Exhibit A-15 - Data Requirements.pdf
PDF 52 KB Posted
- Attached to
- Medical, Dental, Vision Insurance Services
- Solicitation number
- 2604-002
- Issued by
- Travis County, Austin City, Texas
About this file
Exhibit A-15 is a data requirements specification document that establishes standardized data field definitions and specifications for health insurance claims and eligibility data submission. The document outlines three distinct data categories: Medical/Dental claims data, Pharmacy claims data, and Eligibility data. The Medical/Dental section requires 63 fields encompassing policy information, patient demographics, provider details, claim specifics, diagnosis and procedure codes, and payment breakdowns. The Pharmacy section specifies 59 fields including prescription details, drug information, cost components, and pharmacy provider information. The Eligibility section contains 34 fields covering insured and member identification, enrollment status, coverage tiers, effective dates, and member contact information. These standardized fields enable consistent data collection and reporting across multiple claim types and insurance products.
The data requirements document serves as a technical specification for data submission processes, establishing the precise field names, field numbers, and descriptions necessary for organizations to submit claims and eligibility information in a standardized format. The specification includes identification codes, personal information fields, clinical and procedural codes (ICD-9/ICD-10 and CPT/HCPCS), provider network information, benefit calculations, and administrative status indicators. The three-part structure accommodates different data submission pathways while maintaining consistency in core identifier fields such as Policy ID, Member ID, and employee/patient demographic information. This standardized approach enables streamlined processing, data validation, and integration across multiple healthcare plan types and claim categories.
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Text version
Field Number Field Name Field Description
1 PolicyID Identification of Group (Policy Number)
2 GroupName GroupName (ABC Company, etc.)
3 PolicyPlanID Policy Plan Code (base, buy up, etc.)
4 PolicyDepCode Department Code (Sales, Finance, etc.)
5 PolicyLocCode Location Code (Austin, Dallas, Site1, Site2, etc.)
6 PolicyGroupID Group Code (Division 1, Division2, etc.)
7 InsSSN Social Security Number of Insured
8 EEFirst Employee First Name
9 EELast Employee Last Name
10 EEStatus Employee Status (Active/Retiree, etc.)
11 MedicarePrimInd Medicare primary indicator (Y/N)
12 MemberID Unique Identification Number for each Claimant
13 PatientFirst Patient First Name
14 PatientLast Patient Last Name
15 Relationship Patient Relationship to Insured
16 MemberCode Member/Person Number
17 Sex Patient Gender
18 DOB Patient Date of Birth
19 ClaimID Claim Number
20 EOB EOB Entry Number / Claim Line Number
21 POS CMS Place of Service (11 = Office, etc.)
22 TOS Type of Service (facility, chiro, etc.)
23 ICD9_1 or ICD10_1 Primary ICD Diagnosis Code
24 ICD9_2 or ICD10_2 Secondary ICD Diagnosis Code
25 ICD9_3 or ICD10_3 Tertiary ICD Diagnosis Code
26 ICD9_4 or ICD10_4 Fourth ICD Diagnosis Code
27 ICD9_5 or ICD10_5 Fifth ICD Diagnosis Code
28 ICD Indicator ICD9 or ICD10 indicator
29 ProcCode Procedure Code (CPT, HCPCS, etc.)
30 ProcMod Procedure Code Modifier
31 RevCode Hospital/Facility Revenue Code
32 Units Number of Units
33 CalcCode Carrier or TPA Benefit/Service Code
34 ProviderNPI Provider NPI
35 ProvTIN Provider Identification Number (federal tax ID if available)
36 ProvName Provider Name
37 ProvStreet Provider Street Address
38 ProvCity Provider City
39 ProvState Provider State
40 ProvZip Provider Zip
41 ProvType Provider Type (Facility, Physician, Skilled Nursing, etc.)
42 ProvSplty Provider Specialty (Family Practice, Cardiology, etc.)
43 NetInd Network Indicator (Par/Non-Par)
44 NetCode Network Code (PHCS, Beech Street, etc.)
45 BegDOS Incurred Service Date Start
46 EndDOS Incurred Service Date End
47 PaidDate Paid Date (or date processed)
48 Billed Total Charged Amount
49 Ineligible Amount Ineligible
50 InelCode Ineligible Code (duplicate, not covered, etc.)
51 Discount Discounted Amount
52 Allowed Amount Allowed
53 Copay Copay Amount paid by Member
54 CopayCode Copay Code (if applicable)
55 Deduct Deductible paid by Member
56 Coins Coinsurance paid by Member
57 PlanPaid Total Plan Paid Amount
58 HRAPaid HRA Paid Amount
59 COBAmt COB Amount Paid by Other Insurer
60 COBCode COB Code (Other Insurer ID)
61 SubrogAmt Amount Subrogated
62 AdmitDays Total Hospital Admission Days
63 CheckNum Check or Draft Number to Provider iCAF Data Requirements - Medical / Dental
1 PolicyID Identification of Group (Policy Number)
2 GroupName GroupName (ABC Company, etc.)
3 PolicyPlanID Policy Plan Code (base, buy up, etc.)
4 PolicyDepCode Department Code (Sales, Finance, etc.)
5 PolicyLocCode Location Code (Austin, Dallas, Site1, Site2, etc.)
6 PolicyGroupID Group Code (Division 1, Division2, etc.)
7 InsSSN Social Security Number of Insured
8 EEFirst Employee First Name
9 EELast Employee Last Name
10 EEStatus Employee Status (Active/Retiree, etc.)
11 MedicarePrimInd Medicare primary indicator (Y/N)
12 MemberID Unique Identification Number for each Claimant
13 PatientSSN Patient Social Security Number
14 PatientFirst Patient First Name
15 PatientLast Patient Last Name
16 Relationship Patient Relationship to Insured
17 MemberCode Member/Person Number
18 Sex Patient Gender
19 DOB Patient Date of Birth
20 RxNum Prescription Number
21 NewRefillCode New/Refill Indicator
22 DateWritten Date Prescription was Written
23 FilledDate Date Prescription was Filled
24 PaidDate Date Prescription was Paid
25 NDC National Drug Code Number
26 DrugName Dispensed Drug Label Name
27 DAWCode Dispense as written code
28 CompoundCode Compounding Code
29 FormularyInd Formulary Indicator
30 Quantity Metric Quantity Dispensed
31 GenericCode Drug Type (Single Source Brand, Multi Source Brand, Generic)
32 DaysSupply Days Supply Dispensed
33 GNCCode Generic Classification Number
34 GNCDesc Generic Classification Description
35 AHFSCode AHFS Code
36 AHFSDesc AHFS Description
37 MailInd Mail/Retail Indicator
38 MaintenanceInd Maintenance Drug Flag
39 GPICode GPI Code
40 AWPAmt Total Average Wholesale Price
41 MemCoshare Total Member Cost
42 Copay Total Copayment
43 Deduct Total Deductible
44 DispFee Total Dispensing Fee
45 DrugCost Total Drug Cost
46 ExceedBenefit Total Exceeding Benefit
47 IngrCost Total Ingredient Cost
48 PlanPaid Total Plan Cost
49 HRAPaid HRA Paid Cost
50 SalesTax Total Sales Tax
51 UC Total U&C
52 PharmacyID Pharmacy Code
53 PharmacyName Pharmacy Name
54 PharmacyCity Pharmacy City
55 PharmacyState Pharmacy State
56 PharmacyZip Pharmacy Zip Code
57 PrescriberID Prescriber Code (Tax ID Number)
58 PrescriberName Prescriber Name
59 PrescriberNPI Prescribing Provider NPI iCAF Data Requirements - Pharmacy
1 InsSSN Social Security Number of Insured
2 InsID Unique Identification Number for each Insured
3 EEFirst Employee First Name
4 EELast Employee Last Name
5 MemberSSN Member SSN
6 MemberID Unique Identification Number for each Claimant
7 MemberFirst Member First Name
8 MemberLast Member Last Name
9 MemberMid Member Middle Initial
10 Relationship Patient Relationship to Insured
11 MemberCode Member/Person Number
12 Sex Patient Gender
13 DOB Member Date of Birth
14 CoverageTier Enrolled Coverage Tier (EO, ES, EC, EF)
15 PolicyID Identification of Group (Policy Number)
16 GroupName GroupName (ABC Company, etc.)
17 PolicyPlanID Policy Plan Code (base, buy up, etc.)
18 PolicyDepCode Department Code (Sales, Finance, etc.)
19 PolicyLocCode Location Code (Austin, Dallas, Site1, Site2, etc.)
20 PolicyGroupID Group Code (Division 1, Division2, etc.)
21 EffectiveDate Effective Date for Coverage
22 TermDate Termination Date for Coverage
23 OrigHireDate Original Date Hired
24 ReHireDate Rehire Start Date
25 Status Member Status (Active, COBRA, etc.)
26 MemAdd Member Street Address
27 MemAdd2 Member Street Address 2
28 MemCity Member City
29 MemState Member State
30 MemZip Member Zip
31 MemEmail Member Email
32 MemPhone Member Phone Number
33 AltID Alternate ID Number
34 InsCardID Insurance Card ID Number iCAF Data Requirements - Eligibility
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