N.H. Admin. Code § Ins 4010.01

Current through Register No. 50, December 12, 2024

Section Ins 4010.01 - Member Eligibility Data Tables

(a) Use Table 4010.7 (a) to determine member eligibility file mapping and formatting.

(b) Member File Header Record Layout

Table 4010.01(b) Member File Header Record Layout
Data Element #	Element	Type	Length (decimal places)	Description/Codes/Sources
HD001	Record Type	Text	2	HD
HD002	Payer	Text	8	Payer submitting payments. NHID Submitter Code
HD003	National Plan ID	Text	30	CMS National Plan ID
HD004	Type of File	Text	2	ME Member Eligibility
HD005	Period Beginning Date	Date	8	Beginning of paid period for claims or beginning of month covered for eligibility
HD006	Period Ending Date	Date	8	End of paid period for claims or end of month covered for eligibility
HD007	Comments	Text	80	Submitter may use to document this submission by assigning a filename, system source, etc.

(c) Member File Trailer Record Layout

Table 4010.01(c) Member File Trailer Record Layout
Data Element #	Element	Type	Length (decimal places)	Description/Codes/Sources
TR001	Record Type	Text	2	TR
TR002	Payer	Text	8	Payer submitting payments. NHID Submitter Code
TR003	National Plan ID	Text	30	CMS National Plan ID
TR004	Type of File	Text	2	ME Member Eligibility
TR005	Period Beginning Date	Date	8	Beginning of paid period for claims or beginning of month covered for eligibility
TR006	Period Ending Date	Date	8	End of paid period for claims or beginning of month covered for eligibility
TR007	Extraction Date	Date	8	Date file was created
TR008	Record Count	Number	10 (0)	Total number of records submitted in this file

(d) Member File Detailed Specification

Table 4010.01(d) Member File Detailed Specification
Column Position	Data Element #	Element	Type	Length (decimal places)	Description/Codes/Sources
1	ME001	Payer	Text	8	Payer submitting payments NHID Submitter Code
2	ME002	National Plan ID	Text	30	CMS National Plan ID
3	ME003	Insurance Type Code/Product	Text	2	See Table 4010.6 (a) Insurance Type/Product Code-Eligibility File
4	ME004	Start Year	Number	4 (0)	Year for which eligibility is reported in this submission. CCYY format
5	ME005	Start Month	Number	2 (0)	Month for which eligibility is reported in this submission. MM format. Leading zero is required for reporting January through September files
6	ME006	Insured Group or Policy Number	Text	50	Group or policy number (not the number that uniquely identifies the subscriber)
7	ME007	Coverage Level Code	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
8	ME008	Subscriber Social Security Number	Text	9	Subscriber's social security number. Do not include dashes. Leave blank if not available.
9	ME009	Plan Specific Contract Number	Text	50	Plan assigned contract number. Leave blank if Plan Specific Contract Number is subscriber's social security number. If this is a Medicaid member, provide Medicaid ID
10	ME010	Member Suffix or Sequence Number	Text	20	Uniquely identifies the member within the contract
11	ME011	Member Social Security Number	Text	9	Member's social security number. Do not include dashes. Leave blank if not available.
12	ME012	Individual Relationship Code	Text	2	See Table 4010.6 (b) Relationship Codes
13	ME013	Member Gender	Text	1	M Male
F Female
U Unknown
O Other
14	ME014	Member Date of Birth	Date	8	Date of birth of member
15	ME015	Member City Name	Text	30	City name of member
16	ME016	Member State or Province	Text	2	As defined by the US Postal Service
17	ME017	Member ZIP Code	Text	9	ZIP Code of member - may include non- US codes. Do not include dash.
18	ME018	Medical Coverage	Text	1	Y Yes
N No
19	ME019	Prescription Drug Coverage	Text	1	Y Yes, member has prescription drug coverage in the period defined with this payer
N No, member does not have prescription drug coverage in the period defined with this payer
20	ME020	Dental Coverage	Text	1	Y Yes, member has dental coverage in the period defined with this payer
N No, member does not have dental coverage in the period defined with this payer
21	ME021	Race 1	Text	6	See Table 4010.6 (c) Race 1/Race 2
22	ME022	Race 2	Text	6	See Table 4010.6 (c) Race 1/Race 2
23	ME023	Placeholder
24	ME024	Hispanic Indicator	Text	1	Y Yes, member is Hispanic/Latino/Spanish
N No, member is not Hispanic/Latino/Spanish
U Unknown
25	ME025	Ethnicity 1	Text	6	See Table 4010.6 (d): Ethnicity 1/ Ethnicity 2
26	ME026	Ethnicity 2	Text	6	See Table 4010.6 (d): Ethnicity 1/ Ethnicity 2
27	ME027	Placeholder	20
28	ME028	Primary Insurance Indicator	Text	1	Y Yes, this is the member's primary insurance
N No, this is not the member's primary insurance
29	ME029	Coverage Type	Text	3	ASW Self-funded plans that are administered by a third party administrator, where the employer has purchased stop-loss, or group excess insurance coverage
ASO Self-funded plans that are administered by a third party administrator, where the employer has not purchased stop-loss, or group excess insurance coverage
STN Short-term non-renewable health insurance, as defined pursuant to RSA 415:5III
MCD Medicaid
MCR Medicare
UND Plans underwritten by the carrier
OTH Any other plan. Carriers and third-party administrators using this code shall obtain prior approval from the N.H. Insurance Department
30	ME030	Market Category	Text	4	Three or four digit character code for identifying market category. Employer size is based on the number of eligible employees in the group as define in INS 4100, (INS 4103.03(g) for the Small Group market, INS 4104.03(i) for the Large Group market)
IND Policies sold and issued directly to individuals, other than those sold on a franchise basis, as defined pursuant to RSA 415:19, or as group conversion Policies as defined pursuant to RSA 415:18 (a)VII
FCH Policies sold and issued directly to individuals on a franchise basis as defined pursuant to RSA 415:19
GCV Policies sold and issued directly to individuals as group conversion Policies as required pursuant to RSA 415:18 (a)VII
GS1 Policies sold and issued directly to employers having exactly one employee
GS2 Policies sold and issued directly to employers having between 2 and 9 employees
GS3 Policies sold and issued directly to employers having between 10 and 25 employees
GS4 Policies sold and issued directly to employers having between 26 and 50 employees
GLG1 Policies sold and issued directly to employers having between 51 and 99 employees
GLG2 Policies sold and issued directly to employers having 100 or more employees
GSA Policies sold and issued directly to small employers through a qualified association trust
OTH Policies sold to other types of entities. Carriers and third-party administrators using this market code shall obtain prior approval from the NH Insurance Department
BLC Policies sold and issued as blanket health insurance Policies to a common carrier
BLE Policies sold and issued as blanket health insurance Policies to an employer
BLV Policies sold and issued as blanket health insurance Policies to a volunteer fire department, first aid, or other such volunteer group
BLS Policies sold and issued as blanket health insurance Policies to a sports team or a camp
BLT Policies sold and issued as blanket health insurance Policies to a travel agency, or other organization that provides travel-related services
BLU Policies sold and issued as blanket health insurance Policies to a university or college
SLG Policies sold and issued as student major medical expense large group coverage to enrolled students at an accredited college, university, or other educational institution
STS Policies sold and issued as group short term student health insurance
SMG Policies sold and issued as student major medical group health insurance
SNM Policies sold and issued as student group health insurance that is not major medical coverage
SIM Policies sold and issued as student individual major medical health insurance
SIN Policies sold and issued as student individual health insurance that is not major medical coverage
31	ME031	NH Health Protection Program	Text	60	For enrollees in the New Hampshire Health Protection Program (NHHPP), indicate if enrollee is part of the Premium Assistance Program (PAP) or Health Insurance Premium Payment (HIPP). Leave blank if enrollee is not a member of the NHHPP
32	ME032	Group Name	Text	4	Name of the group that the member is covered by. If the member is part of a group of one or non-group, indicate I
33	ME101	Subscriber Last Name	Text	60
34	ME102	Subscriber First Name	Text	35
35	ME103	Subscriber Middle Initial	Text	1
36	ME104	Member Last Name	Text	60
37	ME105	Member First Name	Text	35
38	ME106	Member Middle Initial	Text	1
39	Placeholder
40	ME203	Member's Assigned PCP	Text	20	National Provider ID of the member's Primary Care Physician as designated by healthcare claims processor.
41	ME204	HIOS Plan ID	Text	16	The 16 character HIOS Plan ID (Standard component). Including a five digit issuer ID, two character state ID, three digit product number, four digit standard component number and two digit variant component ID. This field may not be available for all market segments;
42	ME205	Plan Effective Date	Date	8	For the plan reported in ME204, report the date eligibility started for this member under this plan type. The purpose of this data element is to maintain an eligibility span for each member.
43	ME206	Minimum Value	Number	3 (0)	For the plan reported in ME204, report the Minimum Value as described in Part Ins4009.03(j). This is reported as a percentage.
44	ME207	Exchange Indicator	Text	1	The plan reported in ME204 was available on the Exchange Marketplace in the month and year reflected in ME004 and ME005
Y Yes
N No
45	ME208	High deductible health plan	Text	1	The plan reported in ME204 meets the IRS definition of a HDHP
Y Yes
N No
U Unknown
46	ME209	Active enrollment	Text	1	The plan reported in ME204 was open for enrollment in the year and month reflected in ME004 and ME005
Y Yes
N No
47	ME210	New Coverage	Text	1	The plan reported in ME204 was being offered for the first time in the reporting year reflected in ME004
Y Yes
N No
48	ME211	Placeholder
49	ME899	Record Type	Text	2	ME
50	ME900	Plan State	Text	2	State in which the plan is sold or used. State codes are maintained by the US Postal Service
51	ME901	Advanced Premium Tax Credit	Number	2(2)	Dollar value of Advanced Premium Tax Credit (APTC) subsidy
52	ME902	NAIC Number	Text	5	Number that the National Association of Insurance Commissioners (NAIC) assigns to each individual underwriting company
53	ME903	Grandfather Plan indicator	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
54	ME904	Metal Level	Text	10	The metal representation of the plan reported in ME204 on the Exchange Marketplace

N.H. Admin. Code § Ins 4010.01

Derived From Volume XXXV Number 32, Filed August 13, 2015, Proposed by #10877, Effective 7/10/2015, Expires7/10/2025.

Amended by Volume XL Number 50, Filed December 10, 2020, Proposed by #13136, Effective 11/24/2020, Expires 11/24/2030