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					                                              NEW HAMPSHIRE CLAIMS DATABASE
                                                     DATA ELEMENTS

ELIGIBILITY FILE                                    PHARMACY CLAIMS FILE
One record for each member for each month           One record for each paid prescription
      eligible
                                                    PC001    Payer                                         PC027 Drug name
ME001   Payer                                       PC002    National plan ID***                           PC028 New prescription
ME002   National plan ID***                         PC003    Insurance type/product code                   PC028A Refill number
ME003   Insurance type code/product                 PC004    Payer claim control number                    PC029 Generic drug indicator
ME004   Year of eligibility                         PC005    Line counter                                  PC030 Dispense as written code
ME005   Month of eligibility                        PC006    Insured group or policy number                PC031 Compound drug indicator
ME006   Insured group or policy number              PC007    Encrypted subscriber social security number   PC032 Date prescription filled
ME007   Coverage level code                         PC008    Encrypted plan specific contract number       PC033 Quantity dispensed
ME008   Encrypted subscriber social security        PC009     Member suffix or sequence number             PC034 Days supply
           number                                   PC010    Encrypted member identification code          PC035 Charge amount
ME009   Encrypted plan specific contract number     PC011    Individual relationship code                  PC036 Paid amount
ME010   Member suffix or sequence number            PC012    Member gender                                 PC037 Ingredient cost/list price
ME011   Encrypted member identification code        PC013    Member date of birth                          PC038 Postage amount claimed
ME012   Individual relationship code                PC014    Member city name                              PC039 Dispensing fee
ME013   Member gender                               PC015    Member state or province                      PC040 Co-pay amount
ME014   Member date of birth                        PC016    Member zip code                               PC041 Coinsurance amount
ME015   Member city name                            PC017    Date service approved                         PC042 Deductible amount
ME016   Member state or province                    PC018    Pharmacy number                               PC043 Record type
ME017   Member zip code                             PC019    Pharmacy tax ID number
ME018   Medical coverage flag                       PC020    Pharmacy name
ME019   Prescription drug coverage flag             PC021    National pharmacy ID number***
ME020   Record type                                 PC022    Pharmacy location city
                                                    PC023    Pharmacy location state
                                                    PC024    Pharmacy zip code
                                                    PC025    Claim status
                                                    PC026    Drug code


*** Will be populated when identification numbers are released by federal government


                                                                       October 2005

                                                                                                                                              1
                                                NEW HAMPSHIRE CLAIMS DATABASE
                                                       DATA ELEMENTS

MEDICAL CLAIMS FILE
One record for each line item of a paid bill.

MC001  Payer                                        MC024     Service provider number                   MC050   Other diagnosis – 9
MC002  National plan ID***                          MC025     Service provider tax ID number            MC051   Other diagnosis – 10
MC003  Insurance type/product code                  MC026     National service provider ID***           MC052   Other diagnosis – 11
MC004  Payer claim control number                   MC027     Service provider entity type qualifier    MC053   Other diagnosis – 12
MC005  Line counter                                 MC028     Service provider first name               MC054   Revenue code
MC005A Version number                               MC029     Service provider middle name              MC055   Procedure code
MC006  Insured group or policy number               MC030     Service provider last name or org. name   MC056   Procedure modifier – 1
MC007  Encrypted subscriber social security         MC031     Service provider suffix                   MC057   Procedure modifier – 2
          number                                    MC032     Service provider specialty                MC058   ICD-9-CM procedure code
MC008 Encrypted plan specific contract number       MC033     Service provider city                     MC059   Date of service – from
MC009 Member suffix or sequence number              MC034     Service provider state                    MC060   Date of service – thru
MC010 Encrypted member identification code          MC035     Service provider zip code                 MC061   Quantity
MC011 Individual relationship code                  MC036     Type of bill – institutional              MC062   Charge amount
MC012 Member gender                                 MC037     Facility type – professional              MC063   Paid amount
MC013 Member date of birth                          MC038     Claim status                              MC064   Prepaid amount
MC014 Member city name                              MC039     Admitting diagnosis                       MC065   Co-pay amount
MC015 Member state or province                      MC040     E-code                                    MC066   Coinsurance amount
MC016 Member zip code                               MC041     Principal diagnosis                       MC067   Deductible amount
MC017 Date service approved                         MC042     Other diagnosis - 1                       MC068   Record type
MC018 Admission date                                MC043     Other diagnosis – 2
MC019 Admission hour                                MC044     Other diagnosis - 3
MC020 Admission type                                MC045     Other diagnosis – 4
MC021 Admission source                              MC046     Other diagnosis – 5
MC022 Discharge hour                                MC047     Other diagnosis – 6
MC022A Discharge date                               MC048     Other diagnosis – 7
MC023 Member status                                 MC049     Other diagnosis – 8


*** Will be populated when identification numbers are released by federal government


                                                                       October 2005

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posted:10/17/2011
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