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

Current through 2024-51, December 18, 2024

Appendix 590-243-G-1 - Maine Health Data Organization Capitated Payments File Specification

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