|
1 |
BENE_ID |
Encrypted 723 CCW Beneficiary ID |
| 2 |
MSIS_ID |
Encrypted MSIS Identification Number |
| 3 |
STATE_CD |
State |
| 4 |
YR_NUM |
Year of MAX Record |
| 5 |
EL_DOB |
Birth date |
| 6 |
EL_SEX_CD |
Sex (MAX) |
| 7 |
EL_RACE_ETHNCY_CD |
Race/ethnicity (from MSIS) |
| 8 |
RACE_CODE_1 |
Race - White (from MSIS) |
| 9 |
RACE_CODE_2 |
Race - Black (from MSIS) |
| 10 |
RACE_CODE_3 |
Race - Am Indian/Alaskan (from MSIS) |
| 11 |
RACE_CODE_4 |
Race - Asian (from MSIS) |
| 12 |
RACE_CODE_5 |
Race - Hawaiian/Pac Islands (from MSIS) |
| 13 |
ETHNICITY_CODE |
Ethnicity - Hispanic (from MSIS) |
| 14 |
EL_SS_ELGBLTY_CD_LTST |
State specific eligibility - most recent |
| 15 |
EL_SS_ELGBLTY_CD_MO |
State specific eligibility - mo of svc |
| 16 |
EL_MAX_ELGBLTY_CD_LTST |
MAX eligibility - most recent |
| 17 |
EL_MAX_ELGBLTY_CD_MO |
MAX eligibility - mo of svc |
| 18 |
EL_MDCR_ANN_XOVR_OLD |
Crossover code (Annual) old values |
| 19 |
MSNG_ELG_DATA |
Missing eligibility data |
| 20 |
EL_MDCR_XOVR_CLM_BSD_CD |
Crossover code (from claims only) |
| 21 |
EL_MDCR_ANN_XOVR_99 |
Crossover code (Annual) |
| 22 |
MSIS_TOS |
MSIS Type of Service (TOS) |
| 23 |
MSIS_TOP |
MSIS Type of Program (TOP) |
| 52 |
HCBS_TXNMY_WVR_CD |
Home and community-based services (HCBS) taxonomy code for waviers |
| 25 |
CLTC_FLAG |
Community-based LT care (CLTC) flag |
| 24 |
MAX_TOS |
MAX Type of Service (TOS) |
| 26 |
PRVDR_ID_NMBR |
Billing provider identification number (MAX) |
| 27 |
NPI |
National Provider Identifier (MAX) |
| 28 |
TAXONOMY |
Provider Taxonomy |
| 29 |
TYPE_CLM_CD |
Type of claim |
| 30 |
ADJUST_CD |
Adjustment code |
| 31 |
PHP_TYPE |
Managed care type of plan code |
| 32 |
PHP_ID |
Managed care plan identification code |
| 33 |
MDCD_PYMT_AMT |
Medicaid payment amount |
| 34 |
TP_PYMT_AMT |
Third party payment amount |
| 35 |
PYMT_DT |
Payment/adjudication date |
| 36 |
CHRG_AMT |
Charge amount |
| 37 |
PHP_VAL |
Prepaid plan value |
| 38 |
MDCR_COINSUR_PYMT_AMT |
Medicare coinsurance payment amount |
| 39 |
MDCR_DED_PYMT_AMT |
Medicare deductible payment amount |
| 40 |
SRVC_BGN_DT |
Beginning date of service |
| 41 |
SRVC_END_DT |
Ending date of service |
| 42 |
PRCDR_CD_SYS |
Procedure (service) coding system |
| 43 |
PRCDR_CD |
Procedure (service) code |
| 44 |
PRCDR_SRVC_MDFR_CD |
Procedure (service) code modifier |
| 45 |
DIAG_CD_1 |
Principle Diagnosis code |
| 46 |
DIAG_CD_2 |
Diagnosis codes (2nd diagnosis) |
| 47 |
QTY_SRVC_UNITS |
Quantity of service |
| 48 |
SRVC_PRVDR_ID_NMBR |
Servicing provider identification number (MAX) |
| 49 |
SRVC_PRVDR_SPEC_CD |
Servicing provider specialty code (MAX) |
| 50 |
PLC_OF_SRVC_CD |
Place of service |
| 51 |
UB_92_REV_CD |
UB-92 revenue code |
