nebraska department of health & human servicesdhhs.ne.gov/medicaid health plan reporting...

July 15, 2019

Medicaid & Long-Term CareData & Analytics301 Centennial Mall S.Lincoln NE 68509

Heritage Health: Data Dictionary

Medicaid & Long Term Care - Data and AnalyticsPrepared by:

Date Description of change Initials

08/02/2016

Initial Version AJL

10/28/2016

Fields added to Grievance System Log table and desc. fields changed to Long Text

AJL

02/03/2017

Fields added to Grievance System Log table to address pharmacy and complaint date issues. Random cleaning of table restrictions and minor fixes

AJL

01/01/2018

Template revisions and dictionary clear up AJL

11/02/2018

Revised CAHPS reports LAJ

03/19/2019

Split Grievance System Log into three reports, Appeals Log, Grievance Log and State Fair Hearings Log.

BDP

3/25/2019

Grievance Log - Included description of Complaint Type: Administration and resulting values of provider identifiers

LAJ

7/15/19 Grievance 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.

BDP

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ContentsPrologue................................................................................................................................................................................................................................................ 4

30 Day BH ER Visits................................................................................................................................................................................................................................ 5

30 Day Inpatient Re-Admit.................................................................................................................................................................................................................... 6

Admit and Re-Admit to Psych Inpatient................................................................................................................................................................................................ 7

Appeals Log........................................................................................................................................................................................................................................... 9

CAHPS - Adult...................................................................................................................................................................................................................................... 13

CAHPS - Child/CHIP with CCC............................................................................................................................................................................................................... 26

Care Management Log........................................................................................................................................................................................................................ 44

Facility and Provider Survey................................................................................................................................................................................................................ 47

Grievance Log...................................................................................................................................................................................................................................... 48

Out-of-Network Referrals.................................................................................................................................................................................................................... 50

State Fair Hearings Log........................................................................................................................................................................................................................ 52

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Prologue 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 names Field 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. o Calculated fields do not need to be filled in. o Access stores Yes/No values as follows: No = 0, Yes = -1

Field 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.

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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 NAME FIELD DESCRIPTION FIELD TYPE REQUIRED FIELD REQUIREMENTS AND MASKSMember ID Member Medicaid ID number Short Text Yes N/AClaim ID Claim ID for inpatient stay Short Text Yes N/AAdmission Date Date of admission to inpatient facility Date Yes N/ADischarge Date Date of initial discharge Date Yes N/ADischarge Age Age of the member upon being discharged Number Yes N/APOS Code Place of Service code for inpatient stay Short Text Yes N/AProvider NE Medicaid ID Provider’s NE Medicaid ID (facility) Short Text Yes N/AProvider NPI Provider’s NPI (facility) Short Text Yes N/AProvider Name Name of the provider (facility) Short Text Yes N/APrimary Diagnosis ICD 10 code for the primary diagnosis on the claim Short Text Yes MASKED: Allows 7 digits, first 3 required, 1st

is alpha, 2nd is numeric, the rest are alphanumeric

Secondary Diagnosis ICD 10 code for a secondary diagnosis; if no secondary diagnosis for the readmission, record “A1aaaaa”

Short Text Yes MASKED: Allows 7 digits, first 3 required, 1st


ER Date Date of follow-up Date Yes N/AER Claim ID Claim number for ER presentation Short Text Yes N/AER Interval Number of days between discharge and presenting to

ER. CalculatedCalculated Yes N/A

ER Provider NE Medicaid ID

NE Medicaid ID of the ER provider (facility) Short Text Yes N/A

ER Provider NPI NPI of the ER provider (facility) Short Text Yes N/AER Provider Name Name of the ER provider (facility) Short Text Yes N/AER POS Code Place of service code Short Text Yes N/AER Primary Diagnosis ICD 10 code for the follow-up primary diagnosis on the

claimShort Text Yes MASKED: Allows 7 digits, first 3 required, 1st


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ER Secondary Diagnosis ICD 10 code for the follow-up secondary diagnosis on the claim; if no secondary diagnosis for the readmission, record “A1aaaaa”

Short Text Yes MASKED: Allows 7 digits, first 3 required, 1st


30 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 NAME FIELD DESCRIPTION FIELD TYPE REQUIRED FIELD REQUIREMENTS AND MASKSMember ID Member Medicaid ID number Short Text Yes N/AClaim ID Medicaid claim ID number Short Text Yes N/AAdmission Date Date of admission for the initial inpatient stay Date Yes N/ADischarge Date Date of Discharge for the initial inpatient stay Date Yes N/ADischarge Age Age of the member upon discharge Number Yes N/ALength of Stay Number of days the member was in the facility Calculated Yes N/APOS Code Place of service code for the initial inpatient stay Short Text Yes N/APrimary Diagnosis ICD 10 codes for the primary diagnosis Short Text Yes MASKED: Allows 7 digits, first 3

required, 1st is alpha, 2nd is numeric, the rest are alphanumeric

Secondary Diagnosis ICD 10 codes for a secondary diagnosis; if no secondary diagnosis for the readmission, record “A1aaaaa”

Short Text No MASKED: Allows 7 digits, first 3 required, 1st is alpha, 2nd is numeric, the rest are alphanumeric

Provider NPI NPI of the provider (facility) Short Text Yes N/AProvider NE Medicaid ID NE Medicaid ID of the provider (facility) Short Text Yes N/AProvider Name Name of the provider (facility) Short Text Yes N/AReadmission Date Date of readmission Date Yes N/AReadmission Claim ID Medicaid claim ID for remittance Short Text Yes N/AReadmission Interval Number of days between discharge and remittance Calculated Yes N/AReadmission POS Code Place of service code for the readmission Short Text Yes N/AReadmission Provider NPI NPI of the readmission provider (facility) Short Text Yes N/AReadmission Provider NE Medicaid ID NE Medicaid ID of the readmission provider (facility) Short Text Yes N/AReadmission Provider Name Name of the readmission provider (facility) Short Text Yes N/AReadmission Principle Diagnosis ICD 10 codes for the readmission primary diagnosis Short Text Yes MASKED : Allows 7 digits, first 3


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Readmission Secondary Diagnosis ICD 10 codes for a readmission secondary diagnosis; if no secondary diagnosis for the readmission, record “A1aaaaa”

Short Text No MASKED : Allows 7 digits, first 3 required, 1st is alpha, 2nd is numeric, the rest are alphanumeric

Admit 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 NAME FIELD DESCRIPTION FIELD TYPE REQUIRED FIELD REQUIREMENTS AND MASKSMember ID Member Medicaid ID number Short Text Yes N/AClaim ID Medicaid Claim number Short Text Yes N/AAdmission Date Admission date of the initial inpatient/residential BH stay Date Yes N/A

Discharge Date Date of discharge of the initial inpatient/residential BH stay Date Yes N/ADischarge Age Age of the member upon being discharged Number Yes N/APOS Code Place of service code for the BH inpatient/residential BH stay Short Text Yes N/AProvider NPI Members Providers NPI number (facility) Short Text Yes N/AProvider Medicaid ID Members Providers Medicaid ID number (facility) Short Text Yes N/AProvider Name Providers name (facility) Short Text Yes N/APrimary Diagnosis ICD 10 code of Primary Dx Short Text Yes MASKED: Allows 7 digits, first 3


Secondary Diagnosis ICD 10 code of Secondary Dx; if no secondary diagnosis for the readmission, record “A1aaaaa”

Short Text Yes MASKED: Allows 7 digits, first 3 required, 1st is alpha, 2nd is numeric, the rest are alphanumeric

Readmission Claim ID Medicaid Claim number for readmission Short Text Yes N/AReadmission Date Date of inpatient/residential BH readmission Date Yes N/A

Readmission Interval Number of date between discharge from initial inpatient/residential BH stay and inpatient/residential BH readmission

Calculated Yes N/A

Readmission POS Code Place of service code for inpatient/residential BH readmission Short Text Yes N/AReadmission Provider NPI Provider's NPI (facility upon readmission) Short Text Yes N/AReadmission Provider NE Medicaid ID

Provider's Medicaid ID number (facility upon readmission) Short Text Yes N/A

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Readmission Provider Name Providers name (facility upon readmission) Short Text Yes N/AReadmission Primary Diagnosis

ICD 10 code of readmission's primary dx Short Text Yes MASKED: Allows 7 digits, first 3 required, 1st is alpha, 2nd is numeric, the rest are alphanumeric

Readmission Secondary Diagnosis

ICD 10 code of readmission's secondary dx; if no secondary diagnosis for the readmission, record “A1aaaaa”

Short Text Yes MASKED: Allows 7 digits, first 3 required, 1st is alpha, 2nd is numeric, the rest are alphanumeric

Member Care Management Status

Is the member receiving Care Management as of the date of readmission?

Yes/No Default: No

N/A

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Appeals 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 NAME FIELD DESCRIPTION FIELD TYPE REQUIRED FIELD REQUIREMENTS AND MASKSCase ID Case ID or file number used by the MCE to

track the status of the appealShort Text Yes N/A

Member ID Member Medicaid ID number Short Text Yes N/AType of Issue CHOOSE:

-Appeal-Expedited Appeal

Short Text Yes N/A

Provider/Client CHOOSE: -Provider-Client-On Behalf of Client

Short Text Yes N/A

Client Relationship Desc Short description of the relationship the person filing has with the Client

Short Text No REQUIRED IF AND ONLY IF: “Provider/Client” is "On Behalf of Client." Leave this field blank if “Provider/Client” is “Provider” or “Client.”

Appeal Type CHOOSE: -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

-Other

Short Text Yes N/A

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Other Appeal Description Short description of the appeal Long Text No REQUIRED IF AND ONLY IF: “Appeal Type” is “Other.” Leave blank if “Appeal Type” is not “Other.”

Claim ID Medicaid member Claim ID number

NOTE: 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 ID

Short Text No Leave 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 Service Date the service was performed Date/Time No N/A

Service Type CHOOSE: -Durable Medical Equipment-Therapy Services-Procedure in Physician Office-Outpatient Procedures-Inpatient Procedures-Home Health Services-Radiology-Pharmacy-Vision Benefits-Other

Short Text Yes N/A

Other Service Type Description Short description of the type of “Other” denial

Short Text No REQUIRED IF AND ONLY IF: “Service Type” is "Other"

ServiceEquipmentAuthDenied Short description of the DME equipment which is the cause of appeal/expedited appeal

Short Text No REQUIRED IF AND ONLY IF: "Service Type" is "Durable Medical Equipment."

Date of Appeal Date the Appeal/Expedited Appeal was received by the MCO

Date/Time Yes N/A

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Extension Type CHOOSE:-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 Text Yes N/A

Date of Extension Date the Appeal/Expedited Appeal received an extension

Date/Time No REQUIRED IF AND ONLY IF: “Extension Type” is “Appellant Driven” or “Plan Driven.”

Extended Due Date Date the Appeal/Expedited Appeal is now due, post extension

Date/Time No REQUIRED IF AND ONLY IF: “Extension Type” is “Appellant Driven” or “Plan Driven.”

Resolution Date Date the Appeal/Expedited Appeal was resolved

Date/Time Yes If the issue is unresolved at the end of the reporting period, enter “1/1/3999” for the Resolution Date.

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Resolution Outcome CHOOSE:-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 Text Yes N/A

Denial Reasoning Description of the rationale given for upholding denial

Long Text No REQUIRED IF AND ONLY IF: “Resolution Outcome” is “Upheld” or “Partially Overturned.”

Reason Unresolved Short description of the reason the appeal/expedited appeal is unresolved

Short Text No REQUIRED IF AND ONLY IF: “Resolution Outcome” is "Unresolved."

Provider Name Name of the provider on the appeal Short Text Yes N/A

Provider NE Medicaid ID Provider’s NE Medicaid ID number Short Text Yes N/A

Provider NPI Provider’s NPI number Short Text Yes N/AProcedure Code If a procedure is a part of the appeal, list

the code of the procedureShort Text No N/A

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NDC The NDC code of the medication associated with the Appeal/Expedited Appeal.

Short Text No SIZE: 11 CharactersREQUIRED IF AND ONLY IF: “Appeal Type” is “Denial or Limited Authorization of Requested Medication”

Rx Description Short description of the Prescription as identified by the NDC, including drug names, strength, and quantity.

Long Text No REQUIRED IF AND ONLY IF: “Appeal Type” is “Denial or Limited Authorization of Requested Medication”

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CAHPS - AdultFIELD NAME FIELD DESCRIPTION FIELD TYPE REQUIRED FIELD

REQUIREMENTS AND MASKS

ID Unique record ID for everyone receiving a CAHPS survey request, regardless of whether or not survey was returned/completed. Should be a positive integer.

Number Yes N/A

Disposition 0 = 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) list

Number Yes N/A

Mode 0 = Incomplete/Ineligible1 = Mail2 = Telephone3 = Internet

Number Yes N/A

Round 0 = Incomplete/Ineligible1 = First attempt2 = Second attempt3 = Third attempt4 = Fourth attempt5 = Fifth attempt6 = Sixth attempt

Yes N/A

Language 0 = Incomplete/Ineligible1 = English2 = Spanish

Number Yes N/A

Address Viable 1 = Valid2 = Not Valid

Number Yes N/A

Telephone Viable 0 = Survey protocol did not require telephone number1 = Valid2 = Not Valid

Number Yes N/A

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Email Viable 0 = Survey protocol did not require email address1 = Valid2 = Not Valid

Number Yes N/A

Sex 1 = Male2 = Female9 = Missing

Number Yes N/A

Flu Vaccinations Eligibility 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 = Ineligible

Number Yes N/A

Q1 Our records show that you are now in {insert health plan name/state Medicaid program name}. Is that right? 1 = Yes2 = No9 = Missing

Number Yes N/A

Q2 Open response/possibly no response depending on answer 1 Short Text Yes N/AQ3 In 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 = Missing

Number Yes N/A

Q4 In 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 = Missing

Number Yes N/A

Q5 In 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 = Missing

Number Yes N/A

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Q6 In 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 = Missing

Number Yes N/A

Q7 In 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 = Missing

Number Yes N/A

Q8 In 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 = Missing

Number Yes N/A

Q9 In the last 6 months, did you and a doctor or other health provider talk about starting or stopping a prescription medicine?1 = Yes2 = No9 = Missing

Number Yes N/A

Q10 Did you and a doctor or other health provider talk about the reasons you might want to take a medicine?1 = Yes2 = No9 = Missing

Number Yes N/A

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Q11 Did you and a doctor or other health provider talk about the reasons you might NOT want to take a medicine?1 = Yes2 = No9 = Missing

Number Yes N/A

Q12 When 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 = Missing

Number Yes N/A

Q13 Using 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 = Missing

Number Yes N/A

Q14 In the last 6 months, how often was it easy to get the care, tests, or treatment you needed? 1 = Never2 = Sometimes3 = Usually4 = Always9 = Missing

Number Yes N/A

Q15 A 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 = Missing

Number Yes N/A

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Q16 In 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 = Missing

Number Yes N/A

Q17 In 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 = Missing

Number Yes N/A

Q18 In the last 6 months, how often did your personal doctor listen carefully to you?1 = Never2 = Sometimes3 = Usually4 = Always9 = Missing

Number Yes N/A

Q19 In the last 6 months, how often did your personal doctor show respect for what you had to say?1 = Never2 = Sometimes3 = Usually4 = Always9 = Missing

Number Yes N/A

Q20 In the last 6 months, how often did your personal doctor spend enough time with you?1 = Never2 = Sometimes3 = Usually4 = Always9 = Missing

Number Yes N/A

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Q21 In the last 6 months, did you get care from a doctor or other health provider besides your personal doctor?1 = Yes2 = No9 = Missing

Number Yes N/A

Q22 In 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=Missing

Number Yes N/A

Q23 Using 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 = Missing

Number Yes N/A

Q24 Specialists 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 = Missing

Number Yes N/A

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Q25 In 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 = Missing

Number Yes N/A

Q26 How many specialists have you seen in the last 6 months?0 = None1 = 1 specialist2 = 23 = 34 = 45 = 5 or more specialists9 = Missing

Number Yes N/A

Q27 We 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=Missing

Number Yes N/A

Q28 In 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 = Missing

Number Yes N/A

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Q29 In 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 = Missing

Number Yes N/A

Q30 In the last 6 months, did you get information or help from your health plan's customer service?1 = Yes2 = No9 = Missing

Number Yes N/A

Q31 In 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 = Missing

Number Yes N/A

Q32 In 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 = Missing

Number Yes N/A

Q33 In the last 6 months, did your health plan give you any forms to fill out?1 = Yes2 = No9 = Missing

Number Yes N/A

Q34 In the last 6 months, how often were the forms from your health plan easy to fill out?1 = Never2 = Sometimes3 = Usually4 = Always9 = Missing

Number Yes N/A

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Q35 Using 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 = Missing

Number Yes N/A

Q36 In general, how would you rate your overall health?1 = excellent2 = very good3 = good4 = fair5 = poor9 = Missing

Number Yes N/A

Q37 In general, how would you rate your overall mental or emotional health?1 = excellent2 = very good3 = good4 = fair5 = poor9 = Missing

Number Yes N/A

Q38 Have you had either a flu shot or flu spray in the nose since July 1, 2017?1 = Yes2 = No3 = Don't know9 = Missing

Number Yes N/A

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Q39 Do 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 = Missing

Number Yes N/A

Q40 In 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 = Missing

Number Yes N/A

Q41 In 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 = Missing

Number Yes N/A

Q42 In 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 = Missing

Number Yes N/A

Q43 In the last 6 months, did you get health care 3 or more times for the same condition or problem? 1 = Yes2 = No9 = Missing

Number Yes N/A

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Q44 Is this a condition or problem that has lasted for at least 3 months? Do not include pregnancy or menopause.1 = Yes2 = No9 = Missing

Number Yes N/A

Q45 Do you now need or take medicine prescribed by a doctor? Do not include birth control.1 = Yes2 = No9 = Missing

Number Yes N/A

Q46 Is this medicine to treat a condition that has lasted for at least 3 months? Do not include pregnancy or menopause. 1 = Yes2 = No9 = Missing

Number Yes N/A

Q47 What 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 = Missing

Number Yes N/A

Q48 Are you male or female?1 = Male2 = Female9 = Missing

Number Yes N/A

Q49 What 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 = Missing

Number Yes N/A

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Q50 Are you of Hispanic or Latino origin or descent?1 = Yes2 = No9 = Missing

Number Yes N/A

Q51a What is your race? Mark one or more.1 = Respondent checked "White"9 = Missing

Number Yes N/A

Q51b What is your race? Mark one or more.1 = Respondent checked "Black or African American"9 = Missing

Number Yes N/A

Q51c What is your race? Mark one or more.1 = Respondent checked "Asian"9 = Missing

Number Yes N/A

Q51d What is your race? Mark one or more.1 = Respondent checked "Native Hawaiian or other Pacific Islander"9 = Missing

Number Yes N/A

Q51e What is your race? Mark one or more.1 = Respondent checked "American Indian or Alaska Native"9 = Missing

Number Yes N/A

Q51f What is your race? Mark one or more. 1 = Respondent checked "Other"9 = Missing

Number Yes N/A

Q52 Did someone help you complete this survey?1 = Yes2 = No9 = Missing

Number Yes N/A

Q53a How did that person help you? 1 = Respondent checked “Read the questions to me” 9 = Missing

Number Yes N/A

Q53b How did that person help you?1 = Respondent checked “Wrote down the answers I gave”9 = Missing

Number Yes N/A

Q53c How did that person help you?1 = Respondent checked “Answered the questions for me”9 = Missing

Number Yes N/A

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Q53d How did that person help you?1 = Respondent checked “Translated the questions into my language”9 = Missing

Number Yes N/A

Q53e How did that person help you?1 = Respondent checked “Helped in some other way”9 = Missing

Number Yes N/A

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CAHPS - Child/CHIP with CCCFIELD NAME FIELD DESCRIPTION FIELD TYPE REQUIRED FIELD REQUIREMENTS

AND MASKSID Assign unique ID to everyone receiving a CAHPS survey, regardless of whether or not

survey was returnedNumber Yes N/A

Disposition 0 = 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) list

Number Yes N/A

Mode 0 = Incomplete/Ineligible1 = Mail2 = Telephone3 = Internet

Number Yes N/A

Round 0 = Incomplete/Ineligible1 = First attempt2 = Second attempt3 = Third attempt4 = Fourth attempt5 = Fifth attempt6 = Sixth attempt

Yes N/A

Language 0 = Incomplete/Ineligible1 = English2 = Spanish

Number Yes N/A

Address Viable 1 = Valid2 = Not Valid

Number Yes N/A

Telephone Viable 0 = Survey protocol did not require telephone number1 = Valid2 = Not Valid

Number Yes N/A

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Email Viable 0 = Survey protocol did not require email address1 = Valid2 = Not Valid

Number Yes N/A

Sex 1 = Male2 = Female9 = Missing

Number Yes N/A

Prescreen CCC 1 = No claims or encounters that meet CCC criteria2 = Claims or encounters that meet CCC criteria

Number Yes N/A

Sample Code 1 = CAHPS 5.0H Child Survey Sample2 = CAHPS 5.0H Child with CCC Survey Sample

Number Yes N/A

Child Population 1 = Medicaid (General)2 = CHIP

Number Yes N/A

Q1 Our records indicate that your child is now in {insert state Medicaid program name}. Is that right?1 = Yes2 = No9 = Missing

Number Yes N/A

Q2 Open response/possibly No response depending on answer 1 Short Text Yes N/AQ3 In 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 = Missing

Number Yes N/A

Q4 In 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 = Missing

Number Yes N/A

Q5 In 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 = Missing

Number Yes N/A

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Q6 In 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 = Missing

Number Yes N/A

Q7 In 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 = Missing

Number Yes N/A

Q8 In 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 = Missing

Number Yes N/A

Q9 In 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 = Missing

Number Yes N/A

Q10 In 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 = Missing

Number Yes N/A

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Q11 Did you and a doctor or other health provider talk about the reasons you might want your child to take a medicine?1 = Yes2 = No9 = Missing

Number Yes N/A

Q12 Did 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 = Missing

Number Yes N/A

Q13 When 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 = Missing

Number Yes N/A

Q14 Using 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 = Missing

Number Yes N/A

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Q15 In the last 6 months, how often was it easy to get the care, tests, or treatment your child needed?1 = Never2 = Sometimes3 = Usually4 = Always9 = Missing

Number Yes N/A

Q16 Is your child now enrolled in any kind of school or daycare?1 = Yes2 = No9 = Missing

Number Yes N/A

Q17 In 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 = Missing

Number Yes N/A

Q18 In 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 = Missing

Number Yes N/A

Q19 Special 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 = Missing

Number Yes N/A

Q20 In the last 6 months, how often was it easy to get special medical equipment or devices for your child?1 = Never2 = Sometimes3 = Usually4 = Always9 = Missing

Number Yes N/A

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Q21 Did 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 = Missing

Number Yes N/A

Q22 In 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 = Missing

Number Yes N/A

Q23 In the last 6 months, how often was it easy to get this therapy for your child?1 = Never2 = Sometimes3 = Usually4 = Always9 = Missing

Number Yes N/A

Q24 Did anyone from your child's health plan, doctor's office, or clinic help you get this therapy for your child? 1 = Yes2 = No9 = Missing

Number Yes N/A

Q25 In 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 = Missing

Number Yes N/A

Q26 In the last 6 months, how often was it easy to get this treatment or counseling for your child?1 = Never2 = Sometimes3 = Usually4 = Always9 = Missing

Number Yes N/A

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Q27 Did 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 = Missing

Number Yes N/A

Q28 In 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 = Missing

Number Yes N/A

Q29 In 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 = Missing

Number Yes N/A

Q30 A 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 = Missing

Number Yes N/A

Q31 In 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 = Missing

Number Yes N/A

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Q32 In 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 = Missing

Number Yes N/A

Q33 In the last 6 months, how often did your child’s personal doctor listen carefully to you?1 = Never2 = Sometimes3 = Usually4 = Always9 = Missing

Number Yes N/A

Q34 In 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 = Missing

Number Yes N/A

Q35 Is your child able to talk with doctors about his or her health care?1 = Yes2 = No9 = Missing

Number Yes N/A

Q36 In 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 = Missing

Number Yes N/A

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Q37 In the last 6 months, how often did your child’s personal doctor spend enough time with your child?1 = Never2 = Sometimes3 = Usually4 = Always9 = Missing

Number Yes N/A

Q38 In 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 = Missing

Number Yes N/A

Q39 In 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 = Missing

Number Yes N/A

Q40 In 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=Missing

Number Yes N/A

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Q41 Using 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 = Missing

Number Yes N/A

Q42 Does your child have any medical, behavioral, or other health conditions that have lasted for more than 3 months?1 = Yes2 = No9 = Missing

Number Yes N/A

Q43 Does 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 = Missing

Number Yes N/A

Q44 Does 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 = Missing

Number Yes N/A

Q45 Specialists 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 = Missing

Number Yes N/A

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Q46 In 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 = Missing

Number Yes N/A

Q47 How many specialists has your child seen in the last 6 months? 0 = None1 = 1 specialist2 = 23 = 34 = 45 = 5 or more specialists9 = Missing

Number Yes N/A

Q48 We 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 = Missing

Number Yes N/A

Q49 In the last 6 months, did you get information or help from customer service at your child's health plan?1 = Yes2 = No9 = Missing

Number Yes N/A

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Q50 In 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 = Missing

Number Yes N/A

Q51 In 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 = Missing

Number Yes N/A

Q52 In the last 6 months, did your child's health plan give you any forms to fill out?1 = Yes2 = No9 = Missing

Number Yes N/A

Q53 In the last 6 months, how often were the forms from your child's health plan easy to fill out?1 = Never2 = Sometimes3 = Usually4 = Always9 = Missing

Number Yes N/A

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Q54 Using 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 = Missing

Number Yes N/A

Q55 In the last 6 months, did you get or refill any prescription medicines for your child? 1 = Yes2 = No9 = Missing

Number Yes N/A

Q56 In 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 = Missing

Number Yes N/A

Q57 Did anyone from your child's health plan, doctor's office, or clinic help you get your child's prescription medicines?1 = Yes2 = No9 = Missing

Number Yes N/A

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Q58 In general, how would you rate your child's overall health?1 = Excellent2 = Very Good3 = Good4 = Fair5 = Poor9 = Missing

Number Yes N/A

Q59 In general, how would you rate your child's overall mental or emotional health?1 = Excellent2 = Very Good3 = Good4 = Fair5 = Poor9 = Missing

Number Yes N/A

Q60 Does your child currently need or use medicine prescribed by a doctor (other than vitamins)? 1 = Yes2 = No9 = Missing

Number Yes N/A

Q61 Is this because of any medical, behavioral, or other health condition?1 = Yes2 = No9 = Missing

Number Yes N/A

Q62 Is this a condition that has lasted or is expected to last for at least 12 months?1 = Yes2 = No9 = Missing

Number Yes N/A

Q63 Does 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 = Missing

Number Yes N/A


Number Yes N/A

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Q65 Is this a condition that has lasted or is expected to last for at least 12 months? 1 = Yes2 = No9 = Missing

Number Yes N/A

Q66 Is 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 = Missing

Number Yes N/A


Number Yes N/A

Q68 Is this a condition that has lasted or is expected to last for at least 12 months?1 = Yes2 = No9 = Missing

Number Yes N/A

Q69 Does your child need or get special therapy such as physical, occupational, or speech therapy? 1 = Yes2 = No9 = Missing

Number Yes N/A


Number Yes N/A

Q71 Is this a condition that has lasted or is expected to last for at least 12 months? 1 = Yes2 = No9 = Missing

Number Yes N/A

Q72 Does 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 = Missing

Number Yes N/A

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Q73 Has this problem lasted or is expected to last for at least 12 months?1 = Yes2 = No9 = Missing

Number Yes N/A

Q74 What is your child's age? 00 = less than 1 yearEnter reported age if one year or older99 = Missing

Number Yes N/A

Q75 Is your child male or female?1 = Male2 = Female9 = Missing

Number Yes N/A

Q76 Is your child of Hispanic or Latino origin or descent?1 = Yes, Hispanic or Latino2 = No, not Hispanic or Latino9 = Missing

Number Yes N/A

Q77a What is your child’s race? Mark one or more. 1 = Respondent checked "White"9 = Missing

Number Yes N/A

Q77b What is your child’s race? Mark one or more. 1 = Respondent checked "Black or African American"9 = Missing

Number Yes N/A

Q77c What is your child’s race? Mark one or more. 1 = Respondent checked "Asian"9 = Missing

Number Yes N/A

Q77d What is your child’s race? Mark one or more. 1 = Respondent checked "Native Hawaiian or other Pacific Islander"9 = Missing

Number Yes N/A

Q77e What is your child’s race? Mark one or more. 1 = Respondent checked "American Indian or Alaska Native"9 = Missing

Number Yes N/A

Q77f What is your child’s race? Mark one or more. 1 = Respondent checked "Other"9 = Missing

Number Yes N/A

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Q78 What is your age? 0 = Under 181 = 18-242 = 25-343 = 35-444 = 45-545 = 55-646 = 65-747 = 75 or older9 = Missing

Number Yes N/A

Q79 Are you male or female?1 = male2 = female9 = Missing

Number Yes N/A

Q80 What 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 = Missing

Number Yes N/A

Q81 How are you related to the child?1 = Mother or father2 = Grandparent3 = Aunt or uncle4 = Older brother or sister5 = Other relative6 = Legal guardian7 = Someone else9 = Missing

Number Yes N/A

Q82 Did someone help you complete this survey?1 = Yes2 = No9 = Missing

Number Yes N/A

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Q83a How did that person help you?1 = Respondent checked "Read the questions to me"9 = Missing

Number Yes N/A

Q83b How did that person help you? 1 = Respondent checked "Wrote down the answers I gave"9 = Missing

Number Yes N/A

Q83c How did that person help you? 1 = Respondent checked "Answered the questions for me"9 = Missing

Number Yes N/A

Q83d How did that person help you? 1 = Respondent checked "Translated the questions into my language"9 = Missing

Number Yes N/A

Q83e How did that person help you? 1 = Respondent checked "Helped in some other way"9 = Missing

Number Yes N/A

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Care Management LogFIELD NAME FIELD DESCRIPTION FIELD TYPE REQUIRED FIELD REQUIREMENTS AND MASKSMember ID Medicaid member ID Short Text Yes N/AReport Date The Quarter the record was reported in by calendar year

in the following format: Qx-YYYYShort Text Yes N/A

Sex Members sexCHOOSE FROM:MaleFemaleOther

Short Text Yes N/A

DOB Date of Birth Date/Time Yes N/AContact Frequency Contact 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 moreMonthlyQuarterly

Short Text Yes N/A

Risk Category CHOOSE:LowMediumHigh

Short Text Yes N/A

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Identified Care Needed Choose 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 Text Yes N/A

HCBS waiver CHOOSE:AD WaiverTBI WaiverCDD WaiverDDAD WaiverNone

Short Text Yes N/A

IHS/Tribal Organization Is the member a part of an Indian Health Service (IHS) or other Tribal organization

Yes/No Default: No N/A

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CM ID method The method through which the members were identified for Care ManagementCHOOSE: HRAPlan identifiedMember requestHospital dischargeProvider requestOther

Short Text Yes N/A

CM ID description Brief 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 reasons

Long Text No REQUIRED IF AND ONLY IF: “CM ID method” is “Other”

Date of HRA Date of the members Health Risk Assessment Date/Time No REQUIRED IF AND ONLY IF: “CM ID method” is “HRA”

Date Enrolled in CM Date the member was enrolled into CM Date/Time Yes N/ACM ongoing Is the member still in CM as of the filing of this record Yes/No Default: No N/ADate CM Conclusion Date of the members CM conclusion Date/Time No REQUIRED IF AND ONLY IF: “CM ongoing”

is “No”CM Conclusion Reason CHOOSE:

Member RequestMember DeceasedMember Discharged from PlanGoals Completed

Short Text No REQUIRED IF AND ONLY IF: “CM ongoing” is “No”

PCP NPI members PCP NPI number Short Text Yes N/APCP NE Medicaid ID members PCP Medicaid ID number Short Text Yes N/ASpecialist NPI members specialist NPI number Short Text No N/ASpecialist NE Medicaid ID members specialist Medicaid ID number Short Text No N/A

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Facility and Provider SurveyFIELD NAME FIELD DESCRIPTION FIELD TYPE REQUIRED FIELD REQUIREMENTS AND MASKSID This 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 Text Yes N/A

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Grievance LogFIELD NAME FIELD DESCRIPTION FIELD TYPE REQUIRED FIELD REQUIREMENTS AND MASKSCase ID Case ID or file number used by MCE to

track the complaintShort Text Yes N/A

Member ID Member Medicaid ID number Short Text Yes If the Complaint is from a Provider and there is no Member ID, please enter “99999999999.”

Provider/Client CHOOSE: ProviderClientOn Behalf of Client

Short Text Yes N/A



Complaint Type CHOOSE: -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-Other

Short Text Yes N/A

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Other Complaint Description Short description of the complaint when “Complaint Type” is “Other.”

Long Text No REQUIRED IF AND ONLY IF: “Complaint Type” is “Other”

Complaint Date Date complaint was filed with MCE Date/Time Yes N/A

Complaint Response Method and summary of response to member

Long Text Yes N/A

Complaint Response Date Date of response to complaint Date/Time Yes If the Grievance is unresolved at the end of the reporting period, please enter “1/1/3999” for the Complaint Response Date.


NOTE: If Complaint has an associated Claim ID, it should be populated here.

Short Text No Leave this field blank if Complaint has no associated Claim ID number.

Date of Service Date the service was performed, if the Complaint concerns a service

Date/Time No N/A

Provider Name Name of the provider on the Complaint Short Text Yes N/ANE Medicaid Provider ID Provider’s NE Medicaid ID number

NOTE: If Complaint is directed toward the plan (Complaint Type is Administration), populate this field with “99999999999”.

Short Text Yes N/A

Provider NPI Provider’s NPI number

NOTE: If Complaint is directed toward the plan (Complaint Type is Administration), populate this field with “9999999999”.

Short Text Yes N/A

Procedure Code If a procedure is a part of the Complaint, list the procedure code

Short Text No N/A

NDC The NDC code of the medication associated with the Complaint

Short Text No SIZE: 11 CharactersREQUIRED IF AND ONLY IF: “Complaint Type” is “Pharmacy Benefit Manager”

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Long Text No REQUIRED IF AND ONLY IF: “Complaint Type” is “Pharmacy Benefit Manager

Out-of-Network ReferralsFIELD NAME FIELD DESCRIPTION FIELD TYPE REQUIRED FIELD REQUIREMENTS AND MASKSMember ID Member's Medicaid ID Short Text Yes N/AProvider NE Medicaid ID Providers NE Medicaid ID number Short Text Yes N/AProvider NPI Providers NPI Short Text Yes N/AProvider Name Provider's Name Short Text Yes N/AProvider Specialty Provider’s Specialty Short Text Yes N/AProvider City City in which the provider is located Short Text Yes N/AProvider State State in which the provider is located Short Text Yes N/ADate Auth Request Received

Date the Out-of-Network authorization request was received by the MCO

Date/Time Yes N/A

Type of Service CHOOSE:Acute RehabBH ServicesDMEHome HealthInpatient ServicesOutpatient ServicesPharmacyPT/OT/STOther

Short Text Yes N/A

Other TOS Desc Short narrative describing the type of service Long Text No REQUIRED IF AND ONLY IF: "Type of Service" is "Other"

ICD-10 Code ICD-10 Code of the ask in question Short Text No MASKED: 7 digit max, 3 min (required) first must be letter, second a number, others alpha-numeric

CPT Code CPT code of the ask in question Short Text No MASKED: 5 digit max, all or none (5 digits or empty), all numbers

HCPCS Code HCPCS code of the ask in question Short Text No MASKED: 5 digit max, all or none (5 digits or empty), first digit is alpha numeric and remaining are numeric

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Decision CHOOSE: ApprovedDenied

Short Text Yes N/A

Date of Decision Date of approval or denial Date/Time Yes N/AReason for Decision Choose 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 network

Short Text Yes N/A

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State 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 NAME FIELD DESCRIPTION FIELD TYPE REQUIRED FIELD REQUIREMENTS AND MASKSHearing ID Hearing ID for the State Fair Hearing Short Text Yes N/AMember ID Member Medicaid ID number Short Text Yes N/AProvider/Client CHOOSE:

-Provider-Client-On Behalf of Client

Short Text Yes N/A



State Fair Hearing Type CHOOSE:-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

-Other

Short Text Yes N/A

Other State Fair Hearing Description Short description of the State Fair Hearing Long Text No REQUIRED IF AND ONLY IF: “State Fair Hearing Type” is “Other.” Leave blank if “State Fair Hearing Type” is not “Other.”

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NOTE: 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 ID

Short Text No Leave 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 Service Date the service was performed Date/Time No N/A

Date of State Fair Hearing Date of the State Fair Hearing Date/Time Yes N/A

Resolution Date Date the State Fair Hearing was resolved Date/Time Yes If the State Fair Hearing is unresolved at the end of the reporting period, please enter “1/1/3999” for the Resolution Date.

Resolution Outcome CHOOSE (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 Text Yes N/A

Reason Unresolved Short description of the reason the State Fair Hearing is unresolved

Short Text No REQUIRED IF AND ONLY IF: “Resolution Outcome” is "Unresolved."

Provider Name Name of the provider on the State Fair Hearing

Short Text Yes N/A

Provider NE Medicaid ID Provider’s NE Medicaid ID number Short Text Yes N/A

Provider NPI Provider’s NPI number Short Text Yes N/A

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Procedure Code If a procedure is a part of the State Fair Hearing, list the code of the procedure

Short Text No N/A

NDC The NDC code of the medication associated with the State Fair Hearing.

Short Text No SIZE: 11 CharactersREQUIRED IF AND ONLY IF: “State Fair Hearing Type” is “Denial or Limited Authorization of Requested Medication”


Long Text No REQUIRED IF AND ONLY IF: “State Fair Hearing Type” is “Denial or Limited Authorization of Requested Medication”

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nebraska department of health & human servicesdhhs.ne.gov/medicaid health plan reporting...

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