Statutes, codes, and regulations
Maine Administrative Code
Department 90 - INDEPENDENT AGENCIESDivision 590 - MAINE HEALTH DATA ORGANIZATION
Chapter 243 - UNIFORM REPORTING SYSTEM FOR HEALTH CARE CLAIMS DATA SETS
Appendix 590-243-C-1 - Maine Health Data Organization Member eligibility File Specifications

C.M.R. 90, 590, ch. 243, app 590-243-C-1

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Current through 2024-51, December 18, 2024
Appendix 590-243-C-1 - Maine Health Data Organization Member eligibility File Specifications

Data Element #

Data Element Name

Date Effective

Type

Maximum Length

Description/Codes/Sources

ME001

Submitter

1/1/2003

Text

8

MHDO-assigned identifier of payor submitting claims data. Do not leave blank.

ME002

Payor

7/1/2012

Text

8

MHDO-assigned code of the insurer/underwriter in the case of premiums-based coverage, or of the administrator in the case of self-funded coverage. Do not leave blank.

ME003

Insurance Type/Product Code

1/1/2003

Text

2

Code identifying the type of insurance policy within a specific insurance program. Refer to Appendix A

HN Medicare Part C

MD Medicare Part D

ME004

Year

1/1/2003

Number

4

Year for which eligibility is reported in this submission

ME005

Month

1/1/2003

Text

2

Month for which eligibility is reported in this submission

ME006

Insured Group or Policy Number

1/1/2003

Text

30

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

ME007

Coverage Level Code

1/1/2003

Text

3

Benefit coverage level Refer to Appendix A

ME008

Subscriber Social Security Number

1/1/2003

Text

9

Subscriber's social security number Leave blank if unavailable

ME009

Plan Specific Contract Number

1/1/2003

Text

80

Plan-assigned subscriber's contract number Leave blank if contract number = subscriber's social security number

ME010

Member Suffix or Sequence Number

1/1/2003

Text

20

Unique number of the member within the contract

ME011

Member Identification Code

1/1/2003

Text

50

Member's social security number Leave blank if unavailable

ME012

Individual Relationship Code

1/1/2003

Text

2

Member's relationship to insured Refer to Appendix A

ME013

Member Gender

1/1/2003

Text

1

Refer to Appendix A

ME014

Member Date of Birth

1/1/2003

Text

8

CCYYMMDD

ME015

Member City Name

4/1/2004

Text

30

City name of member Refer to Appendix A

ME016

Member State or Province

4/1/2004

Text

2

As defined by the US Postal Service and Canada Post Refer to Appendix A

ME017

Member ZIP Code

1/1/2003

Text

11

ZIP Code of member - may include non-US codes. Do not include dash Refer to Appendix A

ME018

Medical Coverage

1/1/2003

Text

1

N No

Y Yes

ME019

Prescription Drug Coverage

1/1/2003

Text

1

N No

Y Yes

ME020

Dental Coverage

1/1/2003

Text

1

N No

Y Yes

ME021

Race 1

1/1/2021

Text

2

Report the Member-identified race using the first two characters of the CDC Hierarchical Code. The code value "UN" (Unknown/not specified) should be used ONLY when Member answers unknown or refuses to answer. Report only collected data. If not available, leave blank. Refer to Appendix A.

For quick reference, the two-character subset of the CDC race list is:

R1 American Indian/Alaska Native

R2 Asian

R3 Black/African American

R4 Native Hawaiian or Other Pacific Islander

R5 White

R9 Other Race

UN Unknown/Not Specified

ME022

Race 2

1/1/2021

Text

2

Report the Member-identified race using the first two characters of the CDC Hierarchical Code. The code value "UN" (Unknown/not specified) should be used ONLY when Member answers unknown or refuses to answer. Report only collected data. If not available, leave blank. Refer to Appendix A.

ME023

Race 3

1/1/2021

Text

2

Report the Member-identified race using the first two characters of the CDC Hierarchical Code. The code value "UN" (Unknown/not specified) should be used ONLY when Member answers unknown or refuses to answer. Report only collected data. If not available, leave blank. Refer to Appendix A.

ME024

Hispanic Indicator

1/1/2021

Text

1

Report the value that defines the element. The code value "U" for unknown should be used ONLY when member answers unknown or refuses to answer. Report only collected data. If not available, leave blank.

Y Member is Hispanic/Latino/Spanish

N Member is not Hispanic/Latino/Spanish

U Unknown/not specified.

ME025

Ethnicity 1

1/1/2021

Text

6

Report the Member-identified ethnicity from the External Code Source that best describes the information obtained from the Member / Subscriber. The value "UNKNOW" should be used ONLY when the Member answers unknown or refuses to answer. Report only collected data. If not available, leave blank. Refer to Appendix A. Report the CDC Unique Identifiers (format NNNN-N; 6 characters).

ME026

Ethnicity 2

1/1/2021

Text

6

Report the Member-identified ethnicity from the External Code Source that best describes the information obtained from the Member / Subscriber. The value "UNKNOW" should be used ONLY when the Member answers unknown or refuses to answer. Report only collected data. If not available, leave blank. Refer to Appendix A. Report the CDC Unique Identifiers (format NNNN-N; 6 characters).

ME027

Ethnicity 3

1/1/2021

Text

6

Report the Member-identified ethnicity from the External Code Source that best describes the information obtained from the Member / Subscriber. The value "UNKNOW" should be used ONLY when the Member answers unknown or refuses to answer. Report only collected data. If not available, leave blank. Refer to Appendix A. Report the CDC Unique Identifiers (format NNNN-N; 6 characters).

ME028

Primary Insurance Indicator

1/1/2010

Number

1

1 Yes - primary insurance

2 No - secondary, or tertiary insurance

ME029

Coverage Type

1/1/2010

Text

3

ASO - self-funded plans that are administered by a third-party administrator, where the employer has not purchased stop-loss, or group excess, insurance coverage

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

OTH - any other plan. Insurers using this code shall obtain prior approval.

STN - short-term, non-renewable health insurance

UND - plans underwritten by the insurer

ME030

Market Category Code

1/1/2010

Text

4

IND - coverage sold and issued directly to individuals (non-group)

FCH - coverage sold and issued directly to individuals on a franchise basis

GCV - coverage sold and issued directly to individuals as group conversion policies

GS1 - coverage sold and issued directly to employers having exactly one employee

GS2 - coverage sold and issued directly to employers having between two and nine employees

GS3 - coverage sold and issued directly to employers having between 10 and 25 employees

GS4 - coverage sold and issued directly to employers having between 26 and 50 employees

GLG1 - coverage sold and issued directly to employers having between 51 and 99 employees

GLG2 - coverage sold and issued directly to employers having 100 or more employees

GSA - coverage sold and issued directly to small employers through a qualified association trust

OTH - coverage sold to other types of entities. Insurers using this market code shall obtain prior approval.

ME031

Special Coverage

N/A

Number

3

State-specific assignment. Default value for Maine is "0".

ME032

Group Name

1/1/2010

Text

128

Group name or IND for individual policies, and BLANK if data is not available

ME101

Subscriber Last Name

1/1/2010

Text

60

The subscriber last name

ME102

Subscriber First Name

1/1/2010

Text

35

The subscriber first name

ME103

Subscriber Middle Name

1/1/2010

Text

25

The subscriber middle name or initial

ME104

Member Last Name

1/1/2010

Text

60

The member last name

ME105

Member First Name

1/1/2010

Text

35

The member first name

ME106

Member Middle Name

1/1/2010

Text

25

The member middle name or initial

ME107

Member Address Line 1

2/1/2019

Text

55

ME108

Member Address Line 2

2/1/2019

Text

55

ME109

Member Country Code

2/1/2019

Text

2

Use ISO 3166-1 alpha-2 country codes. Refer to Appendix A.

ME110

Placeholder

2/1/2021

N/A

0

Subscriber's Health Insurance Claim Number retired. Leave blank.

ME111

Subscriber MBI

2/1/2019

Text

11

Subscriber's Medicare Beneficiary Identifier. May be populated starting February 1, 2019 or as soon as MBI is available for reporting. Required starting January 1, 2020 or if ME110 is not present.

ME112

Placeholder

2/1/2021

N/A

0

Member's Health Insurance Claim Number retired. Leave blank.

ME113

Member MBI

2/1/2019

Text

11

Member's Medicare Beneficiary Identifier. Required only for Medicare Supplemental/Companion Plans for which 1) the subscriber and the member are not the same person, 2) the payor is primary and 3) ME112 is not present. Otherwise, leave blank. If not the same as ME111, may be populated starting February 1, 2019; however, only required starting January 1, 2020.

ME114

Plan Begin Date (Member Effective Date)

2/1/2020

Text

8

CCYYMMDD. Effective date of coverage. Date eligibility started for this member under this plan type.

ME115

Plan End Date (Member Cancellation Date)

2/1/2020

Text

8

CCYYMMDD. Last continuous day of coverage (date eligibility ended) for this member under this plan. For open contracts, leave blank.

ME116

Grandfathered Plan Indicator

2/1/2025

Text

1

Indicates if a plan qualifies as a "Grandfathered" or "Transitional Plan" under the Affordable Care Act (ACA). Please see definition for "grandfathered" and "transitional" in HHS rules 45-CFR-147.140: https://www.federalregister.gov/select-citation/2013/06/03/45-CFR-147. The values of the indicator are as follows:

1=Grandfathered;

2=Non-Grandfathered;

3=Transitional;

4=Not Applicable.

ME117

Metal Tier

2/1/2025

Text

1

For Non-Grandfathered health plans for the Individual and Small Group markets (under ACA) ONLY. Health benefit plan metal tier for qualified health plans (QHPs) and catastrophic plans as defined in the Patient Protection and Affordable Care Act, Public Law 111-148, Section 1302 :

Essential Health Benefits Requirements:

0=Not a QHP or catastrophic plan;

1=Catastrophic;

2=Bronze;

3=Silver;

4=Gold;

5=Platinum.

If not applicable, leave blank.

ME118

Enrolled Through a Public Health Insurance Exchange

2/1/2025

Text

1

For Non-Grandfathered health plans for the Individual and Small Group markets (under ACA) ONLY. Use this field to report whether the policy for this eligibility record was enrolled through a Public Health Insurance Exchange.

Valid codes include:

1=Yes;

2=No;

3=Unknown/not applicable.

ME119

Cost-Sharing Reduction Indicator

2/1/2025

Text

1

For Non-Grandfathered health plans for the Individual and Small Group markets (under ACA) ONLY. Indicates cost-sharing reduction under the Affordable Care Act (ACA). This is a person- level indicator in which enrollees who qualify for cost-sharing reduction are assigned cost- sharing indicator values of 1-8. Non-Cost-Sharing recipients are assigned a costsharing indicator value of zero. Valid codes include: 1=Enrollees in 94% Actuarial Value (AV) Silver Plan Variation;

2=Enrollees in 87% AV Silver Plan Variation;

3=Enrollees in 73% AV Silver Plan Variation;

4=Enrollees in Zero Cost Sharing Plan Variation of Platinum Level QHP (Qualified Health Plan);

5=Enrollee in Zero Cost Sharing Plan Variation of Gold Level QHP;

6=Enrollee in Zero Cost Sharing Plan Variation of Silver Level QHP;

7=Enrollee in Zero Cost Sharing Plan Variation of Bronze Level QHP;

8=Enrollee in Limited Cost Sharing Plan Variation;

0=Non-CSR recipient, and enrollees with unknown CSR.

ME899

Record Type

1/1/2003

Text

2

ME

C.M.R. 90, 590, ch. 243, app 590-243-C-1