Eligibility/Membership File Data Elements

This layout represents one continuous extract with separate records for each member and dependent.  All the dependent records must follow directly after the member’s record. This is required for a dependent record to be associated with the correct member.

Note:  Only the most recent eligibility information received is displayed online.

 

The Extract Identifier code for this file is EL.

 

Refer to Appendix B, “Eligibility Data-Map Process,” for details on how eligibility records are added or updated in the Healthx database.

 

Employee/Dependent Section

 

Field #

Field Name

Req.

Len

Type

Notes

1

VersionNumber

K

10

AN

Spec Version Number:  3.04

2

PayorName

R

100

AN

Payor’s Name/ID

3

MemberID

K

64

AN

Member’s ID Number (on their ID card)

4

GroupNumber

K

20

AN

Member’s Group ID Number

5

GroupName

R

100

AN

Member’s Employer Group Name

6

SSN

R

9

AN

Member’s SSN

7

DependentSSN

R

9

AN

Dependent’s SSN

8

DependentNumber

R

64

AN

Dependent’s ID Number – Should be populated for dependent records only.

9

SeqNumber

R

2

AN

Sequence Number

10

Salary

O

8

DE

Member’s Salary

11

Status

R

2

AN

Member’s Status – Refer to Appendix A for HIPAA Member Status Codes

12

HireDate

O

8

DT

Member’s Hire Date

13

LastName

R

50

AN

Member/Dependent Last Name

14

FirstName

R

50

AN

Member/Dependent First Name

15

MiddleName

O

50

AN

Member/Dependent Middle Name or Initial

16

Gender

R

1

AN

Member/Dependent Gender

M = Male

F = Female

U = Unknown

17

Address1

R

100

AN

Member/Dependent Address Line One

18

Address2

O

100

AN

Member/Dependent Address Line Two

19

City

R

50

AN

Member/Dependent City

20

State

R

2

AN

Member/Dependent State

21

Zip

R

10

AN

Member/Dependent Zip Code

(i.e. 12345 or 12345-6789)

22

Location

R

9

AN

Employer’s Location Code


 

Field #

Field Name

Req.

Len

Type

Notes

23

LocationDesc

R

100

AN

Employer’s Location Description

24

TotalDependents

O

2

NU

Number of Dependents

25

CovClass

O

25

AN

Coverage Class

26

COB

R

1

AN

Coordination of Benefits – Y/N

27

COBRA

R

1

AN

COBRA – Y/N

28

PCPName

O

100

AN

Primary Care Physician Name

29

PCPCode

O

25

AN

Primary Care Physician Code

30

DOB

R

8

DT

Member/Dependent Date of Birth

31

OVCopay

O

8

DE

PCP Office Visit Co-Pay

32

BnftPlan

O

50

AN

Member/Dependent Benefit Plan

33

OrigEffDate

R

8

DT

Original Effective Date

34

POS_Flag

O

1

AN

Point of Service – Y/N

35

RelCode

R

2

AN

Relationship Code – Refer to Appendix B for HIPAA Relationship Codes

36

LastChange

O

8

DT

Last Change Date

37

LastChangeOp

O

5

AN

Change Processor Code

38

ChangeReason

O

2

AN

Change Reason Code

39

Medicare

O

1

AN

Medicare – Y/N

40

FlexEE

O

1

AN

Flex Employee – Y/N

41

FlexClass

O

4

AN

Flex Classification

42

FamTermDate

R

8

DT

Family Term Date

43

IndTermDate

R

8

DT

Individual Term Date

44

UserDefinedText1

O

255

AN

User Defined Text Field 1

45

UserDefinedText2

O

255

AN

User Defined Text Field 2

46

UserDefinedText3

O

255

AN

User Defined Text Field 3

47

UserDefinedDate1

O

8

DT

User Defined Date Field 1

48

UserDefinedDate2

O

8

DT

User Defined Date Field 2

49

UserDefinedDate3

O

8

DT

User Defined Date Field 3

50

ProdID

K/O

50

AN

Production Directory ID

51

Email

O

80

AN

Member’s Email Address

52

HomePhone

O

25

AN

Member’s Home Phone Number

53

IntSystemID

O

64

AN

Claim System Internal ID for the Member

54

ProviderIntSystemID

O

64

AN

Claim System Internal ID for the Provider

55

MemberCode

O

1

AN

RIMS Member Code

56

ERCopay

O

8

DE

Emergency Room Copay

57

SCPCopay

O

8

DE

Specialty Care Physician Copay

58

PCPPhone

O

25

AN

PCP Phone Number

59

PCPLocation

O

255

AN

PCP Office Name

60

NPIN

O

10

AN

National Provider ID

61

HCIN

O

64

AN

Medicare HCIN Number

62

SPD1

R

50

AN

SPD Code 1

63

SPD2

R

50

AN

SPD Code 2

64

SPD3

R

50

AN

SPD Code 3

65

SPD4

R

50

AN

SPD Code 4

66

PPO1

R

50

AN

PPO Code 1

67

PPO2

R

50

AN

PPO Code 2

68

PPO3

R

50

AN

PPO Code 3

69

RX1

R

50

AN

Prescription Drug Code 1

70

RX2

R

50

AN

Prescription Drug Code 2



 

Field #

Field Name

Req.

Len

Type

Notes

71

ActionFlag

R

1

AN

D = Delete

R = Restrict

Blank = Load/Update

72

OrgProviderID

R

100

AN

This is a value that uniquely identifies the provider and is used in the HealthPlan Provider Portal to tie all provider data together. It can be an NPI, UPIN, or any other value that uniquely identifies the provider for your organization.  It should be a value the provider knows.

 


 


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