providers and facilities to both Vermont residents and non-residents in specified electronic format to the Department for each health line of business (Comprehensive Major Medical, TPA/ASO, Medicare Supplemental, Medicare Part C, and Medicare Part D) per the data submission requirements contained in the appendices to this Rule.

E. Voluntary Reporters may, with the permission of the Commissioner, participate in VHCURES and submit medical claims files, pharmacy claims files, member eligibility files, provider data, and other information relating to health care provided to Vermont residents and health care provided by Vermont health care providers and facilities to both Vermont residents and non-residents in specified electronic format to the Department per the data submission requirements contained in the appendices to this Rule.

Section 5 Required Healthcare Data Files

Mandated Reporters shall submit to BISHCA or its designee health care claims data for all members who are Vermont residents and all non-residents who received covered services provided by Vermont health care providers or facilities in accordance with the requirements of this section. Each Mandated Reporter is also responsible for the submission of all health care claims processed by any sub-contractor on its behalf unless such subcontractor is already submitting the identical data as a Mandated Reporter in its own right. The health care claims data submitted shall include, where applicable, a member eligibility file containing records associated with each of the claims files reported: a medical claims file and a pharmacy claims file. The data submitted shall also include supporting definition files for payer specific provider specialty taxonomy codes and procedure and/or diagnosis codes.

A. General Requirements for Data Submission
(1) Adjustment Records. Adjustment records shall be reported with the appropriate positive or negative fields with the medical and pharmacy claims file submissions. Negative values shall contain the negative sign before the value. No sign shall appear before a positive value.

(2) Behavioral or Mental Health Claims. All claims related to behavioral or mental health shall be included in the medical claims file.

(3) Capitated Service Claims. Claims for capitated services shall be reported with all medical and pharmacy claims file submissions.

(4) Claims Records. Records for the medical and pharmacy claims file submissions shall be reported at the visit, service, or prescription level. The submission of the medical and pharmacy claims is based upon the paid dates and not upon the dates of service associated with the claims.

(5) Codes and Encryption Requirements
(a) Code Sources. Unless otherwise specified in this regulation, the code sources listed and described in Appendix A shall be utilized in association with the member eligibility file and medical and pharmacy claims file submissions.

(b) Member Identification Code. Reporters shall assign to each of their members a unique identification code that is the member's social security number. If a Reporter does not collect the social security numbers for all members, the Reporter shall use the social security number of the subscriber and then assign a discrete two-digit suffix for each member under the subscriber's contract.

If the subscriber's social security number is not collected by the Reporter, a version of the subscriber's certificate or contract number shall be used in its place. The discrete two-digit suffix shall also be used with the certificate or contract number. The certificate or contract number with the two-digit suffix shall be at least eleven but not more than sixty-four characters in length.

The social security number of the member/ subscriber and the subscriber and member names shall be encrypted prior to submission by the Reporter utilizing a standard encryption methodology provided by BISHCA or its designee. The unique member identification code assigned by each Reporter shall remain with each member/subscriber for the entire period of coverage for that individual.

(c) Specific/Unique Coding. With the exception of provider, provider specialty, and procedure/diagnosis codes, specific or unique coding systems shall not be permitted as part of the health care claims data set submission.

(6) Co-Insurance/Co-Payment. Co-insurance and co-payment are to be reported in two separate fields in the medical and pharmacy claims file submissions.

(7) Coordination of Benefits Claims. Claims where multiple parties have financial responsibility shall be included with all medical and pharmacy claims file submissions.

(8) Denied Claims. Denied claims shall be excluded from all medical and pharmacy claims file submissions. When a claim contains both fully processed/paid service lines and partially processed or denied service lines, only the fully processed/paid service lines shall be included as part of the health care claims data set submittal.

(9) Eligibility Records. Records for the member eligibility file submission shall be reported at the individual member level with one record submitted for each claim type. If a member is covered as both a subscriber and a dependent on two different policies during the same month, two records must be submitted. If a member has 2 contract numbers for 2 different coverage types, 2 member eligibility records shall be submitted.

(10) Exceptions.
(a) Medical Claims File Exclusions. All claims related to services provided under stand-alone health care policies shall be excluded if the services are not covered by comprehensive medical insurance policies and are provided on a stand-alone basis for:
1. Specific disease;

2. Accident:

3. Injury;

4. Hospital indemnity;

5. Disability:

6. Long-term care;

7. Student liability;

8. Vision coverage; or

9. Durable medical equipment.

(b) Claims for pharmacy services containing national drug codes are to be included in the pharmacy claims file, but excluded from the medical claims file.

(c) Member Eligibility File Exclusions. Members without medical or pharmacy coverage for the month reported shall be excluded.

(11) File Format. Each file submission shall be an ASCII file, variable field length, and asterisk delimited. When asterisks are used in any field values, the entire value shall be enclosed in double quotes.

(12) Insured Group or Policy Number Key Look-up Table. Reporters are required to submit a key look-up table when submitting member eligibility files. The key look-up table shall link Insured Group or Policy Number (ME006) to the name of the group associated with each Insured Group or Policy Number, but shall not identify any individual policyholders in connection with non-group policies.

(13) Header and Trailer Records. Each member eligibility file and each medical and pharmacy claims file submission shall contain a header record and a trailer record. The header record is the first record of each separate file submission and the trailer record is the last. The header and trailer record formats shall be as detailed in Appendices B-1 and B-2.

(14) Pharmacy Claims. Claims for pharmacy services shall be included in the following files:
(a) If the pharmacy claims are covered under the medical benefit then the claim shall be included in the medical claims file and not the pharmacy claims file; and

(b) If the claim is covered under the prescription benefit then the claim shall be included in the pharmacy claims file.

(15) Prepaid Amount. Any prepaid amounts are to be reported in a separate field in the medical and pharmacy claims file submissions.

(16) Supplemental Health Insurance. Claims related to supplemental health insurance are to be included if the policies are for health care services entirely excluded by the Medicare, Tricare, or other publicly funded health benefit programs.

B. Detailed File Specifications.
(1) Filled Fields. All required fields shall be filled where applicable. Non-required text, date, and integer fields shall be set to null when unavailable. Non-applicable decimal fields shall be filled with one zero and shall not include decimal points when unavailable.

(2) Position. All text fields are to be left justified. All integer and decimal fields are to be right justified.

(3) Signs. Positive values are assumed and need not be indicated as such. Negative values must be indicated with a minus sign and must appear in the left-most position of all integer and decimal fields. Over-punched signed integers or decimals are not to be utilized.

(4) Individual Elements and Mapping. Individual data elements, data types, field lengths, field description/code assignments, and mapping locators (UB-04, HCFA 1500, ANSI X12N 270/271, 835, 837) for each file shall be as detailed in the following appendices:
(a)
(1) Member Eligibility File Specifications - Appendix C-1

(2) Member Eligibility File Mapping to National Standard Formats - Appendix C-2

(b)
(1) Medical Claims File Specifications - Appendix D-1

(2) Medical Claims File Mapping to National Standard Formats - Appendix D-2

(c)
(1) Pharmacy Claims File Specifications - Appendix E-1

(2) Pharmacy Claims File Mapping to National Standard Formats - Appendix E-2

Section 6 Submission Requirements

Data submission requirements shall be as detailed in the attached appendices.

A. Registration Form. I t is the responsibility of each Health Insurer to resubmit or amend the registration form required by Section 4(A) whenever modifications occur relative to the data files or contact information.

B. File Organization. The member eligibility file, medical claims file and pharmacy claims file shall be submitted to BISHCA or its designee as separate ASCII files. Each record shall terminate with a carriage return (ASCII 13) or a carriage return line feed (ASCII 13, ASCII 10).

C. Filing Media. Files shall be submitted utilizing one of the following media: diskette (1.44 MB), CD-ROM (650 MB), DVD, secure SSL web upload interface, or electronic transmission through a File Transfer Protocol. E-mail attachments shall not be accepted. Space permitting, multiple data files may be submitted utilizing the same media if the external label identifies the multiple files.

D. Transmittal Sheet. All file submissions on physical media shall be accompanied by a hard copy transmittal sheet containing the following information: identification of the Reporter, file name, type of file, data period(s), date sent, record count(s) for the file(s), and a contact person with telephone number and E-mail address. The information on the transmittal sheet shall match the information on the header and trailer records. See Appendix I.

E. Testing of Files. At least sixty days prior to the initial submission of the files or whenever the data element content of the files as described in Section 5 is subsequently altered, each Reporter shall submit to BISHCA or its designee a data set for comparison to the standards listed in Section 7. The size, based upon a calendar period of one month, quarter, or year, of the data files submitted shall correspond to the filing period established for each Reporter under subsection I of this Section.

F. Rejection of Files. Failure to conform to subsections A, B, or C of this Section shall result in the rejection and return of the applicable data file(s). All rejected and returned files shall be resubmitted in the appropriate, corrected form to BISHCA or its designee within 10 days.

G. Replacement of Data Files. No Reporter may replace a complete data file submission more than one year after the end of the month in which the file was submitted unless it can establish exceptional circumstances for the replacement. Any replacements after this period must be approved by BISHCA. Individual adjustment records may be submitted with any monthly data file submission.

H. Run-Out Period. Reporters shall submit medical and pharmacy claims files for at least a six month period following the termination of coverage date for all members who are Vermont residents or non-residents receiving covered services provided by Vermont health care providers or facilities.

I. Data Submission Schedule. The reporting period for submission of each specified file listed in Section 5 shall be determined on a separate basis for Vermont members and non-resident members by the highest total number of Vermont resident members or non-resident members receiving covered services provided by Vermont providers or facilities for which claims are being paid for any one month of the calendar year. Data files are to be submitted in accordance with the following schedule:

Total # of Members

Reporting Period

Reporting Schedule

$(greater than or equal$) 2,000

Monthly

Prior to the end of the month following the month in which claims were paid

500 - 1,999

Quarterly

Prior to April 30, July 31, October 31, January 31 for each preceding calendar quarter in which claims were paid

200 - 499

Annually

Prior to April 30 of the following year for the preceding twelve months in which claims were paid

< 200

N/A

If the data files submitted by an individual Reporter support or are related to the files submitted by another Reporter, BISHCA shall establish a filing period for the parties involved.

Section 7 Compliance with Data Standards

A. Standards. BISHCA or its designee shall evaluate each member eligibility file, medical claims file and pharmacy claims file in accordance with the following standards:
(1) The applicable code for each data element shall be as identified in Appendices C-1, D-1, and E-1 and shall be included within eligible values for the element;

(2) Coding values indicating "data not available", "data unknown", or the equivalent shall not be used for individual data elements unless specified as an eligible value for the element;

(3) Member sex, diagnosis and procedure codes, and date of birth and all other date fields shall be consistent within an individual record;

(4) Member identifiers shall be consistent across files; and

(5) Files submitted shall not contain direct personal identifiers.

B. Notification. Upon completion of this evaluation, BISHCA or its designee will promptly notify each Reporter whose data submissions do not satisfy the standards for any reporting period. This notification will identify the specific file and the data elements that are determined to be unsatisfactory.

C. Response. Each Reporter notified under subsection 7.B shall resubmit within 60 days of the date of notification with the required changes.

D. Compliance. Failure to file, report, or correct health care claims data sets in accordance with the provisions of this regulation may be considered a violation of 18 V.S.A. § 9410(g).

Section 8 Procedures for the Approval and Release of Claims Data

The requirements, procedures and conditions under which persons other than the Department may have access to health care claims data sets and related information received or generated by the Department or its designee pursuant to this regulation shall depend upon the requestor and the characteristics of the particular information requested, all as set forth below.

A. Classification of Data Elements
(1) Unrestricted Data Elements: Data elements designated in Appendix J as "Unrestricted" shall be available for general use and public release as part of a Public Use File.

(2) Restricted Data Elements: Data elements designated in Appendix J as "Restricted" shall not be available for use and release outside the Department except as part of a Limited Use Research Health Care Claims Data Set approved by the commissioner pursuant to the requirements of this regulation.

(3) Unavailable Data Elements: Data elements which are not designated in Appendix J as either Unrestricted or Restricted, or are designated as "Unavailable", shall not be available for release or use outside the Department in any data set or disclosed in publicly released reports in any circumstance.

B. Public Use Data Sets: Release and Availability
(1) Unrestricted Data Elements collected or generated by the Department or its designee shall be made available in public use files and provided to any person upon written request, except where otherwise prohibited by law.

(2) The Department shall maintain a public record of all requests for and releases of public use data sets.

C. Limited Use Health Care Claims Research Data Sets- Release and Availability
(1) Limited Use Health Care Claims Research Data Sets shall be those sets which contain restricted data elements, shall not be available to the general public and shall be released to a requestor only for the purpose of research upon a determination by the Commissioner that the following conditions have been met:
(a) Application: Any person requesting access to or use of Limited Use Health Care Claims Research Data Sets shall submit an application, in written and electronic form, to the Commissioner disclosing the information listed below. Studies utilizing data sets for longer than 2 years may be required to reapply.
(1) Identity of principal investigator:
(a) Name, address, and phone number;

(b) Organizational affiliation;

(c) Professional qualification; and

(d) Phone number of principal investigator's contact person, if any.

(2) Identity of person requesting access, including any entities for whom that person is acting in requesting the data.
(a) Name, address, and phone number;

(b) Organizational affiliation;

(c) Professional qualification; and

(d) Name and phone number of contact person.

(3) Identity of and qualifications of any other persons who may have access to the data.

(4) A detailed research protocol, to include:
(a) A summary of background, purposes, and origin of the research;

(b) A statement of the health-related problem or issue to be addressed by the research;

(c) The research design and methodology, including either the topics of exploratory research or the specific research hypotheses to be tested;

(d) The procedures that will be followed to maintain the confidentiality of any data or copies of records provided to the principal investigator or other persons; and

(e) The intended research completion date;

(5) Particular data set requested, including:
(a) The time period of the data requested;

(b) The specific data elements or fields of information required;

(c) A justification of the need for each restricted element or field, as identified in the data release schedule;

(d) The minimum needed specificity of the requested data elements, including the manner in which the data may be recoded by the department to be less specific;

(e) The selection criteria for the minimum needed data records required; and

(f) Any particular format or layout of data requested by the principal investigator.

(6) Any changes to information submitted as part of an application pursuant to (a)(1)-(4) shall require notice to the Department by the applicant and shall be subject to the approval of the Commissioner.

(b) The person or entity requesting access and the principal investigator or investigators shall be subject to the following requirements and limitations and shall, in addition, sign and submit a data use agreement acknowledging and accepting these same provisions as a necessary condition to any data access:
(1) Use of data for any purpose other than as specified in the application and approved by the Commissioner shall be prohibited;

(2) Appropriate safeguards to protect the confidentiality of the data and prevent unauthorized use of the data shall be established;

(3) The use or disclosure, sale, or dissemination of the data set or statistical tabulations derived from the data set to any person or organization for any purpose other than as described in the application and as permitted by the data use agreement shall be prohibited without the express written consent of the Commissioner.

(4) The use or disclosure, sale, or dissemination of any information contrary to law shall be prohibited;

(5) No person shall disclose the identity of patients, employer groups or purchaser groups from information contained in the limited use data set;

(6) No person shall disclose any of the information that has been encrypted or removed from the data;

(7) The content of cells that contain counts of persons in statistical tables in which the cell size is more than 0 and less than 5 shall not be disclosed, published or made public in any manner except as "<5";

(8) The publication, dissemination or disclosure of any information that could be used to identify providers of abortion services shall be prohibited;

(9) Any use or disclosure of the information that is contrary to the Data Use Agreement or this Regulation shall be reported to the Department within five (5) days of when the principal investigator becomes aware of such disclosure.

(10) The Department and the "Vermont Healthcare Claims Uniform Reporting and Evaluation System" shall be acknowledged as the source and owner of the data in any and all public reports, publications, or presentations generated from the data;

(11) Written materials shall prominently state that the analyses, conclusions and recommendations drawn from such data are solely those of the requestor or principal investigator and are not necessarily those of the Department;

(12) The Department shall be provided with a copy of any proposed report or publication containing information derived from the data at least 15 days prior to any publication or release to allow the department to review the proposed report or publication and confirm that the conditions of the agreement have been applied. When multiple reports of a similar nature will be created from the data, the Department may, on request, waive the requirement that any subsequent reports or publications be provided to the Department prior to release by the requesting party

(13) Data elements shall not be retained for any period of time beyond that necessary to fulfill the requirements of the data request.

(14) Within 30 days after the scheduled completion date of the project, the requestor shall delete, destroy or otherwise render the data unreadable, so certifying by submitting a written notice to the Department or by reapplying for approval if the end date of the project needs to be extended;

(15) Any draft reports or publications supplied to the department shall be considered confidential and exempt from public review under 1 V.S.A. § 315 et seq. and shall not be released by the Department; and

(16) Failure to adhere to the data use agreement or the limitations and restrictions detailed above will be cause for immediate recall by the Department of the data, revocation of permission to use the data, and grounds for civil or administrative enforcement action by the Department under applicable Vermont state law.

(c) The Department shall establish a claims data release advisory committee with a chair person and members appointed annually by the Commissioner, to provide non-binding advice and opinion to the Commissioner, as and when requested, on the merits of applications for access to limited use data sets. If the Commissioner has requested a review of the application, the claims data release advisory committee shall provide the Commissioner with any comment on the merits of the application and the research protocol described therein within thirty (30) days. The committee shall be comprised of seven (7) members and include:
(1) At least one member representing health insurers;

(2) At least one member representing health care facilities;

(3) At least one member representing health care providers;

(4) At least one member representing purchasers of health insurance or health benefits; and

(5) At least one member representing healthcare researchers.

(2) The Commissioner may approve the release of limited use data sets only when the Commissioner is satisfied as to the following:
(a) The application submitted is complete and the requesting individuals or entities and principal investigator have signed a data use agreement as specified;

(b) Procedures to ensure the confidentiality of any patient and any confidential data are documented;

(c) The qualifications of the investigator and research staff, as evidenced by:
(1) Training and previous research, including prior publications; and

(2) An affiliation with a university, private research organization, medical center, state agency, or other qualified institutional entity.

(d) No other state or federal law or regulation prohibits release of the requested information.

(3) If the Commissioner declines to release the requested limited use data sets within 60 days of receipt of a complete application, the Department shall give written notice of the basis for denial of the application and the requestor shall have leave to resubmit or supplement the application to address the Commissioner's concerns. Any adverse decision regarding an application may be appealed within 30 days by filing a request for hearing with the Commissioner pursuant to Department Rule 82-1.

Section 9 Prices for Data Sets, Fees for Programming and Report Generation, Duplication Rates

This Section lists the prices for data sets from the Vermont Healthcare Claims Uniform Reporting and Evaluation System, including the fees for programming and report generation, duplicating charges and other costs associated with the production and transmission of data sets approved for release by the Department.

A. An annual public use file consisting of unrestricted fields and data elements shall be made available to any person upon request at the cost required for the Department to process, package and ship the data set, including any electronic medium used to store the data.

B. Limited Use Research Health Care Claims Data Sets approved by the Department shall be made available to the requesting party at the cost charged by the Department's designated vendor to program and process the requested data extract, including any consulting services and costs to package and ship the data set on particular electronic medium.

C. Payments are due in full from the requesting party within thirty days of receipt of BISHCA data sets, files, reports, or other released material.

Section 10 Enforcement

Violations of data submission requirements, confidentiality requirements, data use limitations or any other provisions of this rule shall be subject to sanction by the Commissioner as set out in 18 V.S.A. § 9410 in addition to any other powers granted to the Commissioner to investigate, subpoena, fine or seek other legal or equitable remedies.

Section 11 Severability

If any provision of this regulation or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of the regulation and the application of such provisions to other persons or circumstances shall be not affected thereby.

Appendix A Source Codes

Admission Source Code

(Data Element: MC021)

SOURCE: National Uniform Billing Data Element Specifications

AVAILABLE FROM:

National Uniform Billing Committee

American Hospital Association

840 Lake Shore Drive

Chicago, IL 60697

ABSTRACT: A variety of codes explaining who recommended admission to a medical facility.

Admission Type Code

(Data Element: MC020)

SOURCE: National Uniform Billing Data Element Specifications

AVAILABLE FROM:

National Uniform Billing Committee

American Hospital Association

840 Lake Shore Drive

Chicago, IL 60697

ABSTRACT: A variety of codes explaining the priority of the admission to a medical facility.

Current Procedural Terminology (CPT) Codes

(Data Element: MC055)

SOURCE: Physicians' Current Procedural Terminology (CPT) Manual

AVAILABLE FROM:

Order Department

American Medical Association

515 North State Street

Chicago, IL 60610

ABSTRACT: A listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians.

Health Care Common Procedural Coding System

(Data Element: MC055)

SOURCE: Health Care Common Procedural Coding System

AVAILABLE FROM:

www. cms.gov/medicare/hcpcs.htm

Centers for Medicare and Medicaid Services

Center for Health Plans and Providers

CCPP/DCPC

C5-08-27

7500 Security Boulevard

Baltimore, MD 21244-1850

ABSTRACT: HCPCS is the Centers for Medicare and Medicaid Services (CMS) coding scheme to group procedures performed for payment to providers.

Centers for Medicare and Medicaid Services National Plan ID

(Data Elements: HD003, MC002, ME002, PC002, TR003)

SOURCE: Plan ID Database

AVAILABLE FROM:

Centers for Medicare and Medicaid Services

Center for Beneficiary Services

Administration Group

Division of Membership Operations

SI-05-06

7500 Security Boulevard

Baltimore, MD 21244-1850

ABSTRACT: The Centers for Medicare and Medicaid Services is developing the Plan ID, which will be proposed as the standard unique identifier for each health plan under the Health Insurance Portability and Accountability Act of 1996.

Centers for Medicare and Medicaid Services National Provider Identifier

(Data Elements: MC026)

SOURCE: National Provider System

AVAILABLE FROM:

Centers for Medicare and Medicaid Services

Office of Information Services

Security and Standards Group

Director, Division of Health Care Information Systems

7500 Security Boulevard

Baltimore, MD 21244-1850

ABSTRACT: The Centers for Medicare and Medicaid Services is developing the National Provider Identifiers, which is proposed as the standard unique identifier for each health care provider under the Health Insurance Portability and Accountability Act of 1996.

Discharge Status Code

(Data Element: MC023)

SOURCE: National Uniform Billing Data Element Specifications

AVAILABLE FROM:

National Uniform Billing Committee

American Hospital Association

840 Lake Shore Drive

Chicago, IL 60697

ABSTRACT: A variety of codes indicating Member status as of the date of service-thru field.

Appendix A Source Codes

International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure

(Data Elements: MC040, MC041, MC042, MC043, MC044, MC045, MC046, MC047, MC048, MC049, MC050, MC051, MC052, MC053, MC058)

SOURCE: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

AVAILABLE FROM:

U.S. National Center for Health Statistics

Commission of Professional and Hospital Activities

1968 Green Road

Ann Arbor, MI 48105

ABSTRACT: The International Classification of Diseases, 9th Revision, Clinical Modification, describes the classification of morbidity and mortality information for statistical purposes and for the indexing of hospital records by disease and operations.

National Association of Boards of Pharmacy Number

(Data Element: PC021)

SOURCE: National Association of Boards of Pharmacy Database and Listings

AVAILABLE FROM:

National Council for Prescription Drug Programs

4201 North 24th Street

Suite 365

Phoenix, AZ 85016

ABSTRACT: A unique number assigned in the U.S. and its territories to individual clinic, hospital, chain, and independent pharmacy locations that conduct business at retail by billing third-party drug benefit payers. The National Council for Prescription Drug Programs (NCPDP) maintains this database under contract from the National Association of Boards of Pharmacy. The National Association of Boards of Pharmacy is a seven-digit numeric number with the following format SSNNNNC, where SS=NCPDP assigned state code number, NNNN=NCPDP assigned pharmacy location number, and C=check digit calculated by algorithm from previous six digits.

National Association of Insurance Commissioners (NAIC) Code

(Data Elements: HD002, MC001, ME001, PC001, TR002)

SOURCE: National Association of Insurance Commissioners Company Code List Manual

AVAILABLE FROM:

National Association of Insurance Commission Publications Department

12th Street, Suite 1100

Kansas City, MO 64105-1925

ABSTRACT: Codes that uniquely identify each insurance company.

National Drug Code

(Data Element: PC026)

SOURCE: Blue Book, Price Alert, National Drug Data File

AVAILABLE FROM:

First Databank, The Hearst Corporation

1111 Bayhill Drive

San Bruno, CA 94066

ABSTRACT: The National Drug Code is a coding convention established by the Food and Drug Administration to identify the labeler, product number, and package sizes of FDA-approved prescription drugs. There are over 170,000 National Drug Codes on file.

National Uniform Billing Committee (NUBC) Codes

(Data Element: MC054)

SOURCE: National Uniform Billing Data Element Specifications

AVAILABLE FROM:

National Uniform Billing Committee

American Hospital Association

840 Lake Shore Drive

Chicago, IL 60697

ABSTRACT: Revenue codes are a classification of hospital charges in a standard grouping that is controlled by the National Uniform Billing Committee. Place of service codes specify the type of location where a service is provided.

States and Outlying Areas of the U.S.

(Data Elements: MC015, MC034, ME016, PC015, PC023)

SOURCE: National Zip Code and Post Office Directory

AVAILABLE FROM:

U.S. Postal Service

National Information Data Center

P.O. Box 2977

Washington, DC 20013

ABSTRACT: Provides names, abbreviations, and codes for the 50 states, the District of Columbia, and the outlying areas of the U.S. The entities listed are considered to be the first order divisions of the U.S. Microfiche AVAILABLE FROM: NTIS (same as address above). The Canadian Post Office lists the following as "official" codes for Canadian Provinces:

AB - Alberta

BC - British Columbia

MB - Manitoba

NB - New Brunswick

NF - Newfoundland

NS - Nova Scotia

NT - North West Territories

ON - Ontario

PE - Prince Edward Island

PQ - Quebec

SK - Saskatchewan

YT - Yukon

Uniform Billing Claim Form Bill Type

(Data Element: MC036)

SOURCE: National Uniform Billing Data Element Specifications Type of Bill Positions 1 and 2

AVAILABLE FROM:

National Uniform Billing Committee

American Hospital Association

840 Lake Shore Drive

Chicago, IL 60697

ABSTRACT: A variety of codes describing the type of medical facility.

X12 Directories

SOURCE: X12.3 Data Element Dictionary X12.22 Segment Directory

AVAILABLE FROM:

Data Interchange Standards Association, Inc. (DISA)

Suite 200

1800 Diagonal Road

Alexandria, VA 22314-2852

ABSTRACT: The data element dictionary contains the format and descriptions of data elements used to construct X12 segments. It also contains code lists associated with these data elements. The segment directory contains the format and definitions of the data segments used to construct X12 transaction sets.

ZIP Code

(Data Elements: MC016, MC035, ME017, PC016, PC024)

SOURCE: National ZIP Code and Post Office Directory, Publication 65 The USPS Domestic Mail Manual

AVAILABLE FROM:

U. S Postal Service

Washington, DC 20260

New Orders

Superintendent of Documents

P.O. Box 371954

Pittsburgh, PA 15250-7954

ABSTRACT: The ZIP Code is a geographic identifier of areas within the United States and its territories for purposes of expediting mail distribution by the U.S. Postal Service. It is five or nine numeric digits. The ZIP Code structure divides the U.S. into ten large groups of states. The leftmost digit identifies one of these groups. The next two digits identify a smaller geographic area within the large group. The two right- most digits identify a local delivery area. In the nine digit ZIP Code, the four digits that follow the hyphen further subdivide the delivery area. The two leftmost digits identify a sector which may consist of several large buildings, blocks or groups of streets. The rightmost digits divide the sector into segments such as a street, a block, a floor of a building, or a cluster of mailboxes.

The USPS Domestics Mail Manual includes information on the use of the new 11-digit zip code.

Appendix 1 Header Record Specifications

Data Element #

Element

Required Start Date

Type

Maximum Length

Description/Codes/Sources

HD001

Record Type

1/31/2007

Text

2

HD

HD002

Payer

1/31/2007

Text

8

Payer submitting payments

BISHCA Submitter Code

HD003

National Plan ID

1/31/2007

Text

30

CMS National Plan ID

HD004

Type of File

1/31/2007

Text

2

DC Dental Claims

ME Member Eligibility

MC Medical Claims

PC Pharmacy Claims

HD005

Period Beginning Date

1/31/2007

Integer

6

CCYYMM

Beginning of paid period for Claims

Beginning of month covered for Eligibility

HD006

Period Ending Date

1/31/2007

Integer

6

CCYYMM

End of paid period for Claims

End of month covered for Eligibility

HD007

Record Count

1/31/2007

Integer

10

Total number of records submitted in this file

Exclude header and trailer record in count

HD008

Comments

1/31/2007

Text

80

Submitter may use to document this submission by assigning a filename, system source, etc.

Data Element #

Element

Required Start Date

Type

Maximum Length

Description/Codes/Sources

HD001

Record Type

1/31/2007

Text

2

HD

HD002

Payer

1/31/2007

Text

8

Payer submitting payments

BISHCA Submitter Code

HD003

National Plan ID

1/31/2007

Text

30

CMS National Plan ID

HD004

Type of File

1/31/2007

Text

2

DC Dental Claims

ME Member Eligibility

MC Medical Claims

PC Pharmacy Claims

HD005

Period Beginning Date

1/31/2007

Integer

6

CCYYMM

Beginning of paid period for Claims

Beginning of month covered for Eligibility

HD006

Period Ending Date

1/31/2007

Integer

6

CCYYMM

End of paid period for Claims

End of month covered for Eligibility

HD007

Record Count

1/31/2007

Integer

10

Total number of records submitted in this file

Exclude header and trailer record in count

HD008

Comments

1/31/2007

Text

80

Submitter may use to document this submission by assigning a filename, system source, etc.

Appendix 2 Trailer Record Specifications

Data Element #

Element

Required Start Date

Type

Maximum Length

Description/Codes/Sources

TR001

Record Type

1/31/2007

Text

2

TR

TR002

Payer

1/31/2007

Text

8

Payer submitting payments

BISHCA Submitter Code

TR003

National Plan ID

1/31/2007

Text

30

CMS National Plan ID

TR004

Type of File

1/31/2007

Text

2

DC Dental Claims

ME Member Eligibility

MC Medical Claims

PC Pharmacy Claims

TR005

Period Beginning Date

1/31/2007

Integer

6

CCYYMM

Beginning of paid period for Claims

Beginning of month covered for Eligibility

TR006

Period Ending Date

1/31/2007

Integer

6

CCYYMM

End of paid period for Claims

End of month covered for Eligibility

TR007

Date Processed

1/31/2007

Date

8

CCYYMMDD

Date file was created

Data Element #

Element

Required Start Date

Type

Maximum Length

Description/Codes/Sources

TR001

Record Type

1/31/2007

Text

2

TR

TR002

Payer

1/31/2007

Text

8

Payer submitting payments

BISHCA Submitter Code

TR003

National Plan ID

1/31/2007

Text

30

CMS National Plan ID

TR004

Type of File

1/31/2007

Text

2

DC Dental Claims

ME Member Eligibility

MC Medical Claims

PC Pharmacy Claims

TR005

Period Beginning Date

1/31/2007

Integer

6

CCYYMM

Beginning of paid period for Claims

Beginning of month covered for Eligibility

TR006

Period Ending Date

1/31/2007

Integer

6

CCYYMM

End of paid period for Claims

End of month covered for Eligibility

TR007

Date Processed

1/31/2007

Date

8

CCYYMMDD

Date file was created

Appendix 1 Member Eligibility File Specifications

Data Element #

Element

Required Start Date

Type

Maximum Length

Description/Codes/Sources

ME001

Payer

1/31/2007

Text

8

Payer submitting payments

BISHCA Submitter Code

ME002

National Plan ID

1/31/2007

Text

30

CMS National Plan ID

ME003

Insurance Type Code/Product

1/31/2007

Text

2

12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan

13 Medicare Secondary End-Stage Renal Disease Beneficiary in the 12 month coordination period with an employer's group health plan

14 Medicare Secondary, No-fault insurance including Auto is primary

15 Medicare Secondary Worker's Compensation

16 Medicare Secondary Public Health Service or Other Federal Agency

41 Medicare Secondary Black Lung

42 Medicare Secondary Veteran's Administration

43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)

47 Medicare Secondary, Other Liability Insurance is Primary

* AP Auto Insurance Policy

CP Medicare Conditionally Primary

* D Disability

* DB Disability Benefits

EP Exclusive Provider Organization

HM Health Maintenance Organization (HMO)

HN Health Maintenance Organization (HMO) Medicare Advantage

HS Special Low Income Medicare Beneficiary

IN Indemnity

* LC Long Term Care

* LD Long Term Policy

* LI Life Insurance

* LT Litigation

MA Medicare Part A

MB Medicare Part B

MD Medicare Part D

MC Medicaid

MH Medigap Part A

MI Medigap Part B

MP Medicare Primary

PC Personal Care

PE Property Insurance - Personal

PR Preferred Provider Organization (PPO)

PS Point of Service (POS)

QM Qualified Medicare Beneficiary

SP Supplemental Policy

*WC Workers' Compensation

* Indicates that code is not to be included in Vermont submissions. Included in data set for harmonization with other New England states' data collection rules.

ME004

Year

1/31/2007

Integer

4

The year for which eligibility is reported in this submission.

ME005

Month

1/31/2007

Integer

2

The month for which eligibility is reported in this submission.

ME006

Insured Group or Policy Number

1/31/2007

Text

30

The group or policy number - not the number that uniquely identifies the subscriber.

ME007

Coverage Level Code

1/31/2007

Text

3

Benefit coverage level

CHD Children Only

DEP Dependents Only

ECH Employee and Children

EMP Employee Only

ESP Employee and Spouse

FAM Family

IND Individual

SPC Spouse and Children

SPO Spouse Only

ME008

Encrypted Subscriber Unique Identification Number

1/31/2007

Text

128

The encrypted subscriber's social security number; used to create unique member ID. Set as null if unavailable.

ME009

Plan Specific Contract Number

1/31/2007

Text

128

The encrypted plan assigned contract number.

Set as null if contract number equals subscriber's social security number.

ME010

Member Suffix or Sequence Number

1/31/2007

Integer

20

The unique number of the member within the contract.

ME011

Member Identification Code

1/31/2007

Text

128

The encrypted member's social security number; used to create unique member ID. Set as null if unavailable.

ME012

Individual Relationship Code

1/31/2007

Integer

2

Member's relationship to insured as shown below:

01 Spouse

18 Self/Employee

19 Child

21 Unknown

34 Other Adult

ME013

Member Gender

1/31/2007

Text

1

M Male

F Female

U Unknown

ME014

Member Date of Birth

1/31/2007

Date

8

CCYYMMDD

ME015

Member City Name

1/31/2007

Text

30

The city location of the member.

ME016

Member State or Province

1/31/2007

Text

2

As defined by the US Postal Service

ME017

Member ZIP Code

1/31/2007

Text

11

ZIP Code of member - may include non-US codes. Do not include dash.

ME018

Medical Coverage

1/31/2007

Text

1

Y Yes - must be mutually exclusive with MC019.

N No

ME019

Prescription Drug Coverage

1/31/2007

Text

1

Y Yes - must be mutually exclusive with MC018.

N No

ME020

Placeholder

Text

1

Used and or proposed by other states for - Dental coverage.

ME021

Placeholder

Text

6

Used and or proposed by other states for - Race 1.

ME022

Placeholder

Text

6

Used and or proposed by other states for - Race 2.

ME023

Placeholder

Text

15

Used and or proposed by other states for - Other Race.

ME024

Placeholder

Text

1

Used and or proposed by other states for - Hispanic indicator.

ME025

Placeholder

Text

6

Used and or proposed by other states for - Ethnicity 1.

ME026

Placeholder

Text

6

Used and or proposed by other states for - Ethnicity 2.

ME027

Placeholder

Text

20

Used and or proposed by other states for - Other Ethnicity.

ME028

Primary Insurance Indicator

1/31/2007

Text

1

1 Yes, primary insurance 2 No, secondary or tertiary insurance

ME029

Coverage Type

1/31/2007

Text

3

ASW

for self-funded plans that are administered by a third party administrator, where the employer has purchased stop-loss, or group excess, insurance coverage

ASO

for 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

for short-term non-renewable health insurance.

UND

for plans underwritten by the insurer

OTH

for any other plan. Insurers using this code shall obtain prior approval from BISHCA

ME030

Market Category Code

1/31/2007

Text

4

IND

for policies sold and issued directly to individuals (Non-group)

FCH

or policies sold and issued directly to individuals on a franchise basis.

GCV

for policies sold and issued directly to individuals as group conversion policies.

GS1

for policies sold and issued directly to employers having exactly one employee

GS2

for policies sold and issued directly to employers having between two and nine employees

GS3

for policies sold and issued directly to employers having between and 25 employees

GS4

for policies sold and issued directly to employers having between and 50 employees

GLG1

for policies sold and issued directly to employers having between 51 and 99 employees

GLG2

for policies sold and issued directly to employers having 100 or more employees

GSA

for policies sold and issued directly to small employers through a qualified association trust

OTH

For policies sold to other types of entities. Insurers using this market code shall obtain prior approval from BISHCA

ME031

Placeholder

Text

3

Used and or proposed by other states for Special Coverage.

0 N/A

1 NH HealthFirst

2 VT Catamount

ME101

Encrypted Subscriber Last Name

1/31/2007

Text

128

The encrypted subscriber last name.

ME102

Encrypted Subscriber First Name

1/31/2007

Text

128

The encrypted subscriber first name.

ME103

Encrypted Subscriber Middle Initial

1/31/2007

Text

1

The encrypted subscriber middle initial.

ME104

Encrypted Member Last Name

1/31/2007

Text

128

The encrypted member last name.

ME105

Encrypted Member First Name

1/31/2007

Text

128

The encrypted member first name.

ME106

Encrypted Member Middle Initial

1/31/2007

Text

1

The encrypted member middle initial.

ME899

Record Type

1/31/2007

Text

2

Value = ME

Data Element #

Element

Required Start Date

Type

Maximum Length

Description/Codes/Sources

ME001

Payer

1/31/2007

Text

8

Payer submitting payments

BISHCA Submitter Code

ME002

National Plan ID

1/31/2007

Text

30

CMS National Plan ID

ME003

Insurance Type Code/Product

1/31/2007

Text

2

12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan

13 Medicare Secondary End-Stage Renal Disease Beneficiary in the 12 month coordination period with an employer's group health plan

14 Medicare Secondary, No-fault insurance including Auto is primary

15 Medicare Secondary Worker's Compensation

16 Medicare Secondary Public Health Service or Other Federal Agency

41 Medicare Secondary Black Lung

42 Medicare Secondary Veteran's Administration

43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)

47 Medicare Secondary, Other Liability Insurance is Primary

* AP Auto Insurance Policy

CP Medicare Conditionally Primary

* D Disability

* DB Disability Benefits

EP Exclusive Provider Organization

HM Health Maintenance Organization (HMO)

HN Health Maintenance Organization (HMO) Medicare Advantage

HS Special Low Income Medicare Beneficiary

IN Indemnity

* LC Long Term Care

* LD Long Term Policy

* LI Life Insurance

* LT Litigation

MA Medicare Part A

MB Medicare Part B

MD Medicare Part D

MC Medicaid

MH Medigap Part A

MI Medigap Part B

MP Medicare Primary

PC Personal Care

PE Property Insurance - Personal

PR Preferred Provider Organization (PPO)

PS Point of Service (POS)

QM Qualified Medicare Beneficiary

SP Supplemental Policy

*WC Workers' Compensation

* Indicates that code is not to be included in Vermont submissions. Included in data set for harmonization with other New England states' data collection rules.

ME004

Year

1/31/2007

Integer

4

The year for which eligibility is reported in this submission.

ME005

Month

1/31/2007

Integer

2

The month for which eligibility is reported in this submission.

ME006

Insured Group or Policy Number

1/31/2007

Text

30

The group or policy number - not the number that uniquely identifies the subscriber.

ME007

Coverage Level Code

1/31/2007

Text

3

Benefit coverage level

CHD Children Only

DEP Dependents Only

ECH Employee and Children

EMP Employee Only

ESP Employee and Spouse

FAM Family

IND Individual

SPC Spouse and Children

SPO Spouse Only

ME008

Encrypted Subscriber Unique Identification Number

1/31/2007

Text

128

The encrypted subscriber's social security number; used to create unique member ID. Set as null if unavailable.

ME009

Plan Specific Contract Number

1/31/2007

Text

128

The encrypted plan assigned contract number.

Set as null if contract number equals subscriber's social security number.

ME010

Member Suffix or Sequence Number

1/31/2007

Integer

20

The unique number of the member within the contract.

ME011

Member Identification Code

1/31/2007

Text

128

The encrypted member's social security number; used to create unique member ID. Set as null if unavailable.

ME012

Individual Relationship Code

1/31/2007

Integer

2

Member's relationship to insured as shown below:

01 Spouse

18 Self/Employee

19 Child

21 Unknown

34 Other Adult

ME013

Member Gender

1/31/2007

Text

1

M Male

F Female

U Unknown

ME014

Member Date of Birth

1/31/2007

Date

8

CCYYMMDD

ME015

Member City Name

1/31/2007

Text

30

The city location of the member.

ME016

Member State or Province

1/31/2007

Text

2

As defined by the US Postal Service

ME017

Member ZIP Code

1/31/2007

Text

11

ZIP Code of member - may include non-US codes. Do not include dash.

ME018

Medical Coverage

1/31/2007

Text

1

Y Yes - must be mutually exclusive with MC019.

N No

ME019

Prescription Drug Coverage

1/31/2007

Text

1

Y Yes - must be mutually exclusive with MC018.

N No

ME020

Placeholder

Text

1

Used and or proposed by other states for - Dental coverage.

ME021

Placeholder

Text

6

Used and or proposed by other states for - Race 1.

ME022

Placeholder

Text

6

Used and or proposed by other states for - Race 2.

ME023

Placeholder

Text

15

Used and or proposed by other states for - Other Race.

ME024

Placeholder

Text

1

Used and or proposed by other states for - Hispanic indicator.

ME025

Placeholder

Text

6

Used and or proposed by other states for - Ethnicity 1.

ME026

Placeholder

Text

6

Used and or proposed by other states for - Ethnicity 2.

ME027

Placeholder

Text

20

Used and or proposed by other states for - Other Ethnicity.

ME028

Primary Insurance Indicator

1/31/2007

Text

1

1 Yes, primary insurance 2 No, secondary or tertiary insurance

ME029

Coverage Type

1/31/2007

Text

3

ASW

for self-funded plans that are administered by a third party administrator, where the employer has purchased stop-loss, or group excess, insurance coverage

ASO

for 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

for short-term non-renewable health insurance.

UND

for plans underwritten by the insurer

OTH

for any other plan. Insurers using this code shall obtain prior approval from BISHCA

ME030

Market Category Code

1/31/2007

Text

4

IND

for policies sold and issued directly to individuals (Non-group)

FCH

or policies sold and issued directly to individuals on a franchise basis.

GCV

for policies sold and issued directly to individuals as group conversion policies.

GS1

for policies sold and issued directly to employers having exactly one employee

GS2

for policies sold and issued directly to employers having between two and nine employees

GS3

for policies sold and issued directly to employers having between and 25 employees

GS4

for policies sold and issued directly to employers having between and 50 employees

GLG1

for policies sold and issued directly to employers having between 51 and 99 employees

GLG2

for policies sold and issued directly to employers having 100 or more employees

GSA

for policies sold and issued directly to small employers through a qualified association trust

OTH

For policies sold to other types of entities. Insurers using this market code shall obtain prior approval from BISHCA

ME031

Placeholder

Text

3

Used and or proposed by other states for Special Coverage.

0 N/A

1 NH HealthFirst

2 VT Catamount

ME101

Encrypted Subscriber Last Name

1/31/2007

Text

128

The encrypted subscriber last name.

ME102

Encrypted Subscriber First Name

1/31/2007

Text

128

The encrypted subscriber first name.

ME103

Encrypted Subscriber Middle Initial

1/31/2007

Text

1

The encrypted subscriber middle initial.

ME104

Encrypted Member Last Name

1/31/2007

Text

128

The encrypted member last name.

ME105

Encrypted Member First Name

1/31/2007

Text

128

The encrypted member first name.

ME106

Encrypted Member Middle Initial

1/31/2007

Text

1

The encrypted member middle initial.

ME899

Record Type

1/31/2007

Text

2

Value = ME

Appendix 2 Member Eligibility File Mapping to National Standards

Data Element #

Element

HIPAA Reference Transaction Set/Loop/Segment ID/Code Value/Reference Designator

ME001

Payer

N/A

ME002

National Plan ID

271/2100A/NM1/XV/09

ME003

Insurance Type Code/Product

271/2110C/EB//04, 271/2110D/EB//04

ME004

Year

N/A

ME005

Month

N/A

ME006

Insured Group or Policy Number

271/2100C/REF/1L/02, 271/2100C/REF/IG/02, 271/2100C/REF/6P/02, 271/2100D/REF/1L/02, 271/2100D/REF/IG/02, 271/2100D/REF/6P/02

ME007

Coverage Level Code

271/2110C/EB//03, 271/2110D/EB//03

ME008

Encrypted Subscriber Unique Identification Number

271/2100C/NM1/MI/09

ME009

Plan Specific Contract Number

271/2100C/NM1/MI/09

ME010

Member Suffix or Sequence Number

N/A

ME011

Member Identification Code

271/2100C/NM1/MI/09, 271/2100D/NM1/MI/09

ME012

Individual Relationship Code

271/2100C/INS/Y/02, 271/2100D/INS/N/02

ME013

Member Gender

271/2100C/DMG//03, 271/2100D/DMG//03

ME014

Member Date of Birth

271/2100C/DMG/D8/02, 271/2100D/DMG/D8/02

ME015

Member City Name

271/2100C/N4//01, 271/2100D/N4//01

ME016

Member State or Province

271/2100C/N4//02, 271/2100D/N4//02

ME017

Member ZIP Code

271/2100C/N4//03, 271/2100D/N4//03

ME018

Medical Coverage

N/A

ME019

Prescription Drug Coverage

N/A

ME020

Placeholder

N/A

ME021

Placeholder

N/A

ME022

Placeholder

N/A

ME023

Placeholder

N/A

ME024

Placeholder

N/A

ME025

Placeholder

N/A

ME026

Placeholder

N/A

ME027

Placeholder

N/A

ME028

Primary Insurance Indicator

N/A

ME029

Coverage Type

N/A

ME030

Market Category Code

N/A

ME031

Placeholder

N/A

ME101

Encrypted Subscriber Last Name

N/A

ME102

Encrypted Subscriber First Name

N/A

ME103

Encrypted Subscriber Middle Initial

N/A

ME104

Encrypted Member Last Name

N/A

ME105

Encrypted Member First Name

N/A

ME106

Encrypted Member Middle Initial

N/A

ME899

Record Type

N/A

Data Element #

Element

HIPAA Reference Transaction Set/Loop/Segment ID/Code Value/Reference Designator

ME001

Payer

N/A

ME002

National Plan ID

271/2100A/NM1/XV/09

ME003

Insurance Type Code/Product

271/2110C/EB//04, 271/2110D/EB//04

ME004

Year

N/A

ME005

Month

N/A

ME006

Insured Group or Policy Number

271/2100C/REF/1L/02, 271/2100C/REF/IG/02, 271/2100C/REF/6P/02, 271/2100D/REF/1L/02, 271/2100D/REF/IG/02, 271/2100D/REF/6P/02

ME007

Coverage Level Code

271/2110C/EB//03, 271/2110D/EB//03

ME008

Encrypted Subscriber Unique Identification Number

271/2100C/NM1/MI/09

ME009

Plan Specific Contract Number

271/2100C/NM1/MI/09

ME010

Member Suffix or Sequence Number

N/A

ME011

Member Identification Code

271/2100C/NM1/MI/09, 271/2100D/NM1/MI/09

ME012

Individual Relationship Code

271/2100C/INS/Y/02, 271/2100D/INS/N/02

ME013

Member Gender

271/2100C/DMG//03, 271/2100D/DMG//03

ME014

Member Date of Birth

271/2100C/DMG/D8/02, 271/2100D/DMG/D8/02

ME015

Member City Name

271/2100C/N4//01, 271/2100D/N4//01

ME016

Member State or Province

271/2100C/N4//02, 271/2100D/N4//02

ME017

Member ZIP Code

271/2100C/N4//03, 271/2100D/N4//03

ME018

Medical Coverage

N/A

ME019

Prescription Drug Coverage

N/A

ME020

Placeholder

N/A

ME021

Placeholder

N/A

ME022

Placeholder

N/A

ME023

Placeholder

N/A

ME024

Placeholder

N/A

ME025

Placeholder

N/A

ME026

Placeholder

N/A

ME027

Placeholder

N/A

ME028

Primary Insurance Indicator

N/A

ME029

Coverage Type

N/A

ME030

Market Category Code

N/A

ME031

Placeholder

N/A

ME101

Encrypted Subscriber Last Name

N/A

ME102

Encrypted Subscriber First Name

N/A

ME103

Encrypted Subscriber Middle Initial

N/A

ME104

Encrypted Member Last Name

N/A

ME105

Encrypted Member First Name

N/A

ME106

Encrypted Member Middle Initial

N/A

ME899

Record Type

N/A

Appendix 1 Medical Claims File Specifications

Data Element #

Data Element Name

Required Start Date

Type

Maximum Length

Description/Codes/Sources

MC001

Payer

1/31/2007

Text

8

Payer submitting payments BISHCA Submitter Code

MC002

National Plan ID

1/31/2007

Text

30

CMS National Plan ID

MC003

Insurance Type/Product Code

1/31/2007

Text

2

12 Preferred Provider Organization (PPO)

13 Point of Service (POS)

14 Exclusive Provider Organization (EPO)

15 Indemnity Insurance

16 Health Maintenance Organization (HMO) Medicare Advantage

HM Health Maintenance Organization

MA Medicare Part A

MB Medicare Part B

MD Medicare Part D

MC Medicaid

OF Other Federal Program (e.g. Black Lung)

TV Title V

VA Veteran Administration Plan

* WC Worker's Compensation

* Indicates that code is not to be included in Vermont submissions. Included in data set for harmonization with other New England states' data collection rules.

MC004

Payer Claim Control Number

1/31/2007

Text

35

Must apply to the entire claim and be unique within the payer's system.

MC005

Line Counter

1/31/2007

Integer

4

The line number for this service.

The line counter begins with 1 and is incremented by 1 for each additional service line of a claim.

MC005A

Version Number

1/31/2007

Integer

4

The version number of this claim service line.

The version number begins with 0 and is incremented by 1 for each subsequent version of that service line.

MC006

Insured Group or Policy Number

1/31/2007

Text

30

Group or policy number - not the number that uniquely identifies the subscriber.

MC007

Encrypted Subscriber Unique Identification Number

1/31/2007

Text

128

The encrypted subscriber's social security number; used to create unique member ID. Set as null if unavailable.

MC008

Plan Specific Contract Number

1/31/2007

Text

128

The encrypted plan assigned contract number.

Set as null if contract number equals subscriber's social security number.

MC009

Member Suffix or Sequence Number

1/31/2007

Integer

20

The unique number of the member within the contract.

MC010

Member Identification Code

1/31/2007

Text

128

The encrypted member's social security number; used to create unique member ID. Set as null if unavailable.

MC011

Individual Relationship Code

1/31/2007

Integer

2

Member's relationship to insured as shown below:

01 Spouse

04 Grandfather or Grandmother

05 Grandson or Granddaughter

07 Nephew or Niece

10 Foster Child

15 Ward

17 Stepson or Stepdaughter

19 Child

20 Employee/Self

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

76 Dependent

MC012

Member Gender

1/31/2007

Text

1

M Male

F Female

U Unknown

MC013

Member Date of Birth

1/31/2007

Date

8

CCYYMMDD

MC014

Member City Name

1/31/2007

Text

30

The city name of the member.

MC015

Member State or Province

1/31/2007

Text

2

As defined by the US Postal Service

MC016

Member ZIP Code

1/31/2007

Text

11

ZIP Code of member - may include non-US codes. Do not include dash.

MC017

Date Service Approved/Accounts Payable Date/Actual Paid Date

1/31/2007

Date

8

CCYYMMDD

MC018

Admission Date

1/31/2007

Date

8

Required for all inpatient claims. CCYYMMDD

MC019

Admission Hour

1/31/2007

Integer

4

Required for all inpatient claims. Time is expressed in military time - HHMM

MC020

Admission Type

1/31/2007

Integer

1

Required for all inpatient claims. Refer to Appendix A.

MC021

Admission Source

1/31/2007

Text

1

Required for all inpatient claims. Refer to Appendix A.

MC022

Discharge Hour

1/31/2007

Integer

4

Hour in military time - HHMM

MC023

Discharge Status

1/31/2007

Integer

2

Required for all inpatient claims.

01 Discharged to home or self care

02 Discharged/transferred to another short term general hospital for inpatient care

03 Discharged/transferred to skilled nursing facility (SNF)

04 Discharged/transferred to nursing facility (NF)

05 Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution

06 Discharged/transferred to home under care of organized home health service organization

07 Left against medical advice or discontinued care

08 Discharged/transferred to home under care of a Home IV provider

09 Admitted as an inpatient to this hospital

20 Expired

30 Still patient or expected to return for outpatient services

40 Expired at home

41 Expired in a medical facility

42 Expired, place unknown

43 Discharged/transferred to a Federal Hospital

50 Hospice - home

51 Hospice - medical facility

61 Discharged/transferred within this institution to a hospital-based Medicare-approved swing bed

62 Discharged/transferred to an inpatient rehabilitation facility including distinct parts of a hospital

63 Discharged/transferred to a long term care hospital

64 Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare

MC024

Service Provider Number

1/31/2007

Text

30

Payer assigned provider number.

This number should be the identifier used by the payer for internal identification purposes, and does not routinely change. In many cases, it will be the provider Medicare number.

MC025

Service Provider Tax ID Number

1/31/2007

Text

10

Federal taxpayer's identification number.

MC026

National Service Provider ID

1/31/2007

Text

20

Required if National Provider ID is mandated for use under HIPAA.

The preferred code for this element is for the rendering provider. For the billing provider, see MC077.

MC027

Service Provider Entity Type Qualifier

1/31/2007

Text

1

HIPAA provider taxonomy classifies provider groups (clinicians who bill as a group practice or under a corporate name, even if that group is composed of one provider) as a "person", and these shall be coded as a person.

Insurers and health care processors shall code according to:

1 Person

2 Non-Person Entity

MC028

Service Provider First Name

1/31/2007

Text

25

Individual first name.

Set to null if provider is a facility or organization.

MC029

Service Provider Middle Name

1/31/2007

Text

25

Individual middle name or initial.

Set to null if provider is a facility or organization.

MC030

Service Provider Last Name or Organization Name

1/31/2007

Text

60

Full name of provider organization or last name of individual provider.

MC031

Service Provider Suffix

1/31/2007

Text

10

Suffix to individual name.

Set to null if provider is a facility or organization.

The service provider suffix shall be used to capture the generation of the individual clinician (e.g., Jr., Sr., III.), if applicable, rather than the clinician's degree (e.g., MD, LCSW).

MC032

Service Provider Specialty

1/31/2007

Text

50

As defined by payer

Dictionary for specialty code values must be supplied during testing.

MC033

Service Provider City Name

1/31/2007

Text

30

City name of provider and preferably the practice location.

MC034

Service Provider State or Province

1/31/2007

Text

2

As defined by the US Postal Service.

MC035

Service Provider ZIP Code

1/31/2007

Text

11

ZIP Code of provider - may include non-US codes. Do not include dash.

MC036

Type of Bill - Institutional/ Facility Claims, such as those submitted using on UB04 forms

1/31/2007

Integer

2

Required for institutional claims. Not to be used for professional claims.

Type of Facility - First Digit

1 Hospital

2 Skilled Nursing

3 Home Health

4 Christian Science Hospital

5 Christian Science Extended Care

6 Intermediate Care

7 Clinic

8 Special Facility

Bill Classification - Second Digit if First Digit = 1-6

1 Inpatient (Including Medicare Part A)

2 Inpatient (Medicare Part B Only)

3 Outpatient

4 Other (for hospital referenced diagnostic services or home health not under a plan of treatment)

5 Nursing Facility Level I

6 Nursing Facility Level II

7 Intermediate Care - Level III Nursing Facility

8 Swing Beds

Bill Classification - Second Digit if First Digit = 7

1 Rural Health

2 Hospital Based or Independent Renal Dialysis Center

3 Free Standing Outpatient Rehabilitation Facility (ORF)

5 Comprehensive Outpatient Rehabilitation Facilities (CORF)

6 Community Mental Health Center

9 Other

Bill Classification - Second Digit if First Digit = 8

1 Hospice (Non Hospital Based)

2 Hospice (Hospital-Based)

3 Ambulatory Surgery Center

4 Free Standing Birthing Center

9 Other

MC037

Site of Service - on NSF/CMS 1500 Claims

1/31/2007

Text

2

Required for professional claims.

Not to be used for institutional claims.

11 Office

12 Home

21 Inpatient Hospital

22 Outpatient Hospital

23 Emergency Room - Hospital

24 Ambulatory Surgery Center

25 Birthing Center

26 Military Treatment Facility

31 Skilled Nursing Facility

32 Nursing Facility

33 Custodial Care Facility

34 Hospice

35 Boarding Home

41 Ambulance - Land

42 Ambulance - Air or Water

50 Federally Qualified Center

51 Inpatient Psychiatric Facility

52 Psychiatric Facility Partial Hospitalization

53 Community Mental Health Center

54 Intermediate Care Facility/Mentally Retarded

55 Residential Substance Abuse Treatment Facility

56 Psychiatric Residential Treatment Center

60 Mass Immunization Center

61 Comprehensive Inpatient Rehabilitation Facility

62 Comprehensive Outpatient Rehabilitation Facility

65 End Stage Renal Disease Treatment Facility

71 State or Local Public Health Clinic

72 Rural Health Clinic

81 Independent Laboratory

99 Other Unlisted Facility

MC038

Claim Status

1/31/2007

Integer

2

01 Processed as primary

02 Processed as secondary

03 Processed as tertiary

04 Denied

19 Processed as primary, forwarded to additional payer(s)

20 Processed as secondary, forwarded to additional payer(s)

21 Processed as tertiary, forwarded to additional payer(s)

22 Reversal of previous payment

MC039

Admitting Diagnosis

1/31/2007

Text

5

Required on all inpatient admission claims and encounters using the ICD-9-CM. Do not code decimal point.

MC040

E-Code

1/31/2007

Text

5

Describes an injury, poisoning or adverse effect using the ICD-9-CM. Do not include decimal point.

MC041

Principal Diagnosis

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC042

Other Diagnosis - 1

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC043

Other Diagnosis - 2

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC044

Other Diagnosis - 3

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC045

Other Diagnosis - 4

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC046

Other Diagnosis - 5

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC047

Other Diagnosis - 6

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC048

Other Diagnosis - 7

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC049

Other Diagnosis - 8

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC050

Other Diagnosis - 9

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC051

Other Diagnosis - 10

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC052

Other Diagnosis - 11

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC053

Other Diagnosis - 12

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC054

Revenue Code

1/31/2007

Integer

4

National Uniform Billing Committee Codes.

Code using leading zeroes, left justified and four digits.

MC055

Procedure 1 Code

1/31/2007

Text

5

Health Care Common Procedural Coding System (HCPCS).

This includes the CPT codes of the American Medical Association.

MC056

Procedure 1 Modifier - 1

1/31/2007

Text

2

Procedure modifier required when a modifier clarifies or improves the reporting accuracy of the associated procedure code.

When the insurer utilizes a local code system for modifiers, a reference table shall be submitted.

MC057

Procedure 1 Modifier - 2

1/31/2007

Text

2

Procedure modifier required when a modifier clarifies or improves the reporting accuracy of the associated procedure code.

When the insurer utilizes a local code system for modifiers, a reference table shall be submitted.

MC058

ICD-9-CM Procedure Code

1/31/2007

Text

4

Primary ICD-9-CM code for this line of service. Do not code decimal point.

MC059

Date of Service - From

1/31/2007

Date

8

First date of service for this service line.

CCYYMMDD

MC060

Date of Service - Thru

1/31/2007

Date

8

Last date of service for this service line.

CCYYMMDD

MC061

Quantity

1/31/2007

Integer

3

Count of services performed, which shall be set equal to one on all observation bed service lines and should be set equal to zero on all other room and board service lines, regardless of the length of stay.

MC062

Charge Amount

1/31/2007

Decimal

10

Do not code decimal point.

MC063

Paid Amount

1/31/2007

Decimal

10

Includes any withhold amounts. Do not code decimal point.

This element includes all payments made by the insurer except capitation.

MC064

Prepaid Amount

1/31/2007

Decimal

10

For capitated services - the fee for service equivalent amount.

Do not code decimal point.

MC065

Co-pay Amount

1/31/2007

Decimal

10

The preset, fixed dollar amount for which the individual is responsible.

Do not code decimal point.

MC066

Coinsurance Amount

1/31/2007

Decimal

10

The dollar amount an individual is responsible for- not the percentage.

Do not code decimal point.

MC067

Deductible Amount

1/31/2007

Decimal

10

The dollar amount of the deductible. Do not code decimal point.

MC068

Patient Account/Control Number

1/31/2007

Text

20

Number assigned by hospital.

MC069

Discharge Date

1/31/2007

Date

8

Date patient discharged. Required for all inpatient claims. CCYYMMDD

MC070

Service Provider Country Name

1/31/2007

Text

30

Code US for United States.

MC071

DRG

1/31/2007

Text

10

Insurers and health care claims processors shall code using the CMS methodology when available. Precedence shall be given to DRGs transmitted from the hospital provider. When the CMS methodology for DRGs is not available, but the All Payer DRG system is used, the insurer shall format the DRG and the complexity level within the same field with an "A" prefix, and with a hyphen separating the DRG and the complexity level (e.g. AXXX-XX)

MC072

DRG Version

1/31/2007

Text

2

Version number of the grouper used.

MC073

APC

1/31/2007

Text

4

Insurers and health care claims processors shall code using the CMS methodology when available. Precedence shall be given to APCs transmitted from the health care provider.

MC074

APC Version

1/31/2007

Text

2

Version number of the grouper used.

MC075

Drug Code

1/31/2007

Text

11

Insurers and health care claims processors shall code according to NDC code.

MC076

Billing Provider Number

1/31/2007

Text

30

Payer assigned provider number. This number should be the identifier used by the payer for internal identification purposes, and does not routinely change.

MC077

National Billing Provider ID

1/31/2007

Text

20

National Provider ID mandated for use under HIPAA.

MC078

Billing Provider Last Name

1/31/2007

Text

60

Full name of billing organization or last name of individual billing or Organization Name.

MC101

Encrypted Subscriber Last Name

1/31/2007

Text

128

The encrypted subscriber last name.

MC102

Encrypted Subscriber First Name

1/31/2007

Text

128

The encrypted subscriber first name.

MC103

Encrypted Subscriber Middle Initial

1/31/2007

Text

1

The encrypted subscriber middle initial.

MC104

Encrypted Member Last Name

1/31/2007

Text

128

The encrypted member last name.

MC105

Encrypted Member First Name

1/31/2007

Text

128

The encrypted member first name.

MC106

Encrypted Member Middle Initial

1/31/2007

Text

1

The encrypted member middle initial.

MC899

Record Type

1/31/2007

Text

2

Value = MC

Data Element #

Data Element Name

Required Start Date

Type

Maximum Length

Description/Codes/Sources

MC001

Payer

1/31/2007

Text

8

Payer submitting payments BISHCA Submitter Code

MC002

National Plan ID

1/31/2007

Text

30

CMS National Plan ID

MC003

Insurance Type/Product Code

1/31/2007

Text

2

12 Preferred Provider Organization (PPO)

13 Point of Service (POS)

14 Exclusive Provider Organization (EPO)

15 Indemnity Insurance

16 Health Maintenance Organization (HMO) Medicare Advantage

HM Health Maintenance Organization

MA Medicare Part A

MB Medicare Part B

MD Medicare Part D

MC Medicaid

OF Other Federal Program (e.g. Black Lung)

TV Title V

VA Veteran Administration Plan

* WC Worker's Compensation

* Indicates that code is not to be included in Vermont submissions. Included in data set for harmonization with other New England states' data collection rules.

MC004

Payer Claim Control Number

1/31/2007

Text

35

Must apply to the entire claim and be unique within the payer's system.

MC005

Line Counter

1/31/2007

Integer

4

The line number for this service.

The line counter begins with 1 and is incremented by 1 for each additional service line of a claim.

MC005A

Version Number

1/31/2007

Integer

4

The version number of this claim service line.

The version number begins with 0 and is incremented by 1 for each subsequent version of that service line.

MC006

Insured Group or Policy Number

1/31/2007

Text

30

Group or policy number - not the number that uniquely identifies the subscriber.

MC007

Encrypted Subscriber Unique Identification Number

1/31/2007

Text

128

The encrypted subscriber's social security number; used to create unique member ID. Set as null if unavailable.

MC008

Plan Specific Contract Number

1/31/2007

Text

128

The encrypted plan assigned contract number.

Set as null if contract number equals subscriber's social security number.

MC009

Member Suffix or Sequence Number

1/31/2007

Integer

20

The unique number of the member within the contract.

MC010

Member Identification Code

1/31/2007

Text

128

The encrypted member's social security number; used to create unique member ID. Set as null if unavailable.

MC011

Individual Relationship Code

1/31/2007

Integer

2

Member's relationship to insured as shown below:

01 Spouse

04 Grandfather or Grandmother

05 Grandson or Granddaughter

07 Nephew or Niece

10 Foster Child

15 Ward

17 Stepson or Stepdaughter

19 Child

20 Employee/Self

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

76 Dependent

MC012

Member Gender

1/31/2007

Text

1

M Male

F Female

U Unknown

MC013

Member Date of Birth

1/31/2007

Date

8

CCYYMMDD

MC014

Member City Name

1/31/2007

Text

30

The city name of the member.

MC015

Member State or Province

1/31/2007

Text

2

As defined by the US Postal Service

MC016

Member ZIP Code

1/31/2007

Text

11

ZIP Code of member - may include non-US codes. Do not include dash.

MC017

Date Service Approved/Accounts Payable Date/Actual Paid Date

1/31/2007

Date

8

CCYYMMDD

MC018

Admission Date

1/31/2007

Date

8

Required for all inpatient claims. CCYYMMDD

MC019

Admission Hour

1/31/2007

Integer

4

Required for all inpatient claims. Time is expressed in military time - HHMM

MC020

Admission Type

1/31/2007

Integer

1

Required for all inpatient claims. Refer to Appendix A.

MC021

Admission Source

1/31/2007

Text

1

Required for all inpatient claims. Refer to Appendix A.

MC022

Discharge Hour

1/31/2007

Integer

4

Hour in military time - HHMM

MC023

Discharge Status

1/31/2007

Integer

2

Required for all inpatient claims.

01 Discharged to home or self care

02 Discharged/transferred to another short term general hospital for inpatient care

03 Discharged/transferred to skilled nursing facility (SNF)

04 Discharged/transferred to nursing facility (NF)

05 Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution

06 Discharged/transferred to home under care of organized home health service organization

07 Left against medical advice or discontinued care

08 Discharged/transferred to home under care of a Home IV provider

09 Admitted as an inpatient to this hospital

20 Expired

30 Still patient or expected to return for outpatient services

40 Expired at home

41 Expired in a medical facility

42 Expired, place unknown

43 Discharged/transferred to a Federal Hospital

50 Hospice - home

51 Hospice - medical facility

61 Discharged/transferred within this institution to a hospital-based Medicare-approved swing bed

62 Discharged/transferred to an inpatient rehabilitation facility including distinct parts of a hospital

63 Discharged/transferred to a long term care hospital

64 Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare

MC024

Service Provider Number

1/31/2007

Text

30

Payer assigned provider number.

This number should be the identifier used by the payer for internal identification purposes, and does not routinely change. In many cases, it will be the provider Medicare number.

MC025

Service Provider Tax ID Number

1/31/2007

Text

10

Federal taxpayer's identification number.

MC026

National Service Provider ID

1/31/2007

Text

20

Required if National Provider ID is mandated for use under HIPAA.

The preferred code for this element is for the rendering provider. For the billing provider, see MC077.

MC027

Service Provider Entity Type Qualifier

1/31/2007

Text

1

HIPAA provider taxonomy classifies provider groups (clinicians who bill as a group practice or under a corporate name, even if that group is composed of one provider) as a "person", and these shall be coded as a person.

Insurers and health care processors shall code according to:

1 Person

2 Non-Person Entity

MC028

Service Provider First Name

1/31/2007

Text

25

Individual first name.

Set to null if provider is a facility or organization.

MC029

Service Provider Middle Name

1/31/2007

Text

25

Individual middle name or initial.

Set to null if provider is a facility or organization.

MC030

Service Provider Last Name or Organization Name

1/31/2007

Text

60

Full name of provider organization or last name of individual provider.

MC031

Service Provider Suffix

1/31/2007

Text

10

Suffix to individual name.

Set to null if provider is a facility or organization.

The service provider suffix shall be used to capture the generation of the individual clinician (e.g., Jr., Sr., III.), if applicable, rather than the clinician's degree (e.g., MD, LCSW).

MC032

Service Provider Specialty

1/31/2007

Text

50

As defined by payer

Dictionary for specialty code values must be supplied during testing.

MC033

Service Provider City Name

1/31/2007

Text

30

City name of provider and preferably the practice location.

MC034

Service Provider State or Province

1/31/2007

Text

2

As defined by the US Postal Service.

MC035

Service Provider ZIP Code

1/31/2007

Text

11

ZIP Code of provider - may include non-US codes. Do not include dash.

MC036

Type of Bill - Institutional/ Facility Claims, such as those submitted using on UB04 forms

1/31/2007

Integer

2

Required for institutional claims. Not to be used for professional claims.

Type of Facility - First Digit

1 Hospital

2 Skilled Nursing

3 Home Health

4 Christian Science Hospital

5 Christian Science Extended Care

6 Intermediate Care

7 Clinic

8 Special Facility

Bill Classification - Second Digit if First Digit = 1-6

1 Inpatient (Including Medicare Part A)

2 Inpatient (Medicare Part B Only)

3 Outpatient

4 Other (for hospital referenced diagnostic services or home health not under a plan of treatment)

5 Nursing Facility Level I

6 Nursing Facility Level II

7 Intermediate Care - Level III Nursing Facility

8 Swing Beds

Bill Classification - Second Digit if First Digit = 7

1 Rural Health

2 Hospital Based or Independent Renal Dialysis Center

3 Free Standing Outpatient Rehabilitation Facility (ORF)

5 Comprehensive Outpatient Rehabilitation Facilities (CORF)

6 Community Mental Health Center

9 Other

Bill Classification - Second Digit if First Digit = 8

1 Hospice (Non Hospital Based)

2 Hospice (Hospital-Based)

3 Ambulatory Surgery Center

4 Free Standing Birthing Center

9 Other

MC037

Site of Service - on NSF/CMS 1500 Claims

1/31/2007

Text

2

Required for professional claims.

Not to be used for institutional claims.

11 Office

12 Home

21 Inpatient Hospital

22 Outpatient Hospital

23 Emergency Room - Hospital

24 Ambulatory Surgery Center

25 Birthing Center

26 Military Treatment Facility

31 Skilled Nursing Facility

32 Nursing Facility

33 Custodial Care Facility

34 Hospice

35 Boarding Home

41 Ambulance - Land

42 Ambulance - Air or Water

50 Federally Qualified Center

51 Inpatient Psychiatric Facility

52 Psychiatric Facility Partial Hospitalization

53 Community Mental Health Center

54 Intermediate Care Facility/Mentally Retarded

55 Residential Substance Abuse Treatment Facility

56 Psychiatric Residential Treatment Center

60 Mass Immunization Center

61 Comprehensive Inpatient Rehabilitation Facility

62 Comprehensive Outpatient Rehabilitation Facility

65 End Stage Renal Disease Treatment Facility

71 State or Local Public Health Clinic

72 Rural Health Clinic

81 Independent Laboratory

99 Other Unlisted Facility

MC038

Claim Status

1/31/2007

Integer

2

01 Processed as primary

02 Processed as secondary

03 Processed as tertiary

04 Denied

19 Processed as primary, forwarded to additional payer(s)

20 Processed as secondary, forwarded to additional payer(s)

21 Processed as tertiary, forwarded to additional payer(s)

22 Reversal of previous payment

MC039

Admitting Diagnosis

1/31/2007

Text

5

Required on all inpatient admission claims and encounters using the ICD-9-CM. Do not code decimal point.

MC040

E-Code

1/31/2007

Text

5

Describes an injury, poisoning or adverse effect using the ICD-9-CM. Do not include decimal point.

MC041

Principal Diagnosis

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC042

Other Diagnosis - 1

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC043

Other Diagnosis - 2

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC044

Other Diagnosis - 3

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC045

Other Diagnosis - 4

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC046

Other Diagnosis - 5

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC047

Other Diagnosis - 6

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC048

Other Diagnosis - 7

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC049

Other Diagnosis - 8

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC050

Other Diagnosis - 9

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC051

Other Diagnosis - 10

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC052

Other Diagnosis - 11

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC053

Other Diagnosis - 12

1/31/2007

Text

5

ICD-9-CM. Do not code decimal point.

MC054

Revenue Code

1/31/2007

Integer

4

National Uniform Billing Committee Codes.

Code using leading zeroes, left justified and four digits.

MC055

Procedure 1 Code

1/31/2007

Text

5

Health Care Common Procedural Coding System (HCPCS).

This includes the CPT codes of the American Medical Association.

MC056

Procedure 1 Modifier - 1

1/31/2007

Text

2

Procedure modifier required when a modifier clarifies or improves the reporting accuracy of the associated procedure code.

When the insurer utilizes a local code system for modifiers, a reference table shall be submitted.

MC057

Procedure 1 Modifier - 2

1/31/2007

Text

2

Procedure modifier required when a modifier clarifies or improves the reporting accuracy of the associated procedure code.

When the insurer utilizes a local code system for modifiers, a reference table shall be submitted.

MC058

ICD-9-CM Procedure Code

1/31/2007

Text

4

Primary ICD-9-CM code for this line of service. Do not code decimal point.

MC059

Date of Service - From

1/31/2007

Date

8

First date of service for this service line.

CCYYMMDD

MC060

Date of Service - Thru

1/31/2007

Date

8

Last date of service for this service line.

CCYYMMDD

MC061

Quantity

1/31/2007

Integer

3

Count of services performed, which shall be set equal to one on all observation bed service lines and should be set equal to zero on all other room and board service lines, regardless of the length of stay.

MC062

Charge Amount

1/31/2007

Decimal

10

Do not code decimal point.

MC063

Paid Amount

1/31/2007

Decimal

10

Includes any withhold amounts. Do not code decimal point.

This element includes all payments made by the insurer except capitation.

MC064

Prepaid Amount

1/31/2007

Decimal

10

For capitated services - the fee for service equivalent amount.

Do not code decimal point.

MC065

Co-pay Amount

1/31/2007

Decimal

10

The preset, fixed dollar amount for which the individual is responsible.

Do not code decimal point.

MC066

Coinsurance Amount

1/31/2007

Decimal

10

The dollar amount an individual is responsible for- not the percentage.

Do not code decimal point.

MC067

Deductible Amount

1/31/2007

Decimal

10

The dollar amount of the deductible. Do not code decimal point.

MC068

Patient Account/Control Number

1/31/2007

Text

20

Number assigned by hospital.

MC069

Discharge Date

1/31/2007

Date

8

Date patient discharged. Required for all inpatient claims. CCYYMMDD

MC070

Service Provider Country Name

1/31/2007

Text

30

Code US for United States.

MC071

DRG

1/31/2007

Text

10

Insurers and health care claims processors shall code using the CMS methodology when available. Precedence shall be given to DRGs transmitted from the hospital provider. When the CMS methodology for DRGs is not available, but the All Payer DRG system is used, the insurer shall format the DRG and the complexity level within the same field with an "A" prefix, and with a hyphen separating the DRG and the complexity level (e.g. AXXX-XX)

MC072

DRG Version

1/31/2007

Text

2

Version number of the grouper used.

MC073

APC

1/31/2007

Text

4

Insurers and health care claims processors shall code using the CMS methodology when available. Precedence shall be given to APCs transmitted from the health care provider.

MC074

APC Version

1/31/2007

Text

2

Version number of the grouper used.

MC075

Drug Code

1/31/2007

Text

11

Insurers and health care claims processors shall code according to NDC code.

MC076

Billing Provider Number

1/31/2007

Text

30

Payer assigned provider number. This number should be the identifier used by the payer for internal identification purposes, and does not routinely change.

MC077

National Billing Provider ID

1/31/2007

Text

20

National Provider ID mandated for use under HIPAA.

MC078

Billing Provider Last Name

1/31/2007

Text

60

Full name of billing organization or last name of individual billing or Organization Name.

MC101

Encrypted Subscriber Last Name

1/31/2007

Text

128

The encrypted subscriber last name.

MC102

Encrypted Subscriber First Name

1/31/2007

Text

128

The encrypted subscriber first name.

MC103

Encrypted Subscriber Middle Initial

1/31/2007

Text

1

The encrypted subscriber middle initial.

MC104

Encrypted Member Last Name

1/31/2007

Text

128

The encrypted member last name.

MC105

Encrypted Member First Name

1/31/2007

Text

128

The encrypted member first name.

MC106

Encrypted Member Middle Initial

1/31/2007

Text

1

The encrypted member middle initial.

MC899

Record Type

1/31/2007

Text

2

Value = MC

Appendix 2 Medical Claims File Mapping to National Standards

Locator and field changes with updated forms (UB-04) shall comply with standard practices.

HIPAA Reference

Data Element #

Data Element Name

UB-92 Form Locator

UB-92 (Version 6.0) Record Type / Field #

HCFA 1500 #

NSF (National Standard Format) Locator

Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator

MC001

Payer

N/A

N/A

N/A

N/A

N/A

MC002

National Plan ID

N/A

N/A

N/A

N/A

835/1000A/N1/XV/04

MC003

Product/Claim Filing Indicator Code

N/A

30/4

N/A

N/A

835/2100/CLP/ /06

MC004

Payer Claim Control Number

N/A

N/A

N/A

FA0-02.0, FB0-02.0, FB1-02.0, GA0-02.0, GC0-02.0, GX0-02.0, GX2-02.0, HA0-02.0, FB2-02.0, GU0-02.0

835/2100/CLP/ /07

MC005

Line Counter

N/A

N/A

N/A

N/A

837/2400/LX/ /01

MC005A

Version Number

N/A

N/A

N/A

N/A

N/A

MC006

Insured Group or Policy Number

62 (A-C)

30/10

11C

DA0-10.0

837/2000B/SBR/ /03

MC007

Encrypted Subscriber Unique Identification Number

N/A

N/A

N/A

N/A

835/2100/NM1/34/09

MC008

Plan Specific Contract Number

N/A

N/A

N/A

N/A

835/2100/NM1/HN/09

MC009

Member Suffix or Sequence Number

N/A

N/A

N/A

N/A

N/A

MC010

Member Identification Code

N/A

N/A

N/A

N/A

835/2100/NM1/MI/08

MC011

Individual Relationship Code

59 (A-C)

30/18

6

DA0-17.0

837/2000B/SBR/ /02, 837/2000C/PAT/ /01

MC012

Member Gender

15

20/7

3

CA0-09.0

837/2010CA/DMG/ /03

MC013

Member Date of Birth

14

20/8

3

CA0-08.0

837/2010CA/DMG/D8/02

MC014

Member City Name

13

20/14

5

CA0-13.0

837/2010CA/N4/ /01

MC015

Member State or Province

13

20/15

5

CA0-14.0

837/2010CA/N4/ /02

MC016

Member ZIP Code

13

20/16

5

CA0-15.0

837/2010CA/N4/ /03

MC017

Date Service Approved

N/A

N/A

N/A

N/A

N/A

MC018

Admission Date

17

20/17

N/A

N/A

837/2300/DTP/435/03

MC019

Admission Hour

18

20/18

N/A

N/A

837/2300/DTP/435/03

MC020

Admission Type

19

20/10

N/A

N/A

837/2300/CL1/ /01

MC021

Admission Source

20

20/11

N/A

N/A

837/2300/CL1/ /02

MC022

Discharge Hour

21

20/22

N/A

N/A

837/2300/DTP/096/03

MC023

Discharge Status

22

20/21

N/A

N/A

837/2300/CL1/ /03

MC024

Service Provider Number

N/A

N/A

N/A

N/A

835/2100/NM1/BD/09, 835/2100/NM1/BS/09, 835/2100/NM1/MC/09, 835/2100/NM1/PC/09 835/2100/NM1/FI/09

MC025

Service Provider Tax ID Number

5

10/4-5

25

BA0-09.0, CA0-28.0, BA0-02.0, BA1-02.0, YA0-02.0, BA0-06.0, BA0-10.0, BA0-12.0, BA0-13.0, BA0-14.0, BA0-15.0, BA0-16.0, BA0-17.0, BA0-24.0, YA0-06.0

MC026

National Service Provider ID

N/A

10/6

N/A

N/A

835/2100/NM1/XX/09

MC027

Service Provider Entity Type Qualifier

N/A

N/A

N/A

N/A

835/2100/NM1/82/02

MC028

Service Provider First Name

1

10/12

33

BA0-20.0

835/2100/NM1/82/04

MC029

Service Provider Middle Name

1

10/12

33

BA0-21.0

835/2100/NM1/82/05

MC030

Service Provider Last Name or Organization Name

1

10/12

33

BA0-18.0, BA0-19.0

835/2100/NM1/82/03

MC031

Service Provider Suffix

1

10/12

33

BA0-22.0

835/2100/NM1/82/07

MC032

Service Provider Specialty

N/A

N/A

N/A

N/A

837/2000A/PRV/ZZ/03

MC033

Service Provider City Name

1

10/14

N/A

BA1-09.0, 15.0

837/2010A/N4/ /01

MC034

Service Provider State or Province

1

10/15

N/A

BA1-10.0, 16.0

837/2010A/N4/ /02

MC035

Service Provider ZIP Code

1

10/16

N/A

BA1-11.0, 17.0

837/2010A/N4/ /03

MC036

Type of Bill - Institutional/ Facility Claims

4

Positions 1-2: 40/4

N/A

N/A

837/2300/CLM/ /05-1

MC037

Site of Service - on NSF/CMS 1500 Claims

N/A

N/A

24B

FA0-07.0, GU0-0.50

837/2300/CLM/ /05-1

MC038

Claim Status

N/A

N/A

N/A

N/A

835/2100/CLP/ /02

MC039

Admitting Diagnosis

76

70/25

N/A

N/A

837/2300/HI/BJ/02-2

MC040

E-Code

77

70/26

N/A

N/A

837/2300/HI/BN/03-2

MC041

Principal Diagnosis

67

70/4

21.1

EA0-32.0, GX0-31.0, GU0-12.0

837/2300/HI/BK/01-2

MC042

Other Diagnosis - 1

68

70/5

21.2

EA0-33.0, GX0-32.0, GU0-13.0

837/2300/HI/BF/01-2

MC043

Other Diagnosis - 2

69

70/6

21.3

EA0-33.0, GX0-32.0, GU0-13.0

837/2300/HI/BF/02-2

MC044

Other Diagnosis - 3

70

70/7

21.4

EA0-33.0, GX0-32.0, GU0-13.0

837/2300/HI/BF/03-2

MC045

Other Diagnosis - 4

71

70/8

N/A

EA0-35.0, GX0-34.0, GU0-15.0

837/2300/HI/BF/04-2

MC046

Other Diagnosis - 5

72

70/9

N/A

N/A

837/2300/HI/BF/05-2

MC047

Other Diagnosis - 6

73

70/10

N/A

N/A

837/2300/HI/BF/06-2

MC048

Other Diagnosis - 7

74

70/11

N/A

N/A

837/2300/HI/BF/07-2

MC049

Other Diagnosis - 8

75

70/12

N/A

N/A

837/2300/HI/BF/08-2

MC050

Other Diagnosis - 9

N/A

N/A

N/A

N/A

837/2300/HI/BF/09-2

MC051

Other Diagnosis -10

N/A

N/A

N/A

N/A

837/2300/HI/BF/10-2

MC052

Other Diagnosis -11

N/A

N/A

N/A

N/A

837/2300/HI/BF/11-2

MC053

Other Diagnosis -12

N/A

N/A

N/A

N/A

837/2300/HI/BF/12-2

MC054

Revenue Code

42

50/5, 11-13, 60/5, 15-16, 61/5,15-16

N/A

N/A

835/2110/SVC/RB/01-2, 835/2110/SVC/NU/01-2

MC055

Procedure Code

44

60/6, 15-16, 61/6, 15-16

24.1-6 D

FA0-09.0, FB0-15.0, GU0-07.0

835/2110/SVC/HC/01-2

MC056

Procedure Modifier - 1

44

60/7, 15-16, 61/7, 15-16

24.1-6 D

FA0-10.0, GU0-08.0

835/2110/SVC/HC/01-3

MC057

Procedure Modifier - 2

44

60/8,15-16, 61/8,15-16

24.1-6 D

FA0-11.0

835/2110/SVC/HC/01-4

MC058

ICD-9-CM Procedure Code

80, 81(A-E)

70/13, 15, 17, 19, 21, 23

N/A

N/A

835/2110/SVC/ID/01-2

MC059

Date of Service - From

45

61/13, 15-16, 61/13, 15-16

24.1-6 A

N/A

835/2110/DTM/150/02

MC060

Date of Service - Thru

N/A

N/A

24.1-6 A

FA0-05.0, FA0-06.0

835/2110/DTM/151/02

MC061

Quantity

46

50/7, 11-13, 60/9, 15-16, 61/9, 15-16

24.1-6 G

FA0-19.0, FB0-16.0

835/2110/SVC/ /05

MC062

Charge Amount

47

50/8, 11-13, 60/10, 15-16, 61/11, 15-16

24.1-6 F

FA0-13.0

835/2110/SVC/ /02

MC063

Paid Amount

48

N/A

N/A

N/A

835/2110/SVC/ /03

MC064

Prepaid Amount

N/A

N/A

N/A

N/A

N/A

MC065

Co-pay Amount

N/A

N/A

N/A

N/A

N/A

MC066

Coinsurance Amount

N/A

N/A

N/A

N/A

N/A

MC067

Deductible Amount

N/A

N/A

N/A

N/A

N/A

MC068

Patient Account/Control Number

3

20/3

26

CAO-03.0

837/2300/CLM//01

MC069

Discharge Date

6

20/20

24A

EAO-29.0

N/A

MC070

Service Provider Country Name

9

N/A

N/A

N/A

837/2310E/N4/04

MC071

DRG

N/A

N/A

N/A

N/A

N/A

MC072

DRG Version

N/A

N/A

N/A

N/A

N/A

MC073

APC

N/A

N/A

N/A

N/A

N/A

MC074

APC Version

N/A

N/A

N/A

N/A

N/A

MC075

Drug Code

N/A

N/A

N/A

N/A

N/A

MC076

Billing Provider Number

N/A

N/A

N/A

N/A

N/A

MC077

National Billing Provider ID

N/A

N/A

N/A

N/A

N/A

MC078

Billing Provider Last Name

N/A

N/A

N/A

N/A

N/A

MC101

Encrypted Subscriber Last Name

N/A

N/A

N/A

N/A

N/A

MC102

Encrypted Subscriber First Name

N/A

N/A

N/A

N/A

N/A

MC103

Encrypted Subscriber Middle Initial

N/A

N/A

N/A

N/A

N/A

MC104

Encrypted Member Last Name

N/A

N/A

N/A

N/A

N/A

MC105

Encrypted Member First Name

N/A

N/A

N/A

N/A

N/A

MC106

Encrypted Member Middle Initial

N/A

N/A

N/A

N/A

N/A

MC899

Record Type

N/A

N/A

N/A

N/A

N/A

Locator and field changes with updated forms (UB-04) shall comply with standard practices.

HIPAA Reference

Data Element #

Data Element Name

UB-92 Form Locator

UB-92 (Version 6.0) Record Type / Field #

HCFA 1500 #

NSF (National Standard Format) Locator

Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator

MC001

Payer

N/A

N/A

N/A

N/A

N/A

MC002

National Plan ID

N/A

N/A

N/A

N/A

835/1000A/N1/XV/04

MC003

Product/Claim Filing Indicator Code

N/A

30/4

N/A

N/A

835/2100/CLP/ /06

MC004

Payer Claim Control Number

N/A

N/A

N/A

FA0-02.0, FB0-02.0, FB1-02.0, GA0-02.0, GC0-02.0, GX0-02.0, GX2-02.0, HA0-02.0, FB2-02.0, GU0-02.0

835/2100/CLP/ /07

MC005

Line Counter

N/A

N/A

N/A

N/A

837/2400/LX/ /01

MC005A

Version Number

N/A

N/A

N/A

N/A

N/A

MC006

Insured Group or Policy Number

62 (A-C)

30/10

11C

DA0-10.0

837/2000B/SBR/ /03

MC007

Encrypted Subscriber Unique Identification Number

N/A

N/A

N/A

N/A

835/2100/NM1/34/09

MC008

Plan Specific Contract Number

N/A

N/A

N/A

N/A

835/2100/NM1/HN/09

MC009

Member Suffix or Sequence Number

N/A

N/A

N/A

N/A

N/A

MC010

Member Identification Code

N/A

N/A

N/A

N/A

835/2100/NM1/MI/08

MC011

Individual Relationship Code

59 (A-C)

30/18

6

DA0-17.0

837/2000B/SBR/ /02, 837/2000C/PAT/ /01

MC012

Member Gender

15

20/7

3

CA0-09.0

837/2010CA/DMG/ /03

MC013

Member Date of Birth

14

20/8

3

CA0-08.0

837/2010CA/DMG/D8/02

MC014

Member City Name

13

20/14

5

CA0-13.0

837/2010CA/N4/ /01

MC015

Member State or Province

13

20/15

5

CA0-14.0

837/2010CA/N4/ /02

MC016

Member ZIP Code

13

20/16

5

CA0-15.0

837/2010CA/N4/ /03

MC017

Date Service Approved

N/A

N/A

N/A

N/A

N/A

MC018

Admission Date

17

20/17

N/A

N/A

837/2300/DTP/435/03

MC019

Admission Hour

18

20/18

N/A

N/A

837/2300/DTP/435/03

MC020

Admission Type

19

20/10

N/A

N/A

837/2300/CL1/ /01

MC021

Admission Source

20

20/11

N/A

N/A

837/2300/CL1/ /02

MC022

Discharge Hour

21

20/22

N/A

N/A

837/2300/DTP/096/03

MC023

Discharge Status

22

20/21

N/A

N/A

837/2300/CL1/ /03

MC024

Service Provider Number

N/A

N/A

N/A

N/A

835/2100/NM1/BD/09, 835/2100/NM1/BS/09, 835/2100/NM1/MC/09, 835/2100/NM1/PC/09 835/2100/NM1/FI/09

MC025

Service Provider Tax ID Number

5

10/4-5

25

BA0-09.0, CA0-28.0, BA0-02.0, BA1-02.0, YA0-02.0, BA0-06.0, BA0-10.0, BA0-12.0, BA0-13.0, BA0-14.0, BA0-15.0, BA0-16.0, BA0-17.0, BA0-24.0, YA0-06.0

MC026

National Service Provider ID

N/A

10/6

N/A

N/A

835/2100/NM1/XX/09

MC027

Service Provider Entity Type Qualifier

N/A

N/A

N/A

N/A

835/2100/NM1/82/02

MC028

Service Provider First Name

1

10/12

33

BA0-20.0

835/2100/NM1/82/04

MC029

Service Provider Middle Name

1

10/12

33

BA0-21.0

835/2100/NM1/82/05

MC030

Service Provider Last Name or Organization Name

1

10/12

33

BA0-18.0, BA0-19.0

835/2100/NM1/82/03

MC031

Service Provider Suffix

1

10/12

33

BA0-22.0

835/2100/NM1/82/07

MC032

Service Provider Specialty

N/A

N/A

N/A

N/A

837/2000A/PRV/ZZ/03

MC033

Service Provider City Name

1

10/14

N/A

BA1-09.0, 15.0

837/2010A/N4/ /01

MC034

Service Provider State or Province

1

10/15

N/A

BA1-10.0, 16.0

837/2010A/N4/ /02

MC035

Service Provider ZIP Code

1

10/16

N/A

BA1-11.0, 17.0

837/2010A/N4/ /03

MC036

Type of Bill - Institutional/ Facility Claims

4

Positions 1-2: 40/4

N/A

N/A

837/2300/CLM/ /05-1

MC037

Site of Service - on NSF/CMS 1500 Claims

N/A

N/A

24B

FA0-07.0, GU0-0.50

837/2300/CLM/ /05-1

MC038

Claim Status

N/A

N/A

N/A

N/A

835/2100/CLP/ /02

MC039

Admitting Diagnosis

76

70/25

N/A

N/A

837/2300/HI/BJ/02-2

MC040

E-Code

77

70/26

N/A

N/A

837/2300/HI/BN/03-2

MC041

Principal Diagnosis

67

70/4

21.1

EA0-32.0, GX0-31.0, GU0-12.0

837/2300/HI/BK/01-2

MC042

Other Diagnosis - 1

68

70/5

21.2

EA0-33.0, GX0-32.0, GU0-13.0

837/2300/HI/BF/01-2

MC043

Other Diagnosis - 2

69

70/6

21.3

EA0-33.0, GX0-32.0, GU0-13.0

837/2300/HI/BF/02-2

MC044

Other Diagnosis - 3

70

70/7

21.4

EA0-33.0, GX0-32.0, GU0-13.0

837/2300/HI/BF/03-2

MC045

Other Diagnosis - 4

71

70/8

N/A

EA0-35.0, GX0-34.0, GU0-15.0

837/2300/HI/BF/04-2

MC046

Other Diagnosis - 5

72

70/9

N/A

N/A

837/2300/HI/BF/05-2

MC047

Other Diagnosis - 6

73

70/10

N/A

N/A

837/2300/HI/BF/06-2

MC048

Other Diagnosis - 7

74

70/11

N/A

N/A

837/2300/HI/BF/07-2

MC049

Other Diagnosis - 8

75

70/12

N/A

N/A

837/2300/HI/BF/08-2

MC050

Other Diagnosis - 9

N/A

N/A

N/A

N/A

837/2300/HI/BF/09-2

MC051

Other Diagnosis -10

N/A

N/A

N/A

N/A

837/2300/HI/BF/10-2

MC052

Other Diagnosis -11

N/A

N/A

N/A

N/A

837/2300/HI/BF/11-2

MC053

Other Diagnosis -12

N/A

N/A

N/A

N/A

837/2300/HI/BF/12-2

MC054

Revenue Code

42

50/5, 11-13, 60/5, 15-16, 61/5,15-16

N/A

N/A

835/2110/SVC/RB/01-2, 835/2110/SVC/NU/01-2

MC055

Procedure Code

44

60/6, 15-16, 61/6, 15-16

24.1-6 D

FA0-09.0, FB0-15.0, GU0-07.0

835/2110/SVC/HC/01-2

MC056

Procedure Modifier - 1

44

60/7, 15-16, 61/7, 15-16

24.1-6 D

FA0-10.0, GU0-08.0

835/2110/SVC/HC/01-3

MC057

Procedure Modifier - 2

44

60/8,15-16, 61/8,15-16

24.1-6 D

FA0-11.0

835/2110/SVC/HC/01-4

MC058

ICD-9-CM Procedure Code

80, 81(A-E)

70/13, 15, 17, 19, 21, 23

N/A

N/A

835/2110/SVC/ID/01-2

MC059

Date of Service - From

45

61/13, 15-16, 61/13, 15-16

24.1-6 A

N/A

835/2110/DTM/150/02

MC060

Date of Service - Thru

N/A

N/A

24.1-6 A

FA0-05.0, FA0-06.0

835/2110/DTM/151/02

MC061

Quantity

46

50/7, 11-13, 60/9, 15-16, 61/9, 15-16

24.1-6 G

FA0-19.0, FB0-16.0

835/2110/SVC/ /05

MC062

Charge Amount

47

50/8, 11-13, 60/10, 15-16, 61/11, 15-16

24.1-6 F

FA0-13.0

835/2110/SVC/ /02

MC063

Paid Amount

48

N/A

N/A

N/A

835/2110/SVC/ /03

MC064

Prepaid Amount

N/A

N/A

N/A

N/A

N/A

MC065

Co-pay Amount

N/A

N/A

N/A

N/A

N/A

MC066

Coinsurance Amount

N/A

N/A

N/A

N/A

N/A

MC067

Deductible Amount

N/A

N/A

N/A

N/A

N/A

MC068

Patient Account/Control Number

3

20/3

26

CAO-03.0

837/2300/CLM//01

MC069

Discharge Date

6

20/20

24A

EAO-29.0

N/A

MC070

Service Provider Country Name

9

N/A

N/A

N/A

837/2310E/N4/04

MC071

DRG

N/A

N/A

N/A

N/A

N/A

MC072

DRG Version

N/A

N/A

N/A

N/A

N/A

MC073

APC

N/A

N/A

N/A

N/A

N/A

MC074

APC Version

N/A

N/A

N/A

N/A

N/A

MC075

Drug Code

N/A

N/A

N/A

N/A

N/A

MC076

Billing Provider Number

N/A

N/A

N/A

N/A

N/A

MC077

National Billing Provider ID

N/A

N/A

N/A

N/A

N/A

MC078

Billing Provider Last Name

N/A

N/A

N/A

N/A

N/A

MC101

Encrypted Subscriber Last Name

N/A

N/A

N/A

N/A

N/A

MC102

Encrypted Subscriber First Name

N/A

N/A

N/A

N/A

N/A

MC103

Encrypted Subscriber Middle Initial

N/A

N/A

N/A

N/A

N/A

MC104

Encrypted Member Last Name

N/A

N/A

N/A

N/A

N/A

MC105

Encrypted Member First Name

N/A

N/A

N/A

N/A

N/A

MC106

Encrypted Member Middle Initial

N/A

N/A

N/A

N/A

N/A

MC899

Record Type

N/A

N/A

N/A

N/A

N/A

Appendix 1 Pharmacy Claims File Specifications

Data Element #

Data Element Name

Required Start Date

Type

Maximum Length

Description/Codes/Sources

PC001

Payer

1/31/2007

Text

8

Payer submitting payments BISHCA Submitter Code

PC002

National Plan ID

1/31/2007

Text

30

CMS National Plan ID

PC003

Insurance Type/Product Code

1/31/2007

Text

2

12 Preferred Provider Organization (PPO)

13 Point of Service (POS)

14 Exclusive Provider Organization (EPO)

15 Indemnity Insurance

16 Health Maintenance Organization (HMO) Medicare Advantage

* AM Automobile Medical

* DS Disability

HM Health Maintenance Organization

* LI Liability

* LM Liability Medical

MA Medicare Part A

MB Medicare Part B

MD Medicare Part D

MC Medicaid

OF Other Federal Program (e.g. Black Lung)

TV Title V

VA Veteran Administration Plan

* WC Workers' Compensation

* Indicates that code is not to be included in Vermont submissions.

Included in data set for harmonization with other New England states' data collection rules

PC004

Payer Claim Control Number

1/31/2007

Text

35

Must apply to the entire claim and be unique within the payer's system.

PC005

Line Counter

1/31/2007

Integer

4

Line number for this service.

The line counter begins with 1 and is incremented by 1 for each additional service line of a claim.

PC006

Insured Group Number

1/31/2007

Text

50

The group or policy number - not the number that uniquely identifies the subscriber.

PC007

Encrypted Subscriber Unique Identification Number

1/31/2007

Text

128

The encrypted subscriber's social security number; used to create unique member ID. Set as null if unavailable.

PC008

Plan Specific Contract Number

1/31/2007

Text

128

The encrypted plan assigned contract number.

Set as null if contract number equals subscriber's social security number.

PC009

Member Suffix or Sequence Number

1/31/2007

Integer

20

The unique number that identifies the member within the contract.

PC010

Member Identification Code

1/31/2007

Text

128

The encrypted member's social security number; used to create unique member ID. Set as null if unavailable.

PC011

Individual Relationship Code

1/31/2007

Integer

2

Member's relationship to insured as shown below:

01 Spouse

04 Grandfather or Grandmother

05 Grandson or Granddaughter

07 Nephew or Niece

10 Foster Child

15 Ward

17 Stepson or Stepdaughter

19 Child

20 Employee/Self

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

76 Dependent

PC012

Member Gender

1/31/2007

Integer

1

1 Male

2 Female

3 Unknown

PC013

Member Date of Birth

1/31/2007

Date

8

CCYYMMDD

PC014

Member City Name of Residence

1/31/2007

Text

30

The city name of member.

PC015

Member State or Province

1/31/2007

Text

2

As defined by the US Postal Service

PC016

Member ZIP Code

1/31/2007

Text

9

ZIP Code of member - may include non-US codes. Do not include dash.

PC017

Date Service Approved (AP Date)

1/31/2007

Date

8

CCYYMMDD

This date is generally the same date as the paid date or the pharmacy benefits manager's billing date.

PC018

Pharmacy Number

1/31/2007

Text

30

The payer assigned pharmacy number.

This number should be the identifier used by the payer for internal identification purposes, and does not routinely change.

An AHFS number is acceptable.

PC019

Pharmacy Tax ID Number

1/31/2007

Text

10

Federal taxpayer's identification number.

Insurers and health care claims processors shall provide the pharmacy chain's federal tax identification number, if the individual retail pharmacy's tax ID# is not available.

PC020

Pharmacy Name

1/31/2007

Text

30

The name of pharmacy

PC021

National Pharmacy ID Number

1/31/2007

Text

20

Required if National Provider ID is mandated for use under HIPAA

PC022

Pharmacy Location City

1/31/2007

Text

30

The city name of pharmacy, preferably pharmacy location.

PC023

Pharmacy Location State

1/31/2007

Text

2

As defined by the US Postal Service

PC024

Pharmacy ZIP Code

1/31/2007

Text

10

ZIP Code of pharmacy - may include non-US codes. Do not include dash

PC024A

Pharmacy Country Name

1/31/2007

Text

30

Code US for United States

PC025

Claim Status

1/31/2007

Integer

2

01 Processed as primary

02 Processed as secondary

03 Processed as tertiary

04 Denied

19 Processed as primary, forwarded to additional payer(s)

20 Processed as secondary, forwarded to additional payer(s)

21 Processed as tertiary, forwarded to additional payer(s)

22 Reversal of previous payment

PC026

Drug Code

1/31/2007

Text

11

NDC Code

PC027

Drug Name

1/31/2007

Text

80

Text name of drug

PC028

New Prescription or Refill

1/31/2007

Integer

2

00 New prescription

01-99 Number of refill

PC029

Generic Drug Indicator

1/31/2007

Text

1

N No, branded drug

Y Yes, generic drug

PC030

Dispense as Written Code

1/31/2007

Integer

1

0 Not dispensed as written

1 Physician dispense as written

2 Member dispense as written

3 Pharmacy dispense as written

4 No generic available

5 Brand dispensed as generic

6 Override

7 Substitution not allowed - brand drug mandated by law

8 Substitution allowed - generic drug not available in marketplace

9 Other

PC031

Compound Drug Indicator

1/31/2007

Text

1

N Non-compound drug

Y Compound drug

U Non-specified drug compound

PC032

Date Prescription Filled

1/31/2007

Date

8

CCYYMMDD

PC033

Quantity Dispensed

1/31/2007

Integer

5

The number of metric units of medication dispensed.

PC034

Days Supply

1/31/2007

Integer

3

The estimated number of days the prescription will last.

PC035

Charge Amount

1/31/2007

Decimal

10

Do not code decimal point.

PC036

Paid Amount

1/31/2007

Decimal

10

Includes all health plan payments and excludes all member payments. Do not code decimal point.

PC037

Ingredient Cost/List Price

1/31/2007

Decimal

10

The cost of the drug dispensed. Do not code decimal point.

PC038

Postage Amount Claimed

1/31/2007

Decimal

10

Do not code decimal point.

PC039

Dispensing Fee

1/31/2007

Decimal

10

Do not code decimal point.

PC040

Co-pay Amount

1/31/2007

Decimal

10

The preset, fixed dollar amount for which the individual is responsible. Do not code decimal point.

PC041

Coinsurance Amount

1/31/2007

Decimal

10

The dollar amount an individual is responsible for - not the percentage. Do not code decimal point.

PC042

Deductible Amount

1/31/2007

Decimal

10

Do not code decimal point.

PC044

Prescribing Physician First Name

1/31/2007

Text

25

Physician first name. Required if PC046 is not filled.

PC045

Prescribing Physician Middle Name

1/31/2007

Text

25

Physician middle name or initial. Required if PC046 is not filled.

PC046

Prescribing Physician Last Name

1/31/2007

Text

60

Physician last name. Required if PC046 is not filled.

PC047

Prescribing Physician Number

1/31/2007

Text

20

The DEA or NPI number for the prescribing physician.

PC101

Encrypted Subscriber Last Name

1/31/2007

Text

128

The encrypted subscriber last name.

PC102

Encrypted Subscriber First Name

1/31/2007

Text

128

The encrypted subscriber first name.

PC103

Encrypted Subscriber Middle Initial

1/31/2007

Text

1

The encrypted subscriber middle initial.

PC104

Encrypted Member Last Name

1/31/2007

Text

128

The encrypted member last name.

PC105

Encrypted Member First Name

1/31/2007

Text

128

The encrypted member first name.

PC106

Encrypted Member Middle Initial

1/31/2007

Text

1

The encrypted member middle initial.

PC899

Record Type

1/31/2007

Text

2

Value = PC

Data Element #

Data Element Name

Required Start Date

Type

Maximum Length

Description/Codes/Sources

PC001

Payer

1/31/2007

Text

8

Payer submitting payments BISHCA Submitter Code

PC002

National Plan ID

1/31/2007

Text

30

CMS National Plan ID

PC003

Insurance Type/Product Code

1/31/2007

Text

2

12 Preferred Provider Organization (PPO)

13 Point of Service (POS)

14 Exclusive Provider Organization (EPO)

15 Indemnity Insurance

16 Health Maintenance Organization (HMO) Medicare Advantage

* AM Automobile Medical

* DS Disability

HM Health Maintenance Organization

* LI Liability

* LM Liability Medical

MA Medicare Part A

MB Medicare Part B

MD Medicare Part D

MC Medicaid

OF Other Federal Program (e.g. Black Lung)

TV Title V

VA Veteran Administration Plan

* WC Workers' Compensation

* Indicates that code is not to be included in Vermont submissions.

Included in data set for harmonization with other New England states' data collection rules

PC004

Payer Claim Control Number

1/31/2007

Text

35

Must apply to the entire claim and be unique within the payer's system.

PC005

Line Counter

1/31/2007

Integer

4

Line number for this service.

The line counter begins with 1 and is incremented by 1 for each additional service line of a claim.

PC006

Insured Group Number

1/31/2007

Text

50

The group or policy number - not the number that uniquely identifies the subscriber.

PC007

Encrypted Subscriber Unique Identification Number

1/31/2007

Text

128

The encrypted subscriber's social security number; used to create unique member ID. Set as null if unavailable.

PC008

Plan Specific Contract Number

1/31/2007

Text

128

The encrypted plan assigned contract number.

Set as null if contract number equals subscriber's social security number.

PC009

Member Suffix or Sequence Number

1/31/2007

Integer

20

The unique number that identifies the member within the contract.

PC010

Member Identification Code

1/31/2007

Text

128

The encrypted member's social security number; used to create unique member ID. Set as null if unavailable.

PC011

Individual Relationship Code

1/31/2007

Integer

2

Member's relationship to insured as shown below:

01 Spouse

04 Grandfather or Grandmother

05 Grandson or Granddaughter

07 Nephew or Niece

10 Foster Child

15 Ward

17 Stepson or Stepdaughter

19 Child

20 Employee/Self

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

76 Dependent

PC012

Member Gender

1/31/2007

Integer

1

1 Male

2 Female

3 Unknown

PC013

Member Date of Birth

1/31/2007

Date

8

CCYYMMDD

PC014

Member City Name of Residence

1/31/2007

Text

30

The city name of member.

PC015

Member State or Province

1/31/2007

Text

2

As defined by the US Postal Service

PC016

Member ZIP Code

1/31/2007

Text

9

ZIP Code of member - may include non-US codes. Do not include dash.

PC017

Date Service Approved (AP Date)

1/31/2007

Date

8

CCYYMMDD

This date is generally the same date as the paid date or the pharmacy benefits manager's billing date.

PC018

Pharmacy Number

1/31/2007

Text

30

The payer assigned pharmacy number.

This number should be the identifier used by the payer for internal identification purposes, and does not routinely change.

An AHFS number is acceptable.

PC019

Pharmacy Tax ID Number

1/31/2007

Text

10

Federal taxpayer's identification number.

Insurers and health care claims processors shall provide the pharmacy chain's federal tax identification number, if the individual retail pharmacy's tax ID# is not available.

PC020

Pharmacy Name

1/31/2007

Text

30

The name of pharmacy

PC021

National Pharmacy ID Number

1/31/2007

Text

20

Required if National Provider ID is mandated for use under HIPAA

PC022

Pharmacy Location City

1/31/2007

Text

30

The city name of pharmacy, preferably pharmacy location.

PC023

Pharmacy Location State

1/31/2007

Text

2

As defined by the US Postal Service

PC024

Pharmacy ZIP Code

1/31/2007

Text

10

ZIP Code of pharmacy - may include non-US codes. Do not include dash

PC024A

Pharmacy Country Name

1/31/2007

Text

30

Code US for United States

PC025

Claim Status

1/31/2007

Integer

2

01 Processed as primary

02 Processed as secondary

03 Processed as tertiary

04 Denied

19 Processed as primary, forwarded to additional payer(s)

20 Processed as secondary, forwarded to additional payer(s)

21 Processed as tertiary, forwarded to additional payer(s)

22 Reversal of previous payment

PC026

Drug Code

1/31/2007

Text

11

NDC Code

PC027

Drug Name

1/31/2007

Text

80

Text name of drug

PC028

New Prescription or Refill

1/31/2007

Integer

2

00 New prescription

01-99 Number of refill

PC029

Generic Drug Indicator

1/31/2007

Text

1

N No, branded drug

Y Yes, generic drug

PC030

Dispense as Written Code

1/31/2007

Integer

1

0 Not dispensed as written

1 Physician dispense as written

2 Member dispense as written

3 Pharmacy dispense as written

4 No generic available

5 Brand dispensed as generic

6 Override

7 Substitution not allowed - brand drug mandated by law

8 Substitution allowed - generic drug not available in marketplace

9 Other

PC031

Compound Drug Indicator

1/31/2007

Text

1

N Non-compound drug

Y Compound drug

U Non-specified drug compound

PC032

Date Prescription Filled

1/31/2007

Date

8

CCYYMMDD

PC033

Quantity Dispensed

1/31/2007

Integer

5

The number of metric units of medication dispensed.

PC034

Days Supply

1/31/2007

Integer

3

The estimated number of days the prescription will last.

PC035

Charge Amount

1/31/2007

Decimal

10

Do not code decimal point.

PC036

Paid Amount

1/31/2007

Decimal

10

Includes all health plan payments and excludes all member payments. Do not code decimal point.

PC037

Ingredient Cost/List Price

1/31/2007

Decimal

10

The cost of the drug dispensed. Do not code decimal point.

PC038

Postage Amount Claimed

1/31/2007

Decimal

10

Do not code decimal point.

PC039

Dispensing Fee

1/31/2007

Decimal

10

Do not code decimal point.

PC040

Co-pay Amount

1/31/2007

Decimal

10

The preset, fixed dollar amount for which the individual is responsible. Do not code decimal point.

PC041

Coinsurance Amount

1/31/2007

Decimal

10

The dollar amount an individual is responsible for - not the percentage. Do not code decimal point.

PC042

Deductible Amount

1/31/2007

Decimal

10

Do not code decimal point.

PC044

Prescribing Physician First Name

1/31/2007

Text

25

Physician first name. Required if PC046 is not filled.

PC045

Prescribing Physician Middle Name

1/31/2007

Text

25

Physician middle name or initial. Required if PC046 is not filled.

PC046

Prescribing Physician Last Name

1/31/2007

Text

60

Physician last name. Required if PC046 is not filled.

PC047

Prescribing Physician Number

1/31/2007

Text

20

The DEA or NPI number for the prescribing physician.

PC101

Encrypted Subscriber Last Name

1/31/2007

Text

128

The encrypted subscriber last name.

PC102

Encrypted Subscriber First Name

1/31/2007

Text

128

The encrypted subscriber first name.

PC103

Encrypted Subscriber Middle Initial

1/31/2007

Text

1

The encrypted subscriber middle initial.

PC104

Encrypted Member Last Name

1/31/2007

Text

128

The encrypted member last name.

PC105

Encrypted Member First Name

1/31/2007

Text

128

The encrypted member first name.

PC106

Encrypted Member Middle Initial

1/31/2007

Text

1

The encrypted member middle initial.

PC899

Record Type

1/31/2007

Text

2

Value = PC

Appendix 2 Pharmacy Claims Mapping to National Standards

Data Element #

Data Element Name

National Council for Prescription Drug Programs Field #

PC001

Payer

N/A

PC002

Plan ID

N/A

PC003

Insurance Type/Product Code

N/A

PC004

Payer Claim Control Number

N/A

PC005

Line Counter

N/A

PC006

Insured Group Number

301-C1

PC007

Encrypted Subscriber Unique Identification Number

302-C2

PC008

Plan Specific Contract Number

N/A

PC009

Member Suffix or Sequence Number

N/A

PC010

Member Identification Code

302-CY

PC011

Individual Relationship Code

306-C6

PC012

Member Gender

305-C5

PC013

Member Date of Birth

304-C4

PC014

Member City Name of Residence

323-CN

PC015

Member State or Province

324-CO

PC016

Member ZIP Code

325-CP

PC017

Date Service Approved (AP Date)

N/A

PC018

Pharmacy Number

202-B2

PC019

Pharmacy Tax ID Number

N/A

PC020

Pharmacy Name

833-5P

PC021

National Pharmacy ID Number

N/A

PC022

Pharmacy Location City

831-5N

PC023

Pharmacy Location State

832-6F

PC024

Pharmacy ZIP Code

835-5R

PC024A

Pharmacy Country Name

N/A

PC025

Claim Status

N/A

PC026

Drug Code

407-D7

PC027

Drug Name

516-FG

PC028

New Prescription or Refill

403-D3

PC029

Generic Drug Indicator

N/A

PC030

Dispense as Written Code

408-D8

PC031

Compound Drug Indicator

406-D6

PC032

Date Prescription Filled

401-D1

PC033

Quantity Dispensed

442-E7

PC034

Days Supply

405-D5

PC035

Charge Amount

804-5B

PC036

Paid Amount

509-F9

PC037

Ingredient Cost/List Price

506-F6

PC038

Postage Amount Claimed

428-DS

PC039

Dispensing Fee

507-F7

PC040

Co-pay Amount

518-FI

PC041

Coinsurance Amount

518-FI

PC042

Deductible Amount

505-F5

PC044

Prescribing Physician First Name

N/A

PC045

Prescribing Physician Middle Name

N/A

PC046

Prescribing Physician Last Name

N/A

PC047

Prescribing Physician Number

N/A

PC101

Encrypted Subscriber Last Name

N/A

PC102

Encrypted Subscriber First Name

N/A

PC103

Encrypted Subscriber Middle Initial

N/A

PC104

Encrypted Member Last Name

N/A

PC105

Encrypted Member First Name

N/A

PC106

Encrypted Member Middle Initial

N/A

PC899

Record Type

N/A

Data Element #

Data Element Name

National Council for Prescription Drug Programs Field #

PC001

Payer

N/A

PC002

Plan ID

N/A

PC003

Insurance Type/Product Code

N/A

PC004

Payer Claim Control Number

N/A

PC005

Line Counter

N/A

PC006

Insured Group Number

301-C1

PC007

Encrypted Subscriber Unique Identification Number

302-C2

PC008

Plan Specific Contract Number

N/A

PC009

Member Suffix or Sequence Number

N/A

PC010

Member Identification Code

302-CY

PC011

Individual Relationship Code

306-C6

PC012

Member Gender

305-C5

PC013

Member Date of Birth

304-C4

PC014

Member City Name of Residence

323-CN

PC015

Member State or Province

324-CO

PC016

Member ZIP Code

325-CP

PC017

Date Service Approved (AP Date)

N/A

PC018

Pharmacy Number

202-B2

PC019

Pharmacy Tax ID Number

N/A

PC020

Pharmacy Name

833-5P

PC021

National Pharmacy ID Number

N/A

PC022

Pharmacy Location City

831-5N

PC023

Pharmacy Location State

832-6F

PC024

Pharmacy ZIP Code

835-5R

PC024A

Pharmacy Country Name

N/A

PC025

Claim Status

N/A

PC026

Drug Code

407-D7

PC027

Drug Name

516-FG

PC028

New Prescription or Refill

403-D3

PC029

Generic Drug Indicator

N/A

PC030

Dispense as Written Code

408-D8

PC031

Compound Drug Indicator

406-D6

PC032

Date Prescription Filled

401-D1

PC033

Quantity Dispensed

442-E7

PC034

Days Supply

405-D5

PC035

Charge Amount

804-5B

PC036

Paid Amount

509-F9

PC037

Ingredient Cost/List Price

506-F6

PC038

Postage Amount Claimed

428-DS

PC039

Dispensing Fee

507-F7

PC040

Co-pay Amount

518-FI

PC041

Coinsurance Amount

518-FI

PC042

Deductible Amount

505-F5

PC044

Prescribing Physician First Name

N/A

PC045

Prescribing Physician Middle Name

N/A

PC046

Prescribing Physician Last Name

N/A

PC047

Prescribing Physician Number

N/A

PC101

Encrypted Subscriber Last Name

N/A

PC102

Encrypted Subscriber First Name

N/A

PC103

Encrypted Subscriber Middle Initial

N/A

PC104

Encrypted Member Last Name

N/A

PC105

Encrypted Member First Name

N/A

PC106

Encrypted Member Middle Initial

N/A

PC899

Record Type

N/A

Appendix F Reporter Registration Form

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Appendix G Third Party Administrator Registration Form

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Appendix H Pharmacy Benefit Manager Registration Form

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Appendix I Data Transmittal Sheet

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Appendix 1 Data Release Schedule: Public Use Denominator File

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

PUBLIC USE FILE- UNRESTRICTED DATA ELEMENTS

ME004

Year

ME005

Month

ME007

Coverage Level Code

ME013

Member Gender

ME016

Member State or Province

ME018

Medical Coverage

ME019

Prescription Drug Coverage

ME028

Primary Insurance Indicator

ME029

Coverage Type

ME030

Market Category Code

ME004

Year

ME005

Month

ME007

Coverage Level Code

ME013

Member Gender

ME016

Member State or Province

ME018

Medical Coverage

ME019

Prescription Drug Coverage

ME028

Primary Insurance Indicator

ME029

Coverage Type

ME030

Market Category Code

Derived or calculated from submitted data

PAYER901

Payer Name

ME902

Record ID#

ME905

Medicare coverage

ME911

Standardized Insurance Individual Relationship Code

ME912

Standardized Insurance Type/Product Code

ME914

Eligibility Year and Month

ME915

Member County Code

*

Member Age by Age Group (0-17, 18-29, 30-44, 45-54, 55-64, 65+)

*

Unique Member Number (Derived from ME910 and for use only in the Public Use Denominator File)

PAYER901

Payer Name

ME902

Record ID#

ME905

Medicare coverage

ME911

Standardized Insurance Individual Relationship Code

ME912

Standardized Insurance Type/Product Code

ME914

Eligibility Year and Month

ME915

Member County Code

*

Member Age by Age Group (0-17, 18-29, 30-44, 45-54, 55-64, 65+)

*

Unique Member Number (Derived from ME910 and for use only in the Public Use Denominator File)

* No assigned data element number

Appendix 2 Data Release Schedule: Medical Member Eligibility File

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

PUBLIC USE FILE- UNRESTRICTED DATA ELEMENTS

ME007

Coverage Level Code

ME013

Member Gender

ME016

Member State or Province

ME018

Medical Coverage

ME028

Primary Insurance Indicator

ME029

Coverage Type

ME030

Market Category Code

ME007

Coverage Level Code

ME013

Member Gender

ME016

Member State or Province

ME018

Medical Coverage

ME028

Primary Insurance Indicator

ME029

Coverage Type

ME030

Market Category Code

Derived or calculated from submitted data

ME901

Member Age: VT aggregate 90+

ME902

Record ID#

ME905

Medicare coverage

ME910

Double Encrypted Member ID

ME911

Standardized Insurance Individual Relationship Code

ME912

Standardized Insurance Type/Product Code

ME914

Eligibility Year and Month

ME915

Member County Code

ME901

Member Age: VT aggregate 90+

ME902

Record ID#

ME905

Medicare coverage

ME910

Double Encrypted Member ID

ME911

Standardized Insurance Individual Relationship Code

ME912

Standardized Insurance Type/Product Code

ME914

Eligibility Year and Month

ME915

Member County Code

LIMITED USE FILE- RESTRICTED DATA ELEMENTS (Release of each restricted data element must be approved by BISHCA)

ME001

Payer

ME002

National Plan ID

ME006

Insured Group or Policy Number

ME015

Member City Name

ME017

Member ZIP Code

ME001

Payer

ME002

National Plan ID

ME006

Insured Group or Policy Number

ME015

Member City Name

ME017

Member ZIP Code

Derived or calculated from submitted data

ME907

Double Encrypted Subscriber SSN

ME908

Double Encrypted Plan Specific Contract Number

ME909

Double Encrypted Member Identification Code

*

Insured Group Name (Derived from ME006 and Key Look-up Table)

ME907

Double Encrypted Subscriber SSN

ME908

Double Encrypted Plan Specific Contract Number

ME909

Double Encrypted Member Identification Code

*

Insured Group Name (Derived from ME006 and Key Look-up Table)

* No assigned data element number

UNAVAILABLE FOR RELEASE

ME004

Year

ME005

Month

ME003

Insurance Type/Product Code

ME008

Encrypted Subscriber Social Security Number

ME009

Plan Specific Contract Number

ME010

Member Suffix or Sequence Number

ME011

Member Identification Code

ME012

Individual Relationship Code

ME014

Member Date of Birth

ME019

Prescription Drug Coverage

ME101

Encrypted Subscriber Last Name

ME102

Encrypted Subscriber First Name

ME103

Encrypted Subscriber Middle Initial

ME104

Encrypted Member Last Name

ME105

Encrypted Member First Name

ME106

Encrypted Member Middle Initial

ME899

Record Type

ME004

Year

ME005

Month

ME003

Insurance Type/Product Code

ME008

Encrypted Subscriber Social Security Number

ME009

Plan Specific Contract Number

ME010

Member Suffix or Sequence Number

ME011

Member Identification Code

ME012

Individual Relationship Code

ME014

Member Date of Birth

ME019

Prescription Drug Coverage

ME101

Encrypted Subscriber Last Name

ME102

Encrypted Subscriber First Name

ME103

Encrypted Subscriber Middle Initial

ME104

Encrypted Member Last Name

ME105

Encrypted Member First Name

ME106

Encrypted Member Middle Initial

ME899

Record Type

Derived or calculated from submitted data

ME903

BISHCA Extract Date

ME904

Unique Member ID

ME906

Submission ID#

ME913

Duplicate Member Flag

ME903

BISHCA Extract Date

ME904

Unique Member ID

ME906

Submission ID#

ME913

Duplicate Member Flag

Appendix 3 Data Release Schedule: Pharmacy Member Eligibility File

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

PUBLIC USE FILE- UNRESTRICTED DATA ELEMENTS

PE004

Year

PE005

Month

PE007

Coverage Level Code

PE013

Member Gender

PE016

Member State or Province

PE019

Prescription Drug Coverage

PE028

Primary Insurance Indicator

PE029

Coverage Type

PE030

Market Category Code

PE004

Year

PE005

Month

PE007

Coverage Level Code

PE013

Member Gender

PE016

Member State or Province

PE019

Prescription Drug Coverage

PE028

Primary Insurance Indicator

PE029

Coverage Type

PE030

Market Category Code

Derived or calculated from submitted data

PE901

Member Age: VT aggregate 90+

PE902

Record ID#

PE905

Medicare coverage

PE910

Double Encrypted Member ID

PE911

Standardized Insurance Individual Relationship Code

PE912

Standardized Insurance Type/Product Code

PE914

Eligibility Year and Month

PE915

Member County Code

PE901

Member Age: VT aggregate 90+

PE902

Record ID#

PE905

Medicare coverage

PE910

Double Encrypted Member ID

PE911

Standardized Insurance Individual Relationship Code

PE912

Standardized Insurance Type/Product Code

PE914

Eligibility Year and Month

PE915

Member County Code

LIMITED USE FILE- RESTRICTED DATA ELEMENTS (Release of each restricted data element must be approved by BISHCA)

PE001

Payer

PE002

National Plan ID

PE006

Insured Group or Policy Number

PE015

Member City Name

PE017

Member ZIP Code

PE001

Payer

PE002

National Plan ID

PE006

Insured Group or Policy Number

PE015

Member City Name

PE017

Member ZIP Code

Derived or calculated from submitted data

PE907

Double Encrypted Subscriber SSN

PE908

Double Encrypted Plan Specific Contract Number

PE909

Double Encrypted Member Identification Code

*

Insured Group Name (Derived from PE006 and Key Look-up Table)

PE907

Double Encrypted Subscriber SSN

PE908

Double Encrypted Plan Specific Contract Number

PE909

Double Encrypted Member Identification Code

*

Insured Group Name (Derived from PE006 and Key Look-up Table)

[* ] No assigned data element number

UNAVAILABLE FOR RELEASE

PE003

Insurance Type/Product Code

PE008

Encrypted Subscriber Social Security Number

PE009

Plan Specific Contract Number

PE010

Member Suffix or Sequence Number

PE011

Member Identification Code

PE012

Individual Relationship Code

PE014

Member Date of Birth

PE018

Medical Coverage

PE101

Encrypted Subscriber Last Name

PE102

Encrypted Subscriber First Name

PE103

Encrypted Subscriber Middle Initial

PE104

Encrypted Member Last Name

PE105

Encrypted Member First Name

PE106

Encrypted Member Middle Initial

PE899

Record Type

PE003

Insurance Type/Product Code

PE008

Encrypted Subscriber Social Security Number

PE009

Plan Specific Contract Number

PE010

Member Suffix or Sequence Number

PE011

Member Identification Code

PE012

Individual Relationship Code

PE014

Member Date of Birth

PE018

Medical Coverage

PE101

Encrypted Subscriber Last Name

PE102

Encrypted Subscriber First Name

PE103

Encrypted Subscriber Middle Initial

PE104

Encrypted Member Last Name

PE105

Encrypted Member First Name

PE106

Encrypted Member Middle Initial

PE899

Record Type

Derived or calculated from submitted data

PE903

BISHCA Extract Date

PE904

Unique Member ID

PE906

Submission ID#

PE913

Duplicate Member Flag

PE903

BISHCA Extract Date

PE904

Unique Member ID

PE906

Submission ID#

PE913

Duplicate Member Flag

Appendix 4 Data Release Schedule: Medical Claims File

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

PUBLIC USE FILE- UNRESTRICTED DATA ELEMENTS

MC005A

Version Number

MC011

Individual Relationship Code

MC012

Member Gender

MC015

Member State or Province

MC020

Admission Type

MC021

Admission Source

MC023

Discharge Status

MC032

Service Provider Specialty**

MC033

Service Provider City Name**

MC034

Service Provider State or Province**

MC035

Service Provider ZIP Code**

MC036

Type of Bill - Institutional/Facility Claims

MC037

Site of Service- NSF/CMS 1500 Claims

MC038

Claim Status

MC039

Admitting Diagnosis

MC040

E-Code

MC041

Principal Diagnosis

MC042

Other Diagnosis 1

MC043

Other Diagnosis 2

MC044

Other Diagnosis 3

MC045

Other Diagnosis 4

MC046

Other Diagnosis 5

MC047

Other Diagnosis 6

MC048

Other Diagnosis 7

MC049

Other Diagnosis 8

MC050

Other Diagnosis 9

MC051

Other Diagnosis 10

MC052

Other Diagnosis 11

MC053

Other Diagnosis 12

MC054

Revenue Code

MC055

Procedure 1 Code

MC056

Procedure 1 Modifier- 1

MC057

Procedure 1 Modifier- 2

MC058

ICD-9-CM Procedure Code

MC061

Quantity

MC063

Paid Amount

MC064

Prepaid Amount

MC065

Copay Amount

MC066

Coinsurance Amount

MC067

Deductible Amount

MC070

Service Provider Country Name**

MC071

DRG

MC072

DRG Version

MC073

APC

MC074

APC Version

MC075

Drug Code

MC005A

Version Number

MC011

Individual Relationship Code

MC012

Member Gender

MC015

Member State or Province

MC020

Admission Type

MC021

Admission Source

MC023

Discharge Status

MC032

Service Provider Specialty**

MC033

Service Provider City Name**

MC034

Service Provider State or Province**

MC035

Service Provider ZIP Code**

MC036

Type of Bill - Institutional/Facility Claims

MC037

Site of Service- NSF/CMS 1500 Claims

MC038

Claim Status

MC039

Admitting Diagnosis

MC040

E-Code

MC041

Principal Diagnosis

MC042

Other Diagnosis 1

MC043

Other Diagnosis 2

MC044

Other Diagnosis 3

MC045

Other Diagnosis 4

MC046

Other Diagnosis 5

MC047

Other Diagnosis 6

MC048

Other Diagnosis 7

MC049

Other Diagnosis 8

MC050

Other Diagnosis 9

MC051

Other Diagnosis 10

MC052

Other Diagnosis 11

MC053

Other Diagnosis 12

MC054

Revenue Code

MC055

Procedure 1 Code

MC056

Procedure 1 Modifier- 1

MC057

Procedure 1 Modifier- 2

MC058

ICD-9-CM Procedure Code

MC061

Quantity

MC063

Paid Amount

MC064

Prepaid Amount

MC065

Copay Amount

MC066

Coinsurance Amount

MC067

Deductible Amount

MC070

Service Provider Country Name**

MC071

DRG

MC072

DRG Version

MC073

APC

MC074

APC Version

MC075

Drug Code

Derived or calculated from submitted data

MC901

Member Age: VT aggregate 90+

MC902

Record ID#

MC905

Medicare Coverage

MC911

Double Encrypted Member ID#

MC913

Standardized Insurance Type/Product Code

MC914

Medical Abortion Flag**

MC915

Year Paid

MC916

Month Paid

MC917

Year of Service

MC918

Month of Service

MC919

Payment Quarter

MC920

Quarter Service Performed

*

Medication Abortion Flag**

*

Service Provider County Code**

*

Member County Code

*

Admission Year

*

Discharge Year

*

Length of Stay

*

Service Event Primary Key

*

Length of Service in Days

MC901

Member Age: VT aggregate 90+

MC902

Record ID#

MC905

Medicare Coverage

MC911

Double Encrypted Member ID#

MC913

Standardized Insurance Type/Product Code

MC914

Medical Abortion Flag**

MC915

Year Paid

MC916

Month Paid

MC917

Year of Service

MC918

Month of Service

MC919

Payment Quarter

MC920

Quarter Service Performed

*

Medication Abortion Flag**

*

Service Provider County Code**

*

Member County Code

*

Admission Year

*

Discharge Year

*

Length of Stay

*

Service Event Primary Key

*

Length of Service in Days

[* ] No assigned data element number

[** ]Provider data elements will not be released in records where the Medical Abortion Flag MC914 or Medication Abortion Flag=1.

LIMITED USE FILE-RESTRICTED DATA ELEMENTS (Release of each restricted data element must be approved by BISHCA)

MC001

Payer

MC002

National Plan ID

MC006

Insured Group or Policy Number

MC014

Member City Name

MC016

Member ZIP Code

MC017

Date Service Approved (AP Date)

MC018

Admission Date

MC019

Admission Hour

MC022

Discharge Hour

MC024

Service Provider Number**

MC026

National Service Provider ID**

MC027

Service Provider Entity Type Qualifier

MC028

Service Provider First Name**

MC029

Service Provider Middle Name**

MC030

Service Provider Last Name or Organization Name**

MC031

Service Provider Suffix**

MC059

Date of Service From

MC060

Date of Service Thru

MC062

Charge Amount

MC076

Billing Provider Number**

MC077

National Billing Provider ID**

MC078

Billing Provider Last Name or Organization**

MC069

Discharge Date

MC001

Payer

MC002

National Plan ID

MC006

Insured Group or Policy Number

MC014

Member City Name

MC016

Member ZIP Code

MC017

Date Service Approved (AP Date)

MC018

Admission Date

MC019

Admission Hour

MC022

Discharge Hour

MC024

Service Provider Number**

MC026

National Service Provider ID**

MC027

Service Provider Entity Type Qualifier

MC028

Service Provider First Name**

MC029

Service Provider Middle Name**

MC030

Service Provider Last Name or Organization Name**

MC031

Service Provider Suffix**

MC059

Date of Service From

MC060

Date of Service Thru

MC062

Charge Amount

MC076

Billing Provider Number**

MC077

National Billing Provider ID**

MC078

Billing Provider Last Name or Organization**

MC069

Discharge Date

Derived or calculated from submitted data

MC907

Double Encrypted Payer Claim Control Number

MC908

Double Encrypted Subscriber Social Security Number

MC909

Double Encrypted Plan Specific Contract Number

MC910

Double Encrypted Member Identification Code

MC912

Provider ID#

*

Insured Group Name (Derived from MC006 and Key Look-up Table)

MC907

Double Encrypted Payer Claim Control Number

MC908

Double Encrypted Subscriber Social Security Number

MC909

Double Encrypted Plan Specific Contract Number

MC910

Double Encrypted Member Identification Code

MC912

Provider ID#

*

Insured Group Name (Derived from MC006 and Key Look-up Table)

[* ] No assigned data element number

[** ]Provider data elements not be released in records where the Medical Abortion Flag MC914 or Medication Abortion Flag=1.

UNAVAILABLE FOR RELEASE

MC003

Insurance Type/Product Code

MC004

Payer Claim Control Number

MC005

Line Counter

MC007

Encrypted Subscriber Social Security Number

MC008

Plan Specific Contract Number

MC009

Member Suffix or Sequence Number

MC010

Member Identification Code

MC013

Member Date of Birth

MC025

Service Provider Tax ID Number

MC027

Service Provider Entity Type Qualifier

MC068

Patient Account/Control Number

MC101

Encrypted Subscriber Last Name

MC102

Encrypted Subscriber First Name

MC103

Encrypted Subscriber Middle Initial

MC104

Encrypted Member Last Name

MC105

Encrypted Member First Name

MC106

Encrypted Member Middle Initial

MC899

Record Type

MC003

Insurance Type/Product Code

MC004

Payer Claim Control Number

MC005

Line Counter

MC007

Encrypted Subscriber Social Security Number

MC008

Plan Specific Contract Number

MC009

Member Suffix or Sequence Number

MC010

Member Identification Code

MC013

Member Date of Birth

MC025

Service Provider Tax ID Number

MC027

Service Provider Entity Type Qualifier

MC068

Patient Account/Control Number

MC101

Encrypted Subscriber Last Name

MC102

Encrypted Subscriber First Name

MC103

Encrypted Subscriber Middle Initial

MC104

Encrypted Member Last Name

MC105

Encrypted Member First Name

MC106

Encrypted Member Middle Initial

MC899

Record Type

Derived or calculated from submitted data

MC903

BISHCA Extract Date

MC904

Encrypted Member ID#

MC906

Submission ID#

MC903

BISHCA Extract Date

MC904

Encrypted Member ID#

MC906

Submission ID#

Appendix 5 Data Release Schedule: Pharmacy Claims File

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

PUBLIC USE FILE- UNRESTRICTED DATA ELEMENTS

PC011

Individual Relationship Code

PC012

Member Gender

PC015

Member State or Province

PC023

Pharmacy Location State

PC024A

Pharmacy Country Name

PC025

Claim Status

PC026

Drug Code

PC027

Drug Name

PC028

New Prescription or Refill

PC029

Generic Drug Indicator

PC030

Dispense as Written Code

PC031

Compound Drug Indicator

PC033

Quantity Dispensed

PC034

Days Supply

PC036

Paid Amount

PC037

Ingredient Cost/List Price

PC038

Postage Amount Claimed

PC039

Dispensing Fee

PC040

Copay Amount

PC041

Coinsurance Amount

PC042

Deductible Amount

PC011

Individual Relationship Code

PC012

Member Gender

PC015

Member State or Province

PC023

Pharmacy Location State

PC024A

Pharmacy Country Name

PC025

Claim Status

PC026

Drug Code

PC027

Drug Name

PC028

New Prescription or Refill

PC029

Generic Drug Indicator

PC030

Dispense as Written Code

PC031

Compound Drug Indicator

PC033

Quantity Dispensed

PC034

Days Supply

PC036

Paid Amount

PC037

Ingredient Cost/List Price

PC038

Postage Amount Claimed

PC039

Dispensing Fee

PC040

Copay Amount

PC041

Coinsurance Amount

PC042

Deductible Amount

Derived or calculated from submitted data

PC901

Member Age: VT aggregate 90+

PC902

Record ID#

PC910

Double Encrypted Member ID#

PC911

Standardized Member Gender

PC912

Standardized Insurance Type/Product Code

PC914

Year Paid

PC916

Year of Service

PC918

Payment Quarter

PC919

Quarter Service Performed

*

Member County Code

*

Year Prescription Filled

*

Medication Abortion Flag**

PC901

Member Age: VT aggregate 90+

PC902

Record ID#

PC910

Double Encrypted Member ID#

PC911

Standardized Member Gender

PC912

Standardized Insurance Type/Product Code

PC914

Year Paid

PC916

Year of Service

PC918

Payment Quarter

PC919

Quarter Service Performed

*

Member County Code

*

Year Prescription Filled

*

Medication Abortion Flag**

[* ] No assigned data element number

LIMITED USE FILE-RESTRICTED DATA ELEMENTS (Release of each restricted data element must be approved by BISHCA)

PC001

Payer

PC002

National Plan ID

PC006

Insured Group Number

PC014

Member City Name of Residence

PC016

Member ZIP Code

PC017

Date Service Approved (AP Date)

PC018

Pharmacy Number

PC020

Pharmacy Name

PC021

National Pharmacy ID Number

PC022

Pharmacy Location City

PC024

Pharmacy ZIP Code

PC032

Date Prescription Filled

PC035

Charge Amount

PC044

Prescribing Physician First Name**

PC045

Prescribing Physician Middle Name**

PC046

Prescribing Physician Last Name**

PC001

Payer

PC002

National Plan ID

PC006

Insured Group Number

PC014

Member City Name of Residence

PC016

Member ZIP Code

PC017

Date Service Approved (AP Date)

PC018

Pharmacy Number

PC020

Pharmacy Name

PC021

National Pharmacy ID Number

PC022

Pharmacy Location City

PC024

Pharmacy ZIP Code

PC032

Date Prescription Filled

PC035

Charge Amount

PC044

Prescribing Physician First Name**

PC045

Prescribing Physician Middle Name**

PC046

Prescribing Physician Last Name**

Derived or calculated from submitted data

PC906

Double Encrypted Payer Claim Control Number

PC907

Double Encrypted Subscriber Social Security Number

PC908

Double Encrypted Plan Specific Contract Number

PC909

Double Encrypted Member Identification Code

PC913

Pharmacy ID #

PC915

Month Paid

PC917

Month of Service

PC920

Prescribing Physician ID# **

*

Insured Group Name (Derived from PC006 and Key Look-up Table)

PC906

Double Encrypted Payer Claim Control Number

PC907

Double Encrypted Subscriber Social Security Number

PC908

Double Encrypted Plan Specific Contract Number

PC909

Double Encrypted Member Identification Code

PC913

Pharmacy ID #

PC915

Month Paid

PC917

Month of Service

PC920

Prescribing Physician ID# **

*

Insured Group Name (Derived from PC006 and Key Look-up Table)

[* ] No assigned data element number

[** ]Provider data elements will not be released in records where the Medication Abortion Flag =1.

UNAVAILABLE FOR RELEASE

PC003

Insurance Type/Product Code

PC004

Payer Claim Control Number

PC005

Line Counter

PC007

Encrypted Subscriber Social Security Number

PC008

Plan Specific Contract Number

PC009

Member Suffix or Sequence Number

PC010

Member Identification Code

PC013

Member Date of Birth

PC019

Pharmacy Tax ID Number

PC047

Prescribing Physician DEA Number

PC101

Encrypted Subscriber Last Name

PC102

Encrypted Subscriber First Name

PC103

Encrypted Subscriber Middle Initial

PC104

Encrypted Member Last Name

PC105

Encrypted Member First Name

PC106

Encrypted Member Middle Initial

PC899

Record Type

PC003

Insurance Type/Product Code

PC004

Payer Claim Control Number

PC005

Line Counter

PC007

Encrypted Subscriber Social Security Number

PC008

Plan Specific Contract Number

PC009

Member Suffix or Sequence Number

PC010

Member Identification Code

PC013

Member Date of Birth

PC019

Pharmacy Tax ID Number

PC047

Prescribing Physician DEA Number

PC101

Encrypted Subscriber Last Name

PC102

Encrypted Subscriber First Name

PC103

Encrypted Subscriber Middle Initial

PC104

Encrypted Member Last Name

PC105

Encrypted Member First Name

PC106

Encrypted Member Middle Initial

PC899

Record Type

Derived or calculated from submitted data

PC903

BISHCA Transfer Date

PC904

Unique Member ID

PC905

Submission ID#

PC903

BISHCA Transfer Date

PC904

Unique Member ID

PC905

Submission ID#

Appendix 6 Data Release Schedule: Medical Service Provider File

Special Note: Provider data elements will not be released in records where the Medical Abortion Flag MC914 or Medication Abortion Flag=1.

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

PUBLIC USE FILE- UNRESTRICTED DATA ELEMENTS

MCSP010

Service Provider Specialty

MCSP011

Service Provider City Name

MCSP012

Service Provider State or Province

MCSP013

Service Provider ZIP Code

MCSP015

Taxonomy Code

MCSP010

Service Provider Specialty

MCSP011

Service Provider City Name

MCSP012

Service Provider State or Province

MCSP013

Service Provider ZIP Code

MCSP015

Taxonomy Code

Derived or calculated from submitted data

*

Service Provider County Code

*

Service Provider County Code

[* ] No assigned data element number

LIMITED USE FILE- RESTRICTED DATA ELEMENTS (Release of each restricted data element must be approved by BISHCA)

MCSP001

Provider ID#

MCSP002

Payer

MCSP006

Service/Prescribing Provider First Name

MCSP007

Service/Prescribing Provider Middle Name

MCSP008

Service/Prescribing Provider Last Name or Organization Name

MCSP009

Service Provider Suffix

MCSP018

National Provider Identifier

MCSP001

Provider ID#

MCSP002

Payer

MCSP006

Service/Prescribing Provider First Name

MCSP007

Service/Prescribing Provider Middle Name

MCSP008

Service/Prescribing Provider Last Name or Organization Name

MCSP009

Service Provider Suffix

MCSP018

National Provider Identifier

UNAVAILABLE FOR RELEASE

MCSP003

Service Provider Number

MCSP004

Service Provider Tax ID Number

MCSP005

Service Provider Entity Type Qualifier

MCSP017

Prescribing Physician's DEA (Drug Enforcement Authority) Registration Number

MCSP019

Indicates Source of Information as Medical or Pharmacy File

MCSP003

Service Provider Number

MCSP004

Service Provider Tax ID Number

MCSP005

Service Provider Entity Type Qualifier

MCSP017

Prescribing Physician's DEA (Drug Enforcement Authority) Registration Number

MCSP019

Indicates Source of Information as Medical or Pharmacy File

Appendix 7 Data Release Schedule: Medical Provider Master File

Special Note: Provider data elements will not be released in records where the Medical Abortion Flag MC914 or Medication Abortion Flag=1.

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

PUBLIC USE FILE- UNRESTRICTED DATA ELEMENTS

MPM904

Service Provider Facility Code

MPM910

Service Provider State or Province

MPM911

Taxonomy Code

MPM904

Service Provider Facility Code

MPM910

Service Provider State or Province

MPM911

Taxonomy Code

Derived or calculated from submitted data

*

Service Provider County Code

*

Service Provider County Code

[* ] No assigned data element number

LIMITED USE FILE- RESTRICTED DATA ELEMENTS (Release of each restricted data element must be approved by BISHCA)

MPM901

Data Processing Center Code

MPM903

Service Provider Facility Name

MPM905

Service Provider First Name

MPM906

Service Provider Middle Name

MPM907

Service Provider Last Name

MPM908

Service Provider Suffix

MPM909

Service Provider Title

MPM912

Unique Physician Identification Number

MPM913

National Provider Identifier

MPM901

Data Processing Center Code

MPM903

Service Provider Facility Name

MPM905

Service Provider First Name

MPM906

Service Provider Middle Name

MPM907

Service Provider Last Name

MPM908

Service Provider Suffix

MPM909

Service Provider Title

MPM912

Unique Physician Identification Number

MPM913

National Provider Identifier

UNAVAILABLE FOR RELEASE

MPM902

Service Provider Tax ID Number

MPM914

Prescribing Physician's DEA Registration Number

MPM902

Service Provider Tax ID Number

MPM914

Prescribing Physician's DEA Registration Number

Appendix 8 Data Release Schedule: Pharmacy Detail File

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

PUBLIC USE FILE- UNRESTRICTED DATA ELEMENTS

PCSP908

Pharmacy Location State

PCSP908

Pharmacy Location State

LIMITED USE FILE- RESTRICTED DATA ELEMENTS (Release of each restricted data element must be approved by BISHCA)

PCSP901

Payer

PCSP902

Data Processing Center Code

PCSP903

Pharmacy Number

PCSP905

Pharmacy Name

PCSP906

National Pharmacy ID Number

PCSP907

Pharmacy Location City

PCSP909

Pharmacy ZIP Code

PCSP910

Key to Pharmacy Claims

PCSP901

Payer

PCSP902

Data Processing Center Code

PCSP903

Pharmacy Number

PCSP905

Pharmacy Name

PCSP906

National Pharmacy ID Number

PCSP907

Pharmacy Location City

PCSP909

Pharmacy ZIP Code

PCSP910

Key to Pharmacy Claims

UNAVAILABLE FOR RELEASE

PCSP904

Pharmacy Tax ID Number

PCSP904

Pharmacy Tax ID Number

Appendix 9 Data Release Schedule: Pharmacy Master File

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

PUBLIC USE FILE- UNRESTRICTED DATA ELEMENTS

PM906

Pharmacy Location State

PM906

Pharmacy Location State

LIMITED USE FILE- RESTRICTED DATA ELEMENTS (Release of each restricted data element must be approved by BISHCA)

PM901

Data Processing Center Code

PM903

Pharmacy Name

PM904

National Pharmacy ID Number

PM905

Pharmacy Location City

PM907

Pharmacy ZIP Code

PM901

Data Processing Center Code

PM903

Pharmacy Name

PM904

National Pharmacy ID Number

PM905

Pharmacy Location City

PM907

Pharmacy ZIP Code

UNAVAILABLE FOR RELEASE

PM902

Pharmacy Tax ID Number

PM902

Pharmacy Tax ID Number

Appendix 10 Data Release Schedule: Local Cpt Codes

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

PUBLIC USE FILE- UNRESTRICTED DATA ELEMENTS

Currently there are no fields or data elements in this release category from this file.

LIMITED USE FILE- RESTRICTED DATA ELEMENTS (Release of each restricted data element must be approved by BISHCA)

HGCPT901

Procedure Code

HGCPT902

Payer Code

HGCPT903

Procedure Code Description

HGCPT904

Date HGCPT code was inserted into table

HGCPT901

Procedure Code

HGCPT902

Payer Code

HGCPT903

Procedure Code Description

HGCPT904

Date HGCPT code was inserted into table

UNAVAILABLE FOR RELEASE

Currently there are no fields or data elements in this release category from this file.

Appendix 11 Data Release Schedule: Local Diagnosis Codes

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

PUBLIC USE FILE- UNRESTRICTED DATA ELEMENTS

Currently there are no fields or data elements in this release category from this file.

LIMITED USE FILE- RESTRICTED DATA ELEMENTS (Release of each restricted data element must be approved by BISHCA)

HGDX901

Principal Diagnosis

HGDX902

Payer Code

HGDX903

Principal Diagnosis Description

HGDX901

Principal Diagnosis

HGDX902

Payer Code

HGDX903

Principal Diagnosis Description

UNAVAILABLE FOR RELEASE

Currently there are no fields or data elements in this release category from this file.

Appendix 12 Data Release Schedule: Payer Specialty Codes

Special Note: Provider data elements will not be released in records were the Abortion Flag MC914=1.

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

PUBLIC USE FILE- UNRESTRICTED DATA ELEMENTS

Currently there are no fields or data elements in this release category from this file.

LIMITED USE FILE- RESTRICTED DATA ELEMENTS (Release of each restricted data element must be approved by BISHCA)

PS901

Service Provider Specialty

PS902

Payer Code

PS903

Service Provider Specialty Description

PS901

Service Provider Specialty

PS902

Payer Code

PS903

Service Provider Specialty Description

UNAVAILABLE FOR RELEASE

Currently there are no fields or data elements in this release category from this file.

Appendix 13 Data Release Schedule: Payer Codes

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

PUBLIC USE FILE- UNRESTRICTED DATA ELEMENTS

Currently there are no fields or data elements in this release category from this file.

LIMITED USE FILE- RESTRICTED DATA ELEMENTS (Release of each restricted data element must be approved by BISHCA)

PAYER901

Payer Name

PAYER902

Payer Code

PAYER901

Payer Name

PAYER902

Payer Code

UNAVAILABLE FOR RELEASE

Currently there are no fields or data elements in this release category from this file.

Appendix 14 Data Release Schedule: Taxonomy for Provider Specialty Codes

Special Note: Provider data elements will not be released in records were the Abortion Flag MC914=1.

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

DATA ELEMENT NUMBER

ELEMENT NAME

Unrestricted

Included in the public use file for public release and general use.

Restricted

May be included in limited use research health care data sets as approved by BISHCA.

Unavailable for release

Unavailable for release by the department due to a variety of factors including: used for internal tracking purposes only; used to calculate other more useful variables; unreliable data; and potential for misuse.

PUBLIC USE FILE- UNRESTRICTED DATA ELEMENTS

TX901

Category

TX902

Provider Type

TX903

Classification

TX904

Area of Specialization

TX905

Taxonomy Code

TX901

Category

TX902

Provider Type

TX903

Classification

TX904

Area of Specialization

TX905

Taxonomy Code

LIMITED USE FILE- RESTRICTED DATA ELEMENTS (Release of each restricted data element must be approved by BISHCA)

Currently there are no fields or data elements in this release category from this file.

UNAVAILABLE FOR RELEASE

Currently there are no fields or data elements in this release category from this file.

Disclaimer: These regulations may not be the most recent version. Vermont may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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