Quality Strategy for Heritage Health: The Medicaid Managed ...



22701254083050Prepared by:00Prepared by:16573502594610Heritage Health: Data Dictionary00Heritage Health: Data Dictionary4921250912446Medicaid & Long-Term CareData & Analytics301 Centennial Mall S.Lincoln NE 68509020000Medicaid & Long-Term CareData & Analytics301 Centennial Mall S.Lincoln NE 68509144780023685500321818066122Medicaid & Long Term Care - Data and Analytics00Medicaid & Long Term Care - Data and AnalyticsJuly 15, 2019DateDescription of changeInitials08/02/2016Initial VersionAJL10/28/2016Fields added to Grievance System Log table and desc. fields changed to Long TextAJL02/03/2017Fields added to Grievance System Log table to address pharmacy and complaint date issues. Random cleaning of table restrictions and minor fixesAJL01/01/2018Template revisions and dictionary clear upAJL11/02/2018Revised CAHPS reportsLAJ03/19/2019Split Grievance System Log into three reports, Appeals Log, Grievance Log and State Fair Hearings Log.BDP3/25/2019Grievance Log - Included description of Complaint Type: Administration and resulting values of provider identifiersLAJ7/15/19Grievance Log – For the field Complaint Response Date, added the Field Requirement that 1/1/3999 should be used as the Response Date if the Grievance is Unresolved at the end of the reporting period.BDPContents TOC \o "1-3" \h \z \u Prologue PAGEREF _Toc3279724 \h 430 Day BH ER Visits PAGEREF _Toc3279725 \h 530 Day Inpatient Re-Admit PAGEREF _Toc3279726 \h 6Admit and Re-Admit to Psych Inpatient PAGEREF _Toc3279727 \h 7Appeals Log PAGEREF _Toc3279728 \h 9CAHPS - Adult PAGEREF _Toc3279729 \h 13CAHPS - Child/CHIP with CCC PAGEREF _Toc3279730 \h 26Care Management Log PAGEREF _Toc3279731 \h 44Facility and Provider Survey PAGEREF _Toc3279732 \h 47Grievance Log PAGEREF _Toc3279733 \h 48Out-of-Network Referrals PAGEREF _Toc3279734 \h 50State Fair Hearings Log PAGEREF _Toc3279735 \h 52Prologue This Data dictionary is designed to communicate the layout of the Access Templates required for Heritage Health reporting. Tables below each have 5 columns: Field Name, Field Description, Field Type, Required, and Field Requirements and Masks. Field Name - The given table’s column namesField Description - A short description as to what information should be placed in the column, including a definition. This field also contains any preselected values, identified by “CHOOSE FROM:” in the description, which are the only accepted inputs into the field. Required - Relays whether or not the field is a required field, regardless of how the table is filled in. Note that fields which have a Yes/No field type are defaulted to No. Field Type – Indicated the fields defined type, be it short/long text, Number, Date, Yes/No, or Calculated. Calculated fields do not need to be filled in. Access stores Yes/No values as follows: No = 0, Yes = -1Field Requirements and Masks - Contain information needed when preparing to import/add data to the tables. Information such as which fields have masks, dictating what type of values can put input and how long they can be, any size limitations the fields may have, and how the field’s requirements vary depending upon the input of other fields. This is typically in a “Required If and Only If” rule implemented on the fields.30 Day BH ER VisitsER visits with a behavioral health diagnosis that occur within 30 days of an inpatient behavioral health discharge. Include only BH ER visits that occur within the reporting period, regardless of whether the BH discharge date is in the current or previous reporting period. Providers in the template should be facilities and not attendees.FIELD NAMEFIELD DESCRIPTIONFIELD TYPEREQUIREDFIELD REQUIREMENTS AND MASKSMember IDMember Medicaid ID numberShort TextYesN/AClaim IDClaim ID for inpatient stay Short TextYesN/AAdmission DateDate of admission to inpatient facilityDateYesN/ADischarge DateDate of initial dischargeDateYesN/ADischarge AgeAge of the member upon being dischargedNumberYesN/APOS CodePlace of Service code for inpatient stayShort TextYes N/AProvider NE Medicaid IDProvider’s NE Medicaid ID (facility)Short TextYesN/AProvider NPIProvider’s NPI (facility)Short TextYesN/AProvider NameName of the provider (facility)Short TextYesN/APrimary DiagnosisICD 10 code for the primary diagnosis on the claimShort TextYesMASKED: Allows 7 digits, first 3 required, 1st is alpha, 2nd is numeric, the rest are alphanumericSecondary DiagnosisICD 10 code for a secondary diagnosis; if no secondary diagnosis for the readmission, record “A1aaaaa”Short TextYesMASKED: Allows 7 digits, first 3 required, 1st is alpha, 2nd is numeric, the rest are alphanumericER DateDate of follow-upDateYesN/AER Claim IDClaim number for ER presentationShort TextYesN/AER IntervalNumber of days between discharge and presenting to ER. CalculatedCalculatedYesN/AER Provider NE Medicaid IDNE Medicaid ID of the ER provider (facility)Short TextYesN/AER Provider NPINPI of the ER provider (facility)Short TextYesN/AER Provider NameName of the ER provider (facility)Short TextYesN/AER POS CodePlace of service codeShort TextYesN/AER Primary DiagnosisICD 10 code for the follow-up primary diagnosis on the claimShort TextYesMASKED: Allows 7 digits, first 3 required, 1st is alpha, 2nd is numeric, the rest are alphanumericER Secondary DiagnosisICD 10 code for the follow-up secondary diagnosis on the claim; if no secondary diagnosis for the readmission, record “A1aaaaa”Short TextYesMASKED: Allows 7 digits, first 3 required, 1st is alpha, 2nd is numeric, the rest are alphanumeric30 Day Inpatient Re-AdmitUnplanned inpatient readmissions to any acute care or critical access hospital that occur within 30 days of an inpatient discharge, where neither inpatient stay is due to behavioral health. Include only re-admissions that occur within the reporting period, regardless of whether the initial inpatient discharge date is in the current or previous reporting period. Providers in the template should be facilities and not attendees.FIELD NAMEFIELD DESCRIPTIONFIELD TYPEREQUIREDFIELD REQUIREMENTS AND MASKSMember IDMember Medicaid ID numberShort TextYesN/AClaim IDMedicaid claim ID numberShort TextYesN/AAdmission DateDate of admission for the initial inpatient stayDateYesN/ADischarge DateDate of Discharge for the initial inpatient stayDateYesN/ADischarge AgeAge of the member upon dischargeNumberYesN/ALength of StayNumber of days the member was in the facilityCalculatedYesN/APOS CodePlace of service code for the initial inpatient stayShort TextYes N/APrimary DiagnosisICD 10 codes for the primary diagnosisShort TextYesMASKED: Allows 7 digits, first 3 required, 1st is alpha, 2nd is numeric, the rest are alphanumericSecondary DiagnosisICD 10 codes for a secondary diagnosis; if no secondary diagnosis for the readmission, record “A1aaaaa”Short TextNoMASKED: Allows 7 digits, first 3 required, 1st is alpha, 2nd is numeric, the rest are alphanumericProvider NPINPI of the provider (facility)Short TextYesN/AProvider NE Medicaid IDNE Medicaid ID of the provider (facility)Short TextYesN/AProvider NameName of the provider (facility)Short TextYesN/AReadmission DateDate of readmissionDateYesN/AReadmission Claim IDMedicaid claim ID for remittance Short TextYesN/AReadmission IntervalNumber of days between discharge and remittanceCalculatedYesN/AReadmission POS CodePlace of service code for the readmissionShort TextYesN/AReadmission Provider NPINPI of the readmission provider (facility)Short TextYesN/AReadmission Provider NE Medicaid IDNE Medicaid ID of the readmission provider (facility)Short TextYesN/AReadmission Provider NameName of the readmission provider (facility)Short TextYesN/AReadmission Principle DiagnosisICD 10 codes for the readmission primary diagnosisShort TextYesMASKED : Allows 7 digits, first 3 required, 1st is alpha, 2nd is numeric, the rest are alphanumericReadmission Secondary DiagnosisICD 10 codes for a readmission secondary diagnosis; if no secondary diagnosis for the readmission, record “A1aaaaa”Short TextNoMASKED : Allows 7 digits, first 3 required, 1st is alpha, 2nd is numeric, the rest are alphanumericAdmit and Re-Admit to Psych InpatientBH inpatient and/or residential readmissions that occur within 30 days of an inpatient and/or residential behavioral health discharge. Include only BH inpatient and/or residential readmissions that occur within the reporting period, regardless of whether the initial BH inpatient discharge date is in the current or previous reporting period. Providers in the template should be facilities and not attendees FIELD NAMEFIELD DESCRIPTIONFIELD TYPEREQUIREDFIELD REQUIREMENTS AND MASKSMember IDMember Medicaid ID numberShort TextYesN/AClaim IDMedicaid Claim numberShort TextYesN/AAdmission DateAdmission date of the initial inpatient/residential BH stayDateYesN/ADischarge DateDate of discharge of the initial inpatient/residential BH stayDateYesN/ADischarge AgeAge of the member upon being dischargedNumberYesN/APOS CodePlace of service code for the BH inpatient/residential BH stayShort TextYesN/AProvider NPIMembers Providers NPI number (facility)Short TextYesN/AProvider Medicaid IDMembers Providers Medicaid ID number (facility)Short TextYesN/AProvider NameProviders name (facility)Short TextYesN/APrimary DiagnosisICD 10 code of Primary DxShort TextYesMASKED: Allows 7 digits, first 3 required, 1st is alpha, 2nd is numeric, the rest are alphanumericSecondary DiagnosisICD 10 code of Secondary Dx; if no secondary diagnosis for the readmission, record “A1aaaaa”Short TextYesMASKED: Allows 7 digits, first 3 required, 1st is alpha, 2nd is numeric, the rest are alphanumericReadmission Claim IDMedicaid Claim number for readmissionShort TextYesN/AReadmission DateDate of inpatient/residential BH readmissionDateYesN/AReadmission IntervalNumber of date between discharge from initial inpatient/residential BH stay and inpatient/residential BH readmissionCalculatedYesN/AReadmission POS CodePlace of service code for inpatient/residential BH readmissionShort TextYesN/AReadmission Provider NPIProvider's NPI (facility upon readmission)Short TextYesN/AReadmission Provider NE Medicaid IDProvider's Medicaid ID number (facility upon readmission)Short TextYesN/AReadmission Provider NameProviders name (facility upon readmission)Short TextYesN/AReadmission Primary DiagnosisICD 10 code of readmission's primary dxShort TextYesMASKED: Allows 7 digits, first 3 required, 1st is alpha, 2nd is numeric, the rest are alphanumericReadmission Secondary DiagnosisICD 10 code of readmission's secondary dx; if no secondary diagnosis for the readmission, record “A1aaaaa”Short TextYesMASKED: Allows 7 digits, first 3 required, 1st is alpha, 2nd is numeric, the rest are alphanumericMember Care Management StatusIs the member receiving Care Management as of the date of readmission?Yes/NoDefault: NoN/AAppeals LogReport all appeals received from both members and providers during the time period specified for the report. Additionally, report all appeals closed during the time period that were received during a previous time period and reported as unresolved in a previous report.FIELD NAMEFIELD DESCRIPTIONFIELD TYPEREQUIREDFIELD REQUIREMENTS AND MASKSCase IDCase ID or file number used by the MCE to track the status of the appealShort TextYesN/AMember IDMember Medicaid ID numberShort TextYesN/AType of IssueCHOOSE: -Appeal-Expedited AppealShort TextYesN/AProvider/ClientCHOOSE: -Provider-Client-On Behalf of ClientShort TextYesN/AClient Relationship DescShort description of the relationship the person filing has with the ClientShort TextNoREQUIRED IF AND ONLY IF: “Provider/Client” is "On Behalf of Client." Leave this field blank if “Provider/Client” is “Provider” or “Client.”Appeal TypeCHOOSE: -Denial or Limited Authorization of Requested Service-Denial or Limited Authorization of Requested Medication-Denial, in Whole or in Part, of Payment for Service-Failure to Provide Services in a Timely Manner as Defined by the State-Failure of MCO to Act within Timeframes Regarding Standard Resolution of Grievances and Appeals-Reduction, Suspension or Termination of a Previously Authorized Service-Denial of Request to Dispute a Financial Liability-OtherShort TextYesN/AOther Appeal DescriptionShort description of the appealLong TextNoREQUIRED IF AND ONLY IF: “Appeal Type” is “Other.” Leave blank if “Appeal Type” is not “Other.”Claim IDMedicaid member Claim ID numberNOTE: If an Appeal or Expedited Appeal has an associated Claim ID, it should be populated here. This will not be expected for Appeal/Expedited Appeal which are for pre-authorizations or similar circumstances which would not have a Claim IDShort TextNoLeave this field blank if the Appeal or Expedited Appeal is for a pre-authorization or similar circumstances which would not have a Claim ID.Date of ServiceDate the service was performedDate/TimeNoN/AService TypeCHOOSE: -Durable Medical Equipment-Therapy Services-Procedure in Physician Office-Outpatient Procedures-Inpatient Procedures-Home Health Services-Radiology-Pharmacy-Vision Benefits-OtherShort TextYesN/AOther Service Type DescriptionShort description of the type of “Other” denialShort TextNoREQUIRED IF AND ONLY IF: “Service Type” is "Other" ServiceEquipmentAuthDeniedShort description of the DME equipment which is the cause of appeal/expedited appealShort TextNoREQUIRED IF AND ONLY IF: "Service Type" is "Durable Medical Equipment." Date of AppealDate the Appeal/Expedited Appeal was received by the MCODate/TimeYesN/AExtension TypeCHOOSE:-Appellant Driven (choose this when the appellant asks for an extension of the due date of the appeal)-Plan Driven (choose this when the plan asks for an extension of the due date of the appeal)-None (choose this when there is no extension of the due date of the appeal)Short TextYesN/ADate of ExtensionDate the Appeal/Expedited Appeal received an extensionDate/TimeNoREQUIRED IF AND ONLY IF: “Extension Type” is “Appellant Driven” or “Plan Driven.”Extended Due DateDate the Appeal/Expedited Appeal is now due, post extensionDate/TimeNoREQUIRED IF AND ONLY IF: “Extension Type” is “Appellant Driven” or “Plan Driven.”Resolution DateDate the Appeal/Expedited Appeal was resolvedDate/TimeYesIf the issue is unresolved at the end of the reporting period, enter “1/1/3999” for the Resolution Date.Resolution OutcomeCHOOSE:-Upheld-Overturned-Partially Overturned-Withdrawn (the appellant has withdrawn their appeal request before the plan makes a decision to either uphold, overturn or partially overturn their original decision)-Unresolved (Use this when either of the following is true: 1) case is still being determined at the end of the reporting quarter, where Resolution Date will be entered as “1/1/3999,” or 2) the appellant does not provide all information needed to decide the outcome of the appeal – include an actual Resolution Date and an entry in the Reason Unresolved field.)Short TextYesN/ADenial ReasoningDescription of the rationale given for upholding denialLong TextNoREQUIRED IF AND ONLY IF: “Resolution Outcome” is “Upheld” or “Partially Overturned.”Reason UnresolvedShort description of the reason the appeal/expedited appeal is unresolvedShort TextNoREQUIRED IF AND ONLY IF: “Resolution Outcome” is "Unresolved." Provider NameName of the provider on the appealShort TextYesN/AProvider NE Medicaid IDProvider’s NE Medicaid ID numberShort TextYesN/AProvider NPIProvider’s NPI numberShort TextYesN/AProcedure CodeIf a procedure is a part of the appeal, list the code of the procedureShort TextNoN/ANDCThe NDC code of the medication associated with the Appeal/Expedited Appeal.Short TextNoSIZE: 11 CharactersREQUIRED IF AND ONLY IF: “Appeal Type” is “Denial or Limited Authorization of Requested Medication”Rx DescriptionShort description of the Prescription as identified by the NDC, including drug names, strength, and quantity.Long TextNoREQUIRED IF AND ONLY IF: “Appeal Type” is “Denial or Limited Authorization of Requested Medication”CAHPS - AdultFIELD NAMEFIELD DESCRIPTIONFIELD TYPEREQUIREDFIELD REQUIREMENTS AND MASKSIDUnique record ID for everyone receiving a CAHPS survey request, regardless of whether or not survey was returned/completed. Should be a positive integer.NumberYesN/ADisposition0 = Complete and Eligible1 = Does not meet Eligible Population criteria2 = Incomplete (but Eligible)3 = Language Barrier4 = Mentally or Physically Incapacitated5 = Deceased6 = Refusal7 = Non-response after maximum attempts8 = Added to Do Not Call (DNC) listNumberYesN/AMode0 = Incomplete/Ineligible1 = Mail2 = Telephone3 = InternetNumberYesN/ARound0 = Incomplete/Ineligible1 = First attempt2 = Second attempt3 = Third attempt4 = Fourth attempt5 = Fifth attempt6 = Sixth attemptYesN/ALanguage0 = Incomplete/Ineligible1 = English2 = SpanishNumberYesN/AAddress Viable1 = Valid2 = Not ValidNumberYesN/ATelephone Viable0 = Survey protocol did not require telephone number1 = Valid2 = Not ValidNumberYesN/AEmail Viable0 = Survey protocol did not require email address1 = Valid2 = Not ValidNumberYesN/ASex1 = Male2 = Female9 = MissingNumberYesN/AFlu VaccinationsEligibility for FVU Measure - Ages 18-64 0 = Member is in a product tor product line for which the FVA measure is not being reported1 = Eligible2 = IneligibleNumberYesN/AQ1Our records show that you are now in {insert health plan name/state Medicaid program name}. Is that right? 1 = Yes2 = No9 = MissingNumberYesN/AQ2Open response/possibly no response depending on answer 1Short TextYesN/AQ3In the last 6 months, did you have an illness, injury, or condition that needed care right away in a clinic, emergency room, or doctor's office? 1 = Yes2 = No9 = MissingNumberYesN/AQ4In the last 6 months, when you needed care right away, how often did you get care as soon as you needed? 1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ5In the last 6 months, did you make any appointments for a check-up or routine care at a doctor's office or clinic? 1 = Yes2 = No9 = MissingNumberYesN/AQ6In the last 6 months, how often did you get an appointment for a check-up or routine care at a doctor's office or clinic as soon as you needed? 1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ7In the last 6 months, NOT counting the times you went to an emergency room, how many times did you go to a doctor's office or clinic to get healthcare for yourself?0 = None1 = 1 time2 = 23 = 34 = 45 = 5 to 96 = 10 or more times9 = MissingNumberYesN/AQ8In the last 6 months, did you and a doctor or other health provider talk about specific things you could do to prevent illness?1 = Yes2 = No9 = MissingNumberYesN/AQ9In the last 6 months, did you and a doctor or other health provider talk about starting or stopping a prescription medicine?1 = Yes2 = No9 = MissingNumberYesN/AQ10Did you and a doctor or other health provider talk about the reasons you might want to take a medicine?1 = Yes2 = No9 = MissingNumberYesN/AQ11Did you and a doctor or other health provider talk about the reasons you might NOT want to take a medicine?1 = Yes2 = No9 = MissingNumberYesN/AQ12When talked about starting or stopping a prescription medicine, did a doctor or other health provider ask you what you thought was best for you?1 = Yes2 = No9 = MissingNumberYesN/AQ13Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate your healthcare in the last 6 months? 00 = 0 Worst health care possible01 = 102 = 203 = 304 = 405 = 506 = 607 = 708 = 809 = 910 = 10 Best health care possible99 = MissingNumberYesN/AQ14In the last 6 months, how often was it easy to get the care, tests, or treatment you needed? 1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ15A personal doctor is one you would see if you need a check-up, want advice about a health problem, or get sick or hurt. Do you have a personal doctor?1 = Yes2 = No9 = MissingNumberYesN/AQ16In the last 6 months, how many times did you visit your personal doctor to get care for yourself?0 = None1 = 1 time2 = 23 = 34 = 45 = 5 to 96 = 10 or more times9 = MissingNumberYesN/AQ17In the last 6 months, how often did your personal doctor explain things in a way that was easy to understand?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ18In the last 6 months, how often did your personal doctor listen carefully to you?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ19In the last 6 months, how often did your personal doctor show respect for what you had to say?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ20In the last 6 months, how often did your personal doctor spend enough time with you?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ21In the last 6 months, did you get care from a doctor or other health provider besides your personal doctor?1 = Yes2 = No9 = MissingNumberYesN/AQ22In the last 6 months, how often did your personal doctor seem informed and up-to-date about the care you got from these doctors or other health providers?1=Never2=Sometimes3=Usually4=Always9=MissingNumberYesN/AQ23Using any number from 0 to 10, where 0 is the worst personal doctor possible and 10 is the best personal doctor possible, what number would you use to rate your personal doctor?00 = 0 Worst personal doctor possible01 = 102 = 203 = 304 = 405 = 506 = 607 = 708 = 809 = 910 = 10 Best personal doctor possible99 = MissingNumberYesN/AQ24Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care. In the last 6 months did you make any appointments to see a specialist?1 = Yes2 = No9 = MissingNumberYesN/AQ25In the last 6 months, how often did you get an appointment to see a specialist as soon as you needed?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ26How many specialists have you seen in the last 6 months?0 = None1 = 1 specialist2 = 23 = 34 = 45 = 5 or more specialists9 = MissingNumberYesN/AQ27We want to know your rating of the specialist you saw most often in the last 6 months. Using any number from 0 to 10, what number would you use to rate that specialist00 = 0 Worst specialist possible01 = 102 = 203 = 304 = 405 = 506 = 607 = 708 = 809 = 910 = 10 Best specialist possible99=MissingNumberYesN/AQ28In the last 6 months, did you look for any information in written materials or on the internet about how your health plan works?1 = Yes2 = No9 = MissingNumberYesN/AQ29In the last 6 months, how often did the written materials or internet provide the information you needed about how your health plan works?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ30In the last 6 months, did you get information or help from your health plan's customer service?1 = Yes2 = No9 = MissingNumberYesN/AQ31In the last 6 months, how often did your health plan's customer service give you the information or help you needed?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ32In the last 6 months, how often did your health plan's customer service staff treat you with courtesy and respect?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ33In the last 6 months, did your health plan give you any forms to fill out?1 = Yes2 = No9 = MissingNumberYesN/AQ34In the last 6 months, how often were the forms from your health plan easy to fill out?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ35Using any number from 0 to 10, here 0 is the worst health plan possible and 10 is the best health plan possible, what number would you use to rate your health plan? 00 = 0 Worst health plan possible01 = 102 = 203 = 304 = 405 = 506 = 607 = 708 = 809 = 910 = 10 Best health plan possible99 = MissingNumberYesN/AQ36In general, how would you rate your overall health?1 = excellent2 = very good3 = good4 = fair5 = poor9 = MissingNumberYesN/AQ37In general, how would you rate your overall mental or emotional health?1 = excellent2 = very good3 = good4 = fair5 = poor9 = MissingNumberYesN/AQ38Have you had either a flu shot or flu spray in the nose since July 1, 2017?1 = Yes2 = No3 = Don't know9 = MissingNumberYesN/AQ39Do you now smoke cigarettes or use tobacco every day, some days, or not at all?1 = Every day2 = Some days3 = Not at all4 = Don't know9 = MissingNumberYesN/AQ40In the last 6 months, how often were you advised to quit smoking or using tobacco by a doctor or other health provider in your plan?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ41In the last 6 months, how often was medication recommended or discussed by a doctor or health provider to assist you with quitting smoking or using tobacco? Examples of medication are: nicotine gum, patch, nasal spray, inhaler, or prescription medication.1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ42In the last 6 months, how often did your doctor or health provider discuss or provide methods and strategies other than medication to assist you with quitting smoking or using tobacco? Examples of methods and strategies are: telephone helpline, individual or group counseling, or cessation program.1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ43In the last 6 months, did you get health care 3 or more times for the same condition or problem? 1 = Yes2 = No9 = MissingNumberYesN/AQ44Is this a condition or problem that has lasted for at least 3 months? Do not include pregnancy or menopause.1 = Yes2 = No9 = MissingNumberYesN/AQ45Do you now need or take medicine prescribed by a doctor? Do not include birth control.1 = Yes2 = No9 = MissingNumberYesN/AQ46Is this medicine to treat a condition that has lasted for at least 3 months? Do not include pregnancy or menopause. 1 = Yes2 = No9 = MissingNumberYesN/AQ47What is your age?1 = 18 to 242 = 25 to 343 = 35 to 444 = 45 to 545 = 55 to 646 = 65 to 747 = 75 or older9 = MissingNumberYesN/AQ48Are you male or female?1 = Male2 = Female9 = MissingNumberYesN/AQ49What is the highest grade or level of school that you have completed?1 = 8th grade or less2 = Some high school but did not graduate3 = High school graduate or GED4 = Some college or 2-year degree5 = 4-year college graduate6 = More than 4-year college degree9 = MissingNumberYesN/AQ50Are you of Hispanic or Latino origin or descent?1 = Yes2 = No9 = MissingNumberYesN/AQ51aWhat is your race? Mark one or more.1 = Respondent checked "White"9 = MissingNumberYesN/AQ51bWhat is your race? Mark one or more.1 = Respondent checked "Black or African American"9 = MissingNumberYesN/AQ51cWhat is your race? Mark one or more.1 = Respondent checked "Asian"9 = MissingNumberYesN/AQ51dWhat is your race? Mark one or more.1 = Respondent checked "Native Hawaiian or other Pacific Islander"9 = MissingNumberYesN/AQ51eWhat is your race? Mark one or more.1 = Respondent checked "American Indian or Alaska Native"9 = MissingNumberYesN/AQ51fWhat is your race? Mark one or more. 1 = Respondent checked "Other"9 = MissingNumberYesN/AQ52Did someone help you complete this survey?1 = Yes2 = No9 = MissingNumberYesN/AQ53aHow did that person help you? 1 = Respondent checked “Read the questions to me” 9 = MissingNumberYesN/AQ53bHow did that person help you?1 = Respondent checked “Wrote down the answers I gave”9 = MissingNumberYesN/AQ53cHow did that person help you?1 = Respondent checked “Answered the questions for me”9 = MissingNumberYesN/AQ53dHow did that person help you?1 = Respondent checked “Translated the questions into my language”9 = MissingNumberYesN/AQ53eHow did that person help you?1 = Respondent checked “Helped in some other way”9 = MissingNumberYesN/ACAHPS - Child/CHIP with CCCFIELD NAMEFIELD DESCRIPTIONFIELD TYPEREQUIREDFIELD REQUIREMENTS AND MASKSIDAssign unique ID to everyone receiving a CAHPS survey, regardless of whether or not survey was returnedNumberYesN/ADisposition0 = Complete and Eligible1 = Does not meet Eligible Population criteria2 = Incomplete (but Eligible)3 = Language Barrier4 = Mentally or Physically Incapacitated5 = Deceased6 = Refusal7 = Non-response after maximum attempts8 = Added to Do Not Call (DNC) listNumberYesN/AMode0 = Incomplete/Ineligible1 = Mail2 = Telephone3 = InternetNumberYesN/ARound0 = Incomplete/Ineligible1 = First attempt2 = Second attempt3 = Third attempt4 = Fourth attempt5 = Fifth attempt6 = Sixth attemptYesN/ALanguage0 = Incomplete/Ineligible1 = English2 = SpanishNumberYesN/AAddress Viable1 = Valid2 = Not ValidNumberYesN/ATelephone Viable0 = Survey protocol did not require telephone number1 = Valid2 = Not ValidNumberYesN/AEmail Viable0 = Survey protocol did not require email address1 = Valid2 = Not ValidNumberYesN/ASex1 = Male2 = Female9 = MissingNumberYesN/APrescreen CCC1 = No claims or encounters that meet CCC criteria2 = Claims or encounters that meet CCC criteriaNumberYesN/ASample Code1 = CAHPS 5.0H Child Survey Sample2 = CAHPS 5.0H Child with CCC Survey SampleNumberYesN/AChild Population1 = Medicaid (General)2 = CHIPNumberYesN/AQ1Our records indicate that your child is now in {insert state Medicaid program name}. Is that right?1 = Yes2 = No9 = MissingNumberYesN/AQ2Open response/possibly No response depending on answer 1Short TextYesN/AQ3In the last 6 months, did your child have an illness, injury, or condition that needed care right away in a clinic, emergency room, or doctor's office?1 = Yes2 = No9 = MissingNumberYesN/AQ4In the last 6 months, when your child needed care right away, how often did your child get care as soon as you needed?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ5In the last 6 months, did you make any appointments for your child for a check-up or routine care at a doctor's office or clinic?1 = Yes2 = No9 = MissingNumberYesN/AQ6In the last 6 months, when you made an appointment for a check-up or routine care for your child at a doctor’s office or clinic, how often did your child get an appointment for a check-up or routine care at a doctor's office or clinic as soon as you needed?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ7In the last 6 months, NOT counting the times your child went to an emergency room, how many times did your child go to a doctor's office or clinic to get healthcare?0 = None1 = 1 time2 = 23 = 34 = 45 = 5 to 96 = 10 or more times9 = MissingNumberYesN/AQ8In the last 6 months, did you and your child’s doctor or other health provider talk about specific things your child could do to prevent illness in your child?1 = Yes2 = No9 = MissingNumberYesN/AQ9In the last 6 months, how often did you have your questions answered by your child's doctors or other health providers?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ10In the last 6 months, did you and your child's doctor or other health provider talk about starting or stopping a prescription medicine for your child?1 = Yes2 = No9 = MissingNumberYesN/AQ11Did you and a doctor or other health provider talk about the reasons you might want your child to take a medicine?1 = Yes2 = No9 = MissingNumberYesN/AQ12Did you and a doctor or other health provider talk about the reasons you might NOT want your child to take a medicine?1 = Yes2 = No9 = MissingNumberYesN/AQ13When you talked about your child starting or stopping a prescription medicine, did a doctor or other health provider ask you what you thought was best for your child?1 = Yes2 = No9 = MissingNumberYesN/AQ14Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate your child's healthcare in the last 6 months?00 = 0 Worst health care possible01 = 102 = 203 = 304 = 405 = 506 = 607 = 708 = 809 = 910 = 10 Best health care possible99 = MissingNumberYesN/AQ15In the last 6 months, how often was it easy to get the care, tests, or treatment your child needed?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ16Is your child now enrolled in any kind of school or daycare?1 = Yes2 = No9 = MissingNumberYesN/AQ17In the last 6 months, did you need your child's doctors or other health providers to contact a school or daycare center about your child's health or healthcare?1 = Yes2 = No9 = MissingNumberYesN/AQ18In the last 6 months, did you get the help you needed from your child's doctors or other health providers in contacting your child's school or daycare?1 = Yes2 = No9 = MissingNumberYesN/AQ19Special medical equipment or devices include a walker, wheelchair, nebulizer, feeding tubes, or oxygen equipment. In the last 6 months, did you get or try to get any special medical equipment or devices for your child? 1 = Yes2 = No9 = MissingNumberYesN/AQ20In the last 6 months, how often was it easy to get special medical equipment or devices for your child?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ21Did anyone from your child's health plan, doctor's office, or clinic help you get special medical equipment or devices for your child?1 = Yes2 = No9 = MissingNumberYesN/AQ22In the last 6 months, did you get or try to get special therapy such as physical, occupational, or speech therapy for your child?1 = Yes2 = No9 = MissingNumberYesN/AQ23In the last 6 months, how often was it easy to get this therapy for your child?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ24Did anyone from your child's health plan, doctor's office, or clinic help you get this therapy for your child? 1 = Yes2 = No9 = MissingNumberYesN/AQ25In the last 6 months, did you get or try to get treatment or counseling for your child for an emotional, developmental, or behavioral problem?1 = Yes2 = No9 = MissingNumberYesN/AQ26In the last 6 months, how often was it easy to get this treatment or counseling for your child?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ27Did anyone from your child's health plan, doctor's office, or clinic help you get this treatment or counseling for your child?1 = Yes2 = No9 = MissingNumberYesN/AQ28In the last 6 months, did your child get care from more than one kind of healthcare provider or use more than one kind of healthcare service?1 = Yes2 = No9 = MissingNumberYesN/AQ29In the last 6 months, did anyone from your child's health plan, doctor's office, or clinic help coordinate your child's care among these different providers or services? 1 = Yes2 = No9 = MissingNumberYesN/AQ30A personal doctor is one your child would see if he or she needs a check-up, has a health problem, or gets sick or hurt. Does your child have a personal doctor?1 = Yes2 = No9 = MissingNumberYesN/AQ31In the last 6 months, how many times did your child visit his/her personal doctor to get care?0 = None1 = 1 time2 = 23 = 34 = 45 = 5 to 96 = 10 or more times9 = MissingNumberYesN/AQ32In the last 6 months, how often did your child’s personal doctor explain things about your child’s health in a way that was easy to understand? 1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ33In the last 6 months, how often did your child’s personal doctor listen carefully to you?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ34In the last 6 months, how often did your child’s personal doctor show respect for what you had to say?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ35Is your child able to talk with doctors about his or her health care?1 = Yes2 = No9 = MissingNumberYesN/AQ36In the last 6 months, how often did your child's personal doctor explain things in a way that was easy for your child to understand?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ37In the last 6 months, how often did your child’s personal doctor spend enough time with your child?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ38In the last 6 months, did your child's personal doctor talk with you about how your child is feeling, growing, or behaving?1 = Yes2 = No9 = MissingNumberYesN/AQ39In the last 6 months, did your child get care from a doctor or other health provider besides his or her personal doctor?1 = Yes2 = No9 = MissingNumberYesN/AQ40In the last 6 months, how often did your child's personal doctor seem informed and up-to-date about the care your child got from these doctors or other health providers? 1=Never2=Sometimes3=Usually4=Always9=MissingNumberYesN/AQ41Using any number from 0 to 10, here 0 is the worst personal doctor possible and 10 is the best personal doctor possible, what number would you use to rate your child's personal doctor?00 = 0 Worst personal doctor possible01 = 102 = 203 = 304 = 405 = 506 = 607 = 708 = 809 = 910 = 10 Best personal doctor possible99 = MissingNumberYesN/AQ42Does your child have any medical, behavioral, or other health conditions that have lasted for more than 3 months?1 = Yes2 = No9 = MissingNumberYesN/AQ43Does your child's personal doctor understand how these medical, behavioral, or other health conditions affect your child's day-to-day life?1 = Yes2 = No9 = MissingNumberYesN/AQ44Does your child's personal doctor understand how these medical, behavioral, or other health conditions affect your family's day-to-day life?1 = Yes2 = No9 = MissingNumberYesN/AQ45Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care. In the last 6 months, did you make any appointments for your child to see a specialist? 1 = Yes2 = No9 = MissingNumberYesN/AQ46In the last 6 months, how often did you get an appointment for your child to see a specialist as soon as needed?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ47How many specialists has your child seen in the last 6 months? 0 = None1 = 1 specialist2 = 23 = 34 = 45 = 5 or more specialists9 = MissingNumberYesN/AQ48We want to know your rating of the specialist your child saw most often in the last 6 months. Using any number from 0 to 10, where 0 is the worst specialist possible and 10 is the best specialist possible, what number would you use to rate that specialist?00 = 0 Worst specialist possible02 = 203 = 304 = 405 = 506 = 607 = 708 = 809 = 910 = 10 Best specialist possible99 = MissingNumberYesN/AQ49In the last 6 months, did you get information or help from customer service at your child's health plan?1 = Yes2 = No9 = MissingNumberYesN/AQ50In the last 6 months, how often did customer service at your child's health plan give you the information or help you needed?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ51In the last 6 months, how often did customer service staff at your child's health plan service treat you with courtesy and respect?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ52In the last 6 months, did your child's health plan give you any forms to fill out?1 = Yes2 = No9 = MissingNumberYesN/AQ53In the last 6 months, how often were the forms from your child's health plan easy to fill out?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ54Using any number from 0 to 10, where 0 is the worst health plan possible and 10 is the best health plan possible, what number would you use to rate your child's health plan?00 = 0 Worst health plan possible01 = 102 = 203 = 304 = 405 = 506 = 607 = 708 = 809 = 910 = 10 Best health plan possible99 = MissingNumberYesN/AQ55In the last 6 months, did you get or refill any prescription medicines for your child? 1 = Yes2 = No9 = MissingNumberYesN/AQ56In the last 6 months, how often was it easy to get prescription medicines for your child through his or her health plan?1 = Never2 = Sometimes3 = Usually4 = Always9 = MissingNumberYesN/AQ57Did anyone from your child's health plan, doctor's office, or clinic help you get your child's prescription medicines?1 = Yes2 = No9 = MissingNumberYesN/AQ58In general, how would you rate your child's overall health?1 = Excellent2 = Very Good3 = Good4 = Fair5 = Poor9 = MissingNumberYesN/AQ59In general, how would you rate your child's overall mental or emotional health?1 = Excellent2 = Very Good3 = Good4 = Fair5 = Poor9 = MissingNumberYesN/AQ60Does your child currently need or use medicine prescribed by a doctor (other than vitamins)? 1 = Yes2 = No9 = MissingNumberYesN/AQ61Is this because of any medical, behavioral, or other health condition?1 = Yes2 = No9 = MissingNumberYesN/AQ62Is this a condition that has lasted or is expected to last for at least 12 months?1 = Yes2 = No9 = MissingNumberYesN/AQ63Does your child need or use more medical care, more mental health services, or more educational services than is usual for most children of the same age?1 = Yes2 = No9 = MissingNumberYesN/AQ64Is this because of any medical, behavioral, or other health condition?1 = Yes2 = No9 = MissingNumberYesN/AQ65Is this a condition that has lasted or is expected to last for at least 12 months? 1 = Yes2 = No9 = MissingNumberYesN/AQ66Is your child limited or prevented in any way in his or her ability to do the things most children of the same age can do?1 = Yes2 = No9 = MissingNumberYesN/AQ67Is this because of any medical, behavioral, or other health condition?1 = Yes2 = No9 = MissingNumberYesN/AQ68Is this a condition that has lasted or is expected to last for at least 12 months?1 = Yes2 = No9 = MissingNumberYesN/AQ69Does your child need or get special therapy such as physical, occupational, or speech therapy? 1 = Yes2 = No9 = MissingNumberYesN/AQ70Is this because of any medical, behavioral, or other health condition?1 = Yes2 = No9 = MissingNumberYesN/AQ71Is this a condition that has lasted or is expected to last for at least 12 months? 1 = Yes2 = No9 = MissingNumberYesN/AQ72Does your child have any kind of emotional, developmental, or behavioral problem for which he or she needs or gets treatment or counseling?1 = Yes2 = No9 = MissingNumberYesN/AQ73Has this problem lasted or is expected to last for at least 12 months?1 = Yes2 = No9 = MissingNumberYesN/AQ74What is your child's age? 00 = less than 1 yearEnter reported age if one year or older99 = MissingNumberYesN/AQ75Is your child male or female?1 = Male2 = Female9 = MissingNumberYesN/AQ76Is your child of Hispanic or Latino origin or descent?1 = Yes, Hispanic or Latino2 = No, not Hispanic or Latino9 = MissingNumberYesN/AQ77aWhat is your child’s race? Mark one or more. 1 = Respondent checked "White"9 = MissingNumberYesN/AQ77bWhat is your child’s race? Mark one or more. 1 = Respondent checked "Black or African American"9 = MissingNumberYesN/AQ77cWhat is your child’s race? Mark one or more. 1 = Respondent checked "Asian"9 = MissingNumberYesN/AQ77dWhat is your child’s race? Mark one or more. 1 = Respondent checked "Native Hawaiian or other Pacific Islander"9 = MissingNumberYesN/AQ77eWhat is your child’s race? Mark one or more. 1 = Respondent checked "American Indian or Alaska Native"9 = MissingNumberYesN/AQ77fWhat is your child’s race? Mark one or more. 1 = Respondent checked "Other"9 = MissingNumberYesN/AQ78What is your age? 0 = Under 181 = 18-242 = 25-343 = 35-444 = 45-545 = 55-646 = 65-747 = 75 or older9 = MissingNumberYesN/AQ79Are you male or female?1 = male2 = female9 = MissingNumberYesN/AQ80What is the highest grade or level of school that you have completed? 1 = 8th grade or less2 = Some high school but did not graduate3 = High school graduate or GED4 = Some college or 2-year degree5 = 4-year college graduate6 = More than 4-year college degree9 = MissingNumberYesN/AQ81How are you related to the child?1 = Mother or father2 = Grandparent3 = Aunt or uncle4 = Older brother or sister5 = Other relative6 = Legal guardian7 = Someone else9 = MissingNumberYesN/AQ82Did someone help you complete this survey?1 = Yes2 = No9 = MissingNumberYesN/AQ83aHow did that person help you?1 = Respondent checked "Read the questions to me"9 = MissingNumberYesN/AQ83bHow did that person help you? 1 = Respondent checked "Wrote down the answers I gave"9 = MissingNumberYesN/AQ83cHow did that person help you? 1 = Respondent checked "Answered the questions for me"9 = MissingNumberYesN/AQ83dHow did that person help you? 1 = Respondent checked "Translated the questions into my language"9 = MissingNumberYesN/AQ83eHow did that person help you? 1 = Respondent checked "Helped in some other way"9 = MissingNumberYesN/ACare Management LogFIELD NAMEFIELD DESCRIPTIONFIELD TYPEREQUIREDFIELD REQUIREMENTS AND MASKSMember IDMedicaid member IDShort TextYesN/AReport DateThe Quarter the record was reported in by calendar year in the following format: Qx-YYYYShort TextYesN/ASexMembers sexCHOOSE FROM:MaleFemaleOtherShort TextYesN/ADOBDate of BirthDate/TimeYesN/AContact FrequencyContact in this case meaning that communication was not only between the MCO and the member, but also between the member and the MCOCHOOSE:Weekly or moreMonthlyQuarterlyShort TextYesN/ARisk CategoryCHOOSE:LowMediumHighShort TextYesN/AIdentified Care NeededChoose ONE OR MORE of the values beside the accompanying descriptions below:A - Severity of the member’s conditions/disease state/Co-morbidities, or multiple complex health care conditions.B - Recent treatment history and current medications. C - Long-term services and supports the member currently receives/Activities of daily living (including bathing, dressing, toileting, mobility, and eating)/Indirect supports/Instrumental activities of daily living (including medication management, money management, meal preparation, shopping, telephone use, and transportation). D - Social determinants of health E - Communication and cognition. F - Safety (need for welfare/protection to eliminate harm to self or others). G - Behavioral health concerns, including depression, mental illness, suicide risk, and exposure to trauma/Substance use, including alcohol.Short TextYesN/AHCBS waiverCHOOSE:AD WaiverTBI WaiverCDD WaiverDDAD WaiverNoneShort TextYesN/AIHS/Tribal OrganizationIs the member a part of an Indian Health Service (IHS) or other Tribal organizationYes/NoDefault: NoN/ACM ID methodThe method through which the members were identified for Care ManagementCHOOSE: HRAPlan identifiedMember requestHospital dischargeProvider requestOtherShort TextYesN/ACM ID descriptionBrief narrative describing the reason or reasons the member is on care management. If a member has several reasons, they should all be indicated within this field, not a separate record for each reason. In this case “CM ID method” should be populated with “Other” then this field populated with the multitude of reasonsLong TextNoREQUIRED IF AND ONLY IF: “CM ID method” is “Other”Date of HRADate of the members Health Risk AssessmentDate/TimeNoREQUIRED IF AND ONLY IF: “CM ID method” is “HRA”Date Enrolled in CMDate the member was enrolled into CMDate/TimeYesN/ACM ongoingIs the member still in CM as of the filing of this recordYes/NoDefault: NoN/ADate CM ConclusionDate of the members CM conclusionDate/TimeNoREQUIRED IF AND ONLY IF: “CM ongoing” is “No”CM Conclusion ReasonCHOOSE:Member RequestMember DeceasedMember Discharged from PlanGoals CompletedShort TextNoREQUIRED IF AND ONLY IF: “CM ongoing” is “No”PCP NPImembers PCP NPI numberShort TextYesN/APCP NE Medicaid IDmembers PCP Medicaid ID numberShort TextYesN/ASpecialist NPImembers specialist NPI numberShort TextNoN/ASpecialist NE Medicaid IDmembers specialist Medicaid ID numberShort TextNoN/AFacility and Provider SurveyFIELD NAMEFIELD DESCRIPTIONFIELD TYPEREQUIREDFIELD REQUIREMENTS AND MASKSIDThis Field is simply a place holder. These surveys are to be designed and executed by the MCO’s once MLTC has given approval. Once approved, MTLC will make the appropriate changes to this table so that upon completion, line item data can be reported to the state.Short TextYesN/AGrievance LogFIELD NAMEFIELD DESCRIPTIONFIELD TYPEREQUIREDFIELD REQUIREMENTS AND MASKSCase IDCase ID or file number used by MCE to track the complaintShort TextYesN/AMember IDMember Medicaid ID numberShort TextYesIf the Complaint is from a Provider and there is no Member ID, please enter “99999999999.”Provider/ClientCHOOSE: ProviderClientOn Behalf of ClientShort TextYesN/AClient Relationship DescShort description of the relationship the person filing has with the ClientShort TextNoREQUIRED IF AND ONLY IF: “Provider/Client” is "On Behalf of Client." Leave this field blank if “Provider/Client” is “Provider” or “Client.”Complaint TypeCHOOSE: -Access to Care-Health Care Delivery-PCP-Health Care Delivery-Specialist-Health Care Delivery-Hospital-Health Care Delivery-Other Provider Type-Quality of Care-Provider Network Inadequacy-Administration (Use only when the grievance is directed at the plan. The provider IDs should also be populated as outlined)-Pharmacy Benefit Manager-Credentialing or Contracting-Reimbursement Structure-Clinical/UM Decision-Claims Payment-Member Behavior-OtherShort TextYesN/AOther Complaint DescriptionShort description of the complaint when “Complaint Type” is “Other.”Long TextNoREQUIRED IF AND ONLY IF: “Complaint Type” is “Other”Complaint DateDate complaint was filed with MCEDate/TimeYesN/AComplaint ResponseMethod and summary of response to memberLong TextYesN/AComplaint Response DateDate of response to complaintDate/TimeYesIf the Grievance is unresolved at the end of the reporting period, please enter “1/1/3999” for the Complaint Response Date.Claim IDMedicaid member Claim ID numberNOTE: If Complaint has an associated Claim ID, it should be populated here.Short TextNoLeave this field blank if Complaint has no associated Claim ID number.Date of ServiceDate the service was performed, if the Complaint concerns a serviceDate/TimeNoN/AProvider NameName of the provider on the ComplaintShort TextYesN/ANE Medicaid Provider IDProvider’s NE Medicaid ID numberNOTE: If Complaint is directed toward the plan (Complaint Type is Administration), populate this field with “99999999999”.Short TextYesN/AProvider NPIProvider’s NPI numberNOTE: If Complaint is directed toward the plan (Complaint Type is Administration), populate this field with “9999999999”.Short TextYesN/AProcedure CodeIf a procedure is a part of the Complaint, list the procedure codeShort TextNoN/ANDCThe NDC code of the medication associated with the ComplaintShort TextNoSIZE: 11 CharactersREQUIRED IF AND ONLY IF: “Complaint Type” is “Pharmacy Benefit Manager”Rx DescriptionShort description of the Prescription as identified by the NDC, including drug names, strength, and quantity.Long TextNoREQUIRED IF AND ONLY IF: “Complaint Type” is “Pharmacy Benefit ManagerOut-of-Network ReferralsFIELD NAMEFIELD DESCRIPTIONFIELD TYPEREQUIREDFIELD REQUIREMENTS AND MASKSMember IDMember's Medicaid IDShort TextYesN/AProvider NE Medicaid IDProviders NE Medicaid ID numberShort TextYesN/AProvider NPIProviders NPIShort TextYesN/AProvider NameProvider's NameShort TextYesN/AProvider SpecialtyProvider’s SpecialtyShort Text YesN/AProvider CityCity in which the provider is locatedShort TextYesN/AProvider StateState in which the provider is locatedShort TextYesN/ADate Auth Request ReceivedDate the Out-of-Network authorization request was received by the MCODate/TimeYesN/AType of ServiceCHOOSE:Acute RehabBH ServicesDMEHome HealthInpatient ServicesOutpatient ServicesPharmacyPT/OT/STOtherShort TextYesN/AOther TOS DescShort narrative describing the type of serviceLong TextNoREQUIRED IF AND ONLY IF: "Type of Service" is "Other"ICD-10 CodeICD-10 Code of the ask in questionShort TextNoMASKED: 7 digit max, 3 min (required) first must be letter, second a number, others alpha-numericCPT CodeCPT code of the ask in questionShort TextNoMASKED: 5 digit max, all or none (5 digits or empty), all numbersHCPCS CodeHCPCS code of the ask in questionShort TextNoMASKED: 5 digit max, all or none (5 digits or empty), first digit is alpha numeric and remaining are numericDecisionCHOOSE: ApprovedDeniedShort TextYesN/ADate of DecisionDate of approval or denialDate/TimeYesN/AReason for DecisionChoose one of the values beside the accompanying descriptions below:ApprovedA1 - Continuity of CareA2 - Member out of area emergency/post-stabilizationA3 - Member out of area non-emergencyA4 - Network Provider unable to see member in timely manner/not accepting new Medicaid patientsA5 - Non-par specialized – transplantA6 - Non-par specialized services (excluding transplant)A7 - Service is available in the network but in-network provider distance causes undue hardship to member, i.e. cost of transportation for the memberDeniedD1 - Lack of informationD2 - Not medically necessaryD3 - Services available and accessible in networkShort TextYesN/AState Fair Hearings LogReport all State Fair Hearings received from both members and providers during the time period specified for the report. Additionally, report all State Fair Hearings closed during the time period that were received during a previous time period and reported as unresolved in a previous report.FIELD NAMEFIELD DESCRIPTIONFIELD TYPEREQUIREDFIELD REQUIREMENTS AND MASKSHearing IDHearing ID for the State Fair HearingShort TextYesN/AMember IDMember Medicaid ID numberShort TextYesN/AProvider/ClientCHOOSE: -Provider-Client-On Behalf of ClientShort TextYesN/AClient Relationship DescShort description of the relationship the person filing has with the ClientShort TextNoREQUIRED IF AND ONLY IF: “Provider/Client” is "On Behalf of Client." Leave this field blank if “Provider/Client” is “Provider” or “Client.”State Fair Hearing TypeCHOOSE:-Denial or Limited Authorization of Requested Service-Denial or Limited Authorization of Requested Medication-Denial, in Whole or in Part, of Payment for Service-Failure to Provide Services in a Timely Manner as Defined by the State-Failure of MCO to Act within Timeframes Regarding Standard Resolution of Grievances and Appeals-Reduction, Suspension or Termination of a Previously Authorized Service-Denial of Request to Dispute a Financial Liability-OtherShort TextYesN/AOther State Fair Hearing DescriptionShort description of the State Fair HearingLong TextNoREQUIRED IF AND ONLY IF: “State Fair Hearing Type” is “Other.” Leave blank if “State Fair Hearing Type” is not “Other.”Claim IDMedicaid member Claim ID numberNOTE: If the State Fair Hearing has an associated Claim ID, it should be populated here. This will not be expected for State Fair Hearings which are for pre-authorizations or similar circumstances which would not have a Claim IDShort TextNoLeave this field blank if the State Fair Hearing is for a pre-authorization or similar circumstances which would not have a Claim ID.Date of ServiceDate the service was performedDate/TimeNoN/ADate of State Fair HearingDate of the State Fair HearingDate/TimeYesN/AResolution DateDate the State Fair Hearing was resolvedDate/TimeYesIf the State Fair Hearing is unresolved at the end of the reporting period, please enter “1/1/3999” for the Resolution Date.Resolution OutcomeCHOOSE (as decided by the State Hearing Office):-Affirmed-Reversed-Dismissed-Unresolved (Use only when State Fair Hearing remains unresolved at the end of the reporting period)Short TextYesN/AReason UnresolvedShort description of the reason the State Fair Hearing is unresolvedShort TextNoREQUIRED IF AND ONLY IF: “Resolution Outcome” is "Unresolved." Provider NameName of the provider on the State Fair HearingShort TextYesN/AProvider NE Medicaid IDProvider’s NE Medicaid ID numberShort TextYesN/AProvider NPIProvider’s NPI numberShort TextYesN/AProcedure CodeIf a procedure is a part of the State Fair Hearing, list the code of the procedureShort TextNoN/ANDCThe NDC code of the medication associated with the State Fair Hearing.Short TextNoSIZE: 11 CharactersREQUIRED IF AND ONLY IF: “State Fair Hearing Type” is “Denial or Limited Authorization of Requested Medication”Rx DescriptionShort description of the Prescription as identified by the NDC, including drug names, strength, and quantity.Long TextNoREQUIRED IF AND ONLY IF: “State Fair Hearing Type” is “Denial or Limited Authorization of Requested Medication” ................
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