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 |
Medicare 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) |
24 |
HCBS_TXNMY_WVR_CD |
Home and community-based services (HCBS) taxonomy code for waviers |
25 |
MAX_TOS |
MAX Type of Service (TOS) |
26 |
CLTC_FLAG |
Community-based LT care (CLTC) flag |
27 |
PRVDR_ID_NMBR |
Billing provider identification number (MAX) |
28 |
NPI |
National Provider Identifier (MAX) |
29 |
TAXONOMY |
Provider Taxonomy |
30 |
TYPE_CLM_CD |
Type of claim |
31 |
ADJUST_CD |
Adjustment code |
32 |
PHP_TYPE |
Managed care type of plan code |
33 |
PHP_ID |
Managed care plan identification code |
34 |
MDCD_PYMT_AMT |
Medicaid payment amount |
35 |
TP_PYMT_AMT |
Third party payment amount |
36 |
PYMT_DT |
Payment/adjudication date |
37 |
CHRG_AMT |
Charge amount |
38 |
PHP_VAL |
Prepaid plan value |
39 |
MDCR_COINSUR_PYMT_AMT |
Medicare coinsurance payment amount |
40 |
MDCR_DED_PYMT_AMT |
Medicare deductible payment amount |
41 |
SRVC_BGN_DT |
Beginning date of service |
42 |
SRVC_END_DT |
Ending date of service |
43 |
PRCDR_CD_SYS |
Procedure (service) coding system |
44 |
PRCDR_CD |
Procedure (service) code |
45 |
PRCDR_SRVC_MDFR_CD |
Procedure (service) code modifier |
46 |
DIAG_CD_1 |
Principle Diagnosis code |
47 |
ICD_DGNS_VRSN_CD1 |
Claim Diagnosis Code 1 Diagnosis Version Code (ICD-9 or ICD-10) (Encounter) |
48 |
DIAG_CD_2 |
Diagnosis codes (2nd diagnosis) |
49 |
QTY_SRVC_UNITS |
Quantity of service |
50 |
SRVC_PRVDR_ID_NMBR |
Servicing provider identification number (MAX) |
51 |
SRVC_PRVDR_SPEC_CD |
Servicing provider specialty code (MAX) |
52 |
PLC_OF_SRVC_CD |
Place of service |
53 |
UB_92_REV_CD |
UB-92 revenue code |