EDGE Server Schemas

8/18/2019 EDGE Server Schemas

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Centers for Medicare & Medicaid Services

EDGE Server Production and Test SchemaData Dictionary

Version 10.0March 2016


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EDGE Server Production and Test Schema Data Dictionary March Release

Document Version History

Version

NumberDate Author/Owner Description of Change

1.0 10/19/2014 Accenture / CCIIO Initial Version

2.0 1/27/2015 Accenture / CCIIO Added new tables: RISKSCORE, STNG_RADV_POPULATION,

STNG_REINSURANCE and modified table MDCL_CLM_DGNS_CD_ASCTN.

3.0 2/15/2015 Accenture/CCIIO Added new tables: SUBPLCY, SUB_PLCY_CLM_ASSOC, EDGE_EVENT_LOG,

MEDICAL_CLAIM_SRVC_MDFR_ASCTN.

Added a new column: ‘MEDICAL_SRVC_LINE_NUM’ in table

EDGE_ERROR_LOG.

4.0 3/10/2015 Accenture/CCIIO Added group tag to the tables to group them logically. Changed

EDGE_ERROR_LOG category to Staging Table.

5.0 4/17/2015 Accenture/CCIIO Added a new column: ‘CLAIM_TYPE’ in table STNG_REINSURANCE.

6.0 5/26/2015 Accenture/CCIIO Added a new table: SUP_CLM_DGNS_CD_ASCTN.

7.0 10/23/2015 Accenture/CCIIO Changed the data type from BIT(1) to VARCHAR(1) in the column ‘RA_FLAG’of table MEDICAL_CLAIM.

Deleted the columns: ‘RA_FLAG’ and ‘RA_REASON_CODE’ in table

SUPPLEMENTAL_CLAIM.

8.0 1/29/2016 Accenture/CCIIO Added new tables: MMBR_INSRNC_PLCY_CVRG_CRSS_YR_HSTY,

STNG_MMBR_INSRNC_PLCY_CVRG_CRSS_YR,

STNG_MMBR_INSRNC_PLCY_CVRG_PROFILE_ASCTN,

STNG_INSRD_MMBR_CC_ASSOC, STNG_INSRD_MMBR_DGNS_ASSOC,

STNG_INSRD_MMBR_HCC_ASSOC,

STNG_INSRD_MMBR_HCC_GROUP_ASSOC;

Added new columns: ‘CLAIM_FROM_DATE’ in table STNG_REINSURANCE,

‘HCC_UNIQUE_COUNT’ in table RISCKSCORE, V3_INDICATOR in table

RISKSCORE, ‘SEVERITY_INTER_GRP’ in table RISKSCORE;

Removed constraints from these staging tables: SUB_PLCY to MMBR_INSRNC_PLCY_CVRG, SUB_PLCY to

MMBR_INSRNC_PLCY_CVRG_PROFILE_ASCTN, RISKSCORE to

MMBR_INSRNC_PLCY_CVRG, and SUB_PLCY_CLM_ASSOC to SUB_PLCY.

9.0 2/26/2016 Accenture/CCIIO Added new columns: ‘MEDICAL_CLAIM_FAMILY_ID’ in table

SUPPLEMENTAL_CLAIM; ‘INSRNC_PLAN_ID_REP’ in table

STNG_MMBR_INSRNC_PLCY_CVRG_CRSS_YR.

10.0 3/17/2016 Accenture/CCIIO Added new columns: ‘INSRNC_PLAN_ID_REP’, ‘PLCY_RATG_AREA_CD’,

‘INSRD_MMBR_ID’,’MMBR_MNTHS’, ‘UTILIZER_IND’,

‘CROSS_YEAR_CLAIM_UID’, ‘GNDR_CD’, ‘ARF_AGE’, ‘LAST_AGE’,

‘INFANT_HCC_SEVERITY’, ‘’ INFANT_HCC_MATURITY,‘RCVD_INSRD_MMBR_ID’, ‘CVRG_EFCTV_STRT_DT’, ‘CVRG_EFCTV_END_DT’,

‘MTL_LVL’, ‘EXCHANGE_TYPE’, ‘MARKET_TYPE’ in table RISKSCORE.

Added new tables: STNG_INSRD_MMBR_DGNS_UTI_ASSOC,

STNG_INSRD_MMBR_DROP_HCC_ASSOC, RISKSCORE_REMOTE.

Changed a table name: changed the name of table

STNG_INSRD_MMBR_DGNS_ASSOC to

STNG_INSRD_MMBR_DGNS_ASSOC_ACCEP.

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Contents

1. INTRODUCTION ..................................................................................................................................................1

2. DATABASECHANGELOG ......................................................................................................................................2

3. DATABASECHANGELOGLOCK .............................................................................................................................3

4. EDGE_ERROR_LOG .............................................................................................................................................4

5. EDGE_EVENT_LOG ..............................................................................................................................................6

6. INSRD_MMBR .....................................................................................................................................................7

7. MDCL_CLM_DGNS_CD_ASCTN ..........................................................................................................................8

8. MEDICAL_CLAIM .................................................................................................................................................9

9. MEDICAL_CLAIM_SRVC_LINE .......................................................................................................................... 11

10. MEDICAL_CLAIM_SRVC_MDFR_ASCTN ....................................................................................................... 13

11. MMBR_INSRNC_PLCY_CVRG ....................................................................................................................... 14

12. MMBR_INSRNC_PLCY_CVRG_CRSS_YR_HSTY............................................................................................. 16

13. MMBR_INSRNC_PLCY_CVRG_PROFILE_ASCTN ........................................................................................... 18

14. PHARMACY_CLAIM ...................................................................................................................................... 19

15. PRM_STBLZN_SUBMSN_STUS ..................................................................................................................... 21

16. RECORD_LEVEL_HIER .................................................................................................................................. 22

17. RISKSCORE ................................................................................................................................................... 23

18. RISKSCORE_REMOTE ................................................................................................................................... 25

19. STNG_ENRLMT_SUBMSN ............................................................................................................................ 27

20. STNG_INSRD_MMBR_CC_ASSOC ................................................................................................................ 29

21. STNG_INSRD_MMBR_DGNS_ASSOC_ACCEP .............................................................................................. 30

22. STNG_INSRD_MMBR_DGNS_UTI_ASSOC ................................................................................................... 31

23. STNG_INSRD_MMBR_DROP_HCC_ASSOC .................................................................................................. 32

24. STNG_INSRD_MMBR_HCC_ASSOC.............................................................................................................. 33

25. STNG_INSRD_MMBR_HCC_GROUP_ASSOC ................................................................................................ 34

26. STNG_MDCL_SUBMSN ................................................................................................................................ 35

27. STNG_MMBR_INSRNC_PLCY_CVRG_CRSS_YR ............................................................................................ 37

28. STNG_MMBR_INSRNC_PLCY_CVRG_PROFILE_ASCTN ................................................................................ 39

29. STNG_PHRMCY_SUBMSN ............................................................................................................................ 40

30. STNG_RADV_POPULATION.......................................................................................................................... 42

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31. STNG_REINSURANCE ................................................................................................................................... 43

32. STNG_SPLMNTL_SUBMSN ........................................................................................................................... 44

33. SUB_PLCY ..................................................................................................................................................... 46

34. SUPPLEMENTAL_CLAIM............................................................................................................................... 47

35. SUB_PLCY_CLM_ASSOC ............................................................................................................................... 49

36. SUB_CLM_DGNS_CD_ASCTN ....................................................................................................................... 50

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1. INTRODUCTION

This data dictionary documents the External Data Gathering Environment (EDGE) Server Production

and Test schemas. Two (2) schemas are utilized by the EDGE server application. The production and

test schemas are identical data models. The test schema can be used to test and validate inbound

eXtensible Markup Language (XML) files. Summary reports generated from the test schema are not

sent to the Centers for Medicare & Medicaid Services (CMS). Both detailed and error reports are

available to the issuer to facilitate remediation of inbound XML issues that may be encountered.

The EDGE Server Production schema is used by the issuer to process production files. Summary

reports generated from the production schema are sent to CMS. Both detailed and error reports are

available to the issuer to review.

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2. DATABASECHANGELOGTable Name: DATABASECHANGELOG

Group: Tracking Error Liquibase Table

Category: DB change log System Table (for system internal use only)Table Definition: This is a system level table to track database changes. Should not be modified.

Column Name Data Type Null Option Type Column Definiti on

ID VARCHAR(255) Not Null Unique Liquibase ID.

AUTHOR VARCHAR(255) Not Null EDGE server system.

FILENAME VARCHAR(255) Not Null XML file name in Liquibase.

DATEEXECUTED DATETIME Not Null Liquibase execution date.

ORDEREXECUTED DATETIME Not Null UID that Liquibase is executed.

EXECTYPE VARCHAR(10) Not Null Execution type.

MD5SUM VARCHAR(35) Null Checksum value of the changeset.

DESCRIPTION VARCHAR(255) Null Descript ion.

COMMENTS VARCHAR(255) Null Comments.

TAG VARCHAR(255) NullSpecify the tag name when launchingLiquibase.

LIQUIBASE VARCHAR(20) Null Liquibase version.

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3. DATABASECHANGELOGLOCKTable Name: DATABASECHANGELOGLOCK


Category: DB change lock System Table (for system i nternal use only)Table Definition: This is a system level table to track database changes. Should not be modified.


ID INT(11) Not Null Unique ID.

LOCKED BIT(1) Not NullNumber of records locked when launchingLiquibase.

LOCKGRANTED DATETIME Null Date that lock is granted.

LOCKEDBY VARCHAR(255) NullUser that locked records when launchingLiquibase.

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4. EDGE_ERROR_LOGTable Name : EDGE_ERROR_LOG

Group: Staging & Reporting Table

Category: Staging TableTable Definition: The table logs busi ness validation errors, inline validation errors into this table, and it wi ll be used for generatingthe outbound reports.

Column Name Data Type Null Option Type Column Definition

UID INT(10) Not Null Unique database row identifier.

RECORDID BIGINT(19) Not Null Unique identifier for each record in the received file.

RECORDLEVEL VARCHAR(45) Not Null

The record level is used to record the different levels inthe file. For instance, issuer level, plan level, enrolleelevel, enrollment period level, claim detail level and claimservice line level, etc.

ELEMENTNAME VARCHAR(100) NullThe element name represents the XML tag name of theinbound file. The name of the element that has the error.

ELEMENTVALUE VARCHAR(100) NullThe value of the element as it was received onsubmission.

ERRORSPECIFICTYPE VARCHAR(200) NullText description of error specific type that relates toERRORTYPENO.

ERRORCODE VARCHAR(45) NullThe code associated with the error.Internal unique Error Code number.

ERRORDETAIL VARCHAR(500) Null A system generated Error Message for exceptions.

ERRORMESSAGE VARCHAR(500) Null A pre-defined Error Message that corresponds to theError Code.

JOBID BIGINT(19) Not Null Reference to the job that inserted this record.

SUBMISSIONTYPE VARCHAR(80) Null

Type of record submitted. Valid values are:

• ‘M’ – Medical Claim

• ‘P’ – Pharmacy Claim

• ‘E’ – Enrollment• ‘S’ – Supplemental Diagnosis

ERROR_TYPE VARCHAR(50) Null

Description of the error type associated with‘ERRORTYPENO’. Valid values are:

• ‘1’ – For required/situational

• ‘2’ – For face validity

• ‘3’ – Reference

• ‘4’ – Logical

• ‘5’ – Business

• ‘6’ – System

ERRORLEVELNO BIGINT(19) NullThe Error Code consists of three (3) digits. The first digitrepresents the Error Level.

ERRORTYPENO BIGINT(19) Null

Error type number. Valid values are:

• ‘1’ – For required/situational

• ‘2’ – For face validity

• ‘3’ – Reference

• ‘4’ – Logical• ‘5’ – Business

• ‘6’ – System

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Table Name : EDGE_ERROR_LOG (Cont.)


Category: Staging TableTable Definition: The table logs busi ness validation errors, inline validation errors into this table, and it wi ll be used for generatingthe outbound reports.


STATUS_TYPE CHAR(1) Null

Describes the status type of the processeddata element in a received inbound file.Valid values are:

• ‘A’ – Accept

• ‘R’ – Reject

• ‘I’ – Informational (Acceptedwith warning message)

CLAIM_IDENTIFIER VARCHAR(80) Null The unique identifier for a claim.

MEDICAL_SRVC_LINE_NUM VARCHAR(20) Null Medical service line number.

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5. EDGE_EVENT_LOG

Table Name : EDGE_EVENT_LOG


Category: Transaction tableTable Definition: The table logs each event that happens on edge application i nto this table.


UID BIGINT(19) NOT NULLUnique identifier (Primary Key) of thedatabase row.

JOB_ID BIGINT(19) NULLReference to the job that inserted therecord.

JOB_TYPE VARCHAR(25) NULLDefines the type of job the EDGE serverprocessed.

JOB_COND VARCHAR(100) NULL

Condition of the job processed. Validvalues:

• Pre

• Post

EVENT_ID VARCHAR(100) NULL Short description of the job processed.

EVENT_VAL VARCHAR(100) NULL Deprecated.

EVENT_MSG VARCHAR(1000) NULL Full Description of the job processed.

EVENT_RESULT VARCHAR(10) NULL

Provides a status on the job run, identifiedby the Job ID. Valid values are:

• ‘0’ – The job ran but there aredata issues, blank reports aregenerated

• ‘1’ – The job ran successfullyand generated reports

EVENT_ORDER INT(10) NULLOrder in which the event occurred in the

job process.

CREATN_DT DATETIME NULLThis date is used to indicate when the jobis created.

CREATD_BY VARCHAR(50) NULL Deprecated.

LAST_MDFYD_DT DATETIME NULL Deprecated.

MDFYD_BY VARCHAR(50) NULL Deprecated.

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6. INSRD_MMBRTable Name : INSRD_MMBR

Group: Member Table

Category: Ingested Data TableTable Definition: This table has t he ingested enrollee/member info rmation.


INSRD_MMBR_ID INT(10) Not Null Unique database row identifier.

RCVD_SUBMSN_ID BIGINT(19) Not NullReference to the job that inserted thisrecord.

DOB DATE Not Null Date of birth of the enrollee.

CREATN_DT DATETIME Null Creation date of the row in the database.

INACTIVATION_DT DATETIME Null Date enrollee was inactivated (null ifenrollee is active).

LAST_CNFRMED_DT DATETIME Null Date the enrollee data on this row was lastupdated.

CREATD_BY VARCHAR(255) Null Deprecated.

LAST_MDFYD_DT DATETIME Null The last date and time the enrolleeinformation was updated.

MDFYD_BY VARCHAR(255) Null Deprecated.

ISSR_ORG_ID VARCHAR(5) Not Null Unique Health Insurance OversightSystem (HIOS) Issuer ID.

GNDR_CD VARCHAR(1) Not Null

Enrollee gender. Valid values are:

• ‘F’ – Female

• ‘M’ – Male

• ‘U’ – Unknown (accepted onlyfor newborns)

INSRD_MMBR_STUS_CD BIT(1) Not Null

Enrollee status. Valid values are:

• ‘0’ – inactive

• ‘1’ – active

RCVD_INSRD_MMBR_ID VARCHAR(80) Not Null Unique identifier of enrollee. Thisrepresents a MASKED identifier; not amedical record number or cardholder ID.

RCRD_IDNTFR BIGINT(19) Not Null Record identifier for this enrollee from theinbound XML file.

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7. MDCL_CLM_DGNS_CD_ASCTNTable Name: MDCL_CLM_DGNS_CD_ASCTN

Group: Claim Table

Category: Ingested Data TableTable Definition: This table has the ingested Diagnosis Codes from the medical cl aims.


UID BIGINT(19) Not NullUnique identifier (Primary Key) of thedatabase row.

MEDICAL_CLAIM_UID_FK BIGINT(19) Null

The unique identifier of the medical claimin the medical claim table that thisDiagnosis Code is associated. This is aforeign key reference toMEDICAL_CLAIM.UID.

CREATN_DT DATETIME NullThis date is used to indicate when therecord is created.


LAST_MDFYD_DT DATETIME Null The date and time the record is modified.


ACTV_IND VARCHAR(1) Null Deprecated.

DGNS_CD CHAR(30) Null

Code value for the Diagnosis Code asdetermined by classification ofInternational Classification of Diseases.Refer to DGNS_CD_TYPE for validvalues.

DGNS_QLFYR_CD CHAR(2) Null

Indicates if the Diagnosis Code isInternational Classification of Diseases, 9th Revision (ICD 9) or InternationalClassification of Diseases, 10th Revision(ICD 10). Refer to DGNS_CD_QLFYR forvalid values.

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8. MEDICAL_CLAIMTable Name: MEDICAL_CLAIM

Group: Claim Table

Category: Ingest Data TableTable Definition: This table has the ingested data for medical claims.


UID BIGINT(19) Not Null Unique database row identifier.

BENEFIT_YEAR VARCHAR(4) Not Null

The benefit year based for this claim, based on the statementdate. (1) Use Statement Covers To Date if it is not empty, (2)Use Statement Covers From Date if Statement Covers ToDate is empty and the form type is ‘I’, (3) Use Year ‘9999’ ifboth dates are empty. This column is not used for RA/RIprocessing.

STATEMENT_COVERS_TO_DATE DATE Null Medical claim end date.

STATEMENT_COVERS_FROM_DATE DATE Null Medical claim start date.

ADMISSION_DATE DATE Null Deprecated.

DISCHARGE_DATE DATE Null Deprecated.

ORIGINAL_CLAIM_ID VARCHAR(50) NullThe claim identifier of the medical claim that is to be voided or

replaced.

CLAIM_ALLOWED_TOTAL_AMOUNT DECIMAL(18,2) Null The total amount that is allowed on the medical claim.

CLAIM_PAID_TOTAL_AMOUNT DECIMAL(18,2) Null The total amount paid to the issuer for this claim.

CLAIM_STATUS_UPDATE_DATE DATE NullThe date the medical claim status was changed, from active toinactive.

RECEIVED_INSURED_MEMBER_ID VARCHAR(80) NullUnique identifier of enrollee. This represents a MASKEDidentifier; not a medical record number or cardholder ID.

BILLING_PROVIDER_ID CHAR(15) NullThe Billing Provider's Identification (NPI or unique issuerassigned Provider ID).

MEDICAL_CLAIM_ID VARCHAR(50) Null The claim identifier of the medical claim.

INACTIVATION_DT DATETIME Null Date the medical claim was inactivated (voided).

CREATION_DATE DATETIME NullSystem date when the claim was first inserted into thedatabase.


LAST_MODIFIED_DATE DATETIME Null System date when the claim was modified in the database.

MODIFIED_BY VARCHAR(255) Null Deprecated.

INSURANCE_PLAN_ID VARCHAR(16) NullUnique identifier for insurance plan offered by issuer that theenrollee is covered under. The Plan ID includes the CSRvariant.

ISSR_ORG_ID VARCHAR(5) Not Null Unique HIOS Issuer ID.

TRANSACTION_TYPE CHAR(2) Not Null

The type of the transaction. Valid values are:

• ‘O’ – Original

• ‘R’ – Replace• ‘V’ – Void

CLAIM_STATUS VARCHAR(30) Null

Claim status. Valid values are:



CLAIM_FILTERING_STATUS CHAR(1) Null Deprecated.

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Table Name: MEDICAL_CLAIM (Cont.)

Group: Claim Table

Category: Ingest Data TableTable Definition: This table has the ingested data for medical claims.


CLAIM_FORM_TYPE CHAR(1) Null

Describes claim form type as professional orinstitutional. Valid values are:

• ‘P’ – Professional

• ‘I’ – Institutional

CLAIM_BILL_TYPE CHAR(3) NullThe code indicating a specific type of bill asreported on institutional claims only. Refer to theCLAIM_BILL_TYPE table for valid values.

DISCHARGE_STATUS CHAR(2) NullThe facility discharge status of the enrollee. Referto the DSCHRG_STUS_TYPE table for validvalues.

CLAIM_TYPE CHAR(2) Null

The type of claim. Valid values are:



• ‘E’ – Enrollment

• ‘S’ – Supplemental Diagnosis

CLAIM_PROCESSED_DATETIME DATETIME NullThe date and time when the claim wasadjudicated and resulted in a paid amount orreported encounter.

DERIVED_SERVICE_CLAIM_IND CHAR(1) NullIndicator used to distinguish between fee-for-service claims and claims covered undercapitation.

BILLING_PROVIDER_QLFYR_CODE CHAR(2) Null

Identifies the type of Provider ID being submittedin the Billing Provider ID field. Valid values are:

• ‘XX’ – Billing Provider ID is an NPIprovider

• ‘99’ – Can be a 15-digit long identifier

JOB_ID BIGINT(19) Null Reference to the job that inserted this record.

DERIVED_BENEFIT_MONTH VARCHAR(2) Null Deprecated.

RECORD_ID BIGINT(19) Null Unique identifier for claim in medical claim file.

SERVICE_PAID_DATE DATE NullThe date a check or electronic funds transfer wasissued for paid claims. For encounters, the datepaid means the date of claim adjudication.

LAST_CONFIRMED_DATE DATETIME Null Date the claim was last updated.

RA_FLAG VARCHAR(1) NullFlag indicating that a claim was ‘1’ or was not ‘0’selected for Risk Adjustment (RA).

CLAIM_FAMILY_ID BIGINT(19) Not NullUnique identifier for a group of claims that belong

to the same claim family.

RA_REASON_CODE VARCHAR(3) NullReason Code indicating why a claim was notselected.

RI_FLAG VARCHAR(1) NullReinsurance (RI) claim selection flag to indicate ifclaim qualifies for RI.

RA_USED VARCHAR(1) NullFlag used to help calculate multiple fields in RAPayment Hierarchal Condition Category EnrolleeReport (RAPHCCER).

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9. MEDICAL_CLAIM_SRVC_LINETable Name: MEDICAL_CLAIM_SRVC_LINE

Group: Claim Table

Category: Ingest Data TableTable Definition: This table has the ingested data for medical claim service li nes.


MEDICAL_SRVC_LINE_NUM INT(10) Not NullUnique number generated to represent service(s)submitted on the claim.

SRVC_FROM_DT DATE Null

Represents the first date of service on a submittedclaim for a specific claim line.

Also represents the Service Date on aninstitutional claim.

SRVC_TO_DT DATE NullRepresents the last Date of Service on asubmitted claim for a specific claim line.

ALOWD_AMT DECIMAL(18,2) Null Total amount allowed by plan.

PLCY_PD_AMT DECIMAL(18,2) Null Total amount paid, or derived, by plan.

MEDICAL_CLAIM_UID_FK BIGINT(19) Not NullReference to the medical claim this service l ine isassociated with. This is a foreign key reference toMEDICAL_CLAIM.UID.


RNDRNG_PRVDR_ID CHAR(15) Null The Rendering Provider's identif ication number.

CREATN_DT DATETIME NullSystem date when this service line was firstcreated in the database.


LAST_MDFYD_DT DATETIME NullSystem date when this service line was modified inthe database.


SRVC_PLACE_CD CHAR(2) Null A code that identifies where the service wasrendered. Refer to SRVC_PLC_TYPE for validvalues.

REV_CD CHAR(4) NullDescribes the revenue center in which the servicewas provided. Refer to REV_CD_TYPE table forvalid values.

SRVC_CD CHAR(48) Null A code that identifies the source of the procedurecode (CPT or HCPCS). Refer to SRVC_CD_TYPEtable for valid values.

CLAIM_FLTRING_STUS_CD CHAR(1) Null Deprecated.

SRVC_TYPE_CD CHAR(2) Null

A procedure code that identifies the servicerendered: Valid values are:

• ‘01’ – Dental Service Codes

• ‘03’ – Healthcare Common ProcedureCoding System (HCPCS) or CurrentProcedural Terminology (CPT)

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Table Name: MEDICAL_CLAIM_SRVC_LINE (Cont.)

Group: Claim Table

Category: Ingest Data TableTable Definition: This table has the ingested data for medical claim service li nes.


DRVD_SRVC_CLM_CD CHAR(1) Null

Indicator used to distinguish between fee-for-service claims and claims covered undercapitation. Valid values are:

• ‘Y’ – Derived (capitated Service)

• ‘N’– Actual (Fee-For-Service)

RNDRNG_PRVDR_QLFYR_CD CHAR(2) Null

Identifies the type of Provider ID being submittedin the Rendering Provider ID field. Valid valuesare:

• ‘XX’ – Billing Provider ID is an NPIprovider

• ‘99’ – Can be a 15-digit long identifier

RECORD_ID BIGINT(19) NullUnique identifier for each record in medical claimfile.

JOB_ID BIGINT(19) Null Reference to the job that inserted this record.

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10. MEDICAL_CLAIM_SRVC_MDFR_ASCTNTable Name: MEDICAL_CLAIM_SRVC_MDFR_ASCTN

Group: Claim Table

Category: Ingested Data TableTable Definition: This table has the ingested service mod ifier codes from t he medical claim service lines.


SRVC_MDFR_CD CHAR(2) Not NullThe Service Modifier Code from the medical claimservice line. Refer to SRVC_CD_MDFR_TYPE forvalid values.

MEDICAL_CLAIM_SRVC_LINE_UID_FK BIGINT(19) Not Null

The unique identifier of the medical claim serviceline this Service Modifier Code is linked. This is aforeign key reference toMEDICAL_CLAIM_SRVC_LINE.UID.

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11. MMBR_INSRNC_PLCY_CVRGTable Name : MMBR_INSRNC_PLCY_CVRG

Group: Member Table

Category: Ingested Data TableTable Definition: This table has the ingested enrollee polic y/enrollment period infor mation.


MMBR_INSRNC_PLCY_CVRG_ID BIGINT(19) Not Null Unique database row identifier.

RCVD_SUBMSN_ID BIGINT(19) Not Null Reference to the job that inserted this record.

INSRNC_PLAN_ID VARCHAR(16) Not Null

Unique identifier for insurance plan offered by issuer thatthe enrollee is covered under. The Plan ID will correspondto the HIOS Standard Component ID. The Plan ID includesthe Cost-Sharing Reduction (CSR) variant.

CVRG_EFCTV_STRT_DT DATE NullThe date when the enrollment coverage for the enrolleebecame effective for the associated plan.

CVRG_EFCTV_END_DT DATE NullThe date when the enrollment coverage for the enrollee isno longer effective for the associated plan.

INSRNC_PLAN_PRM_AMT DECIMAL(18,2) Null

The Premium Amount is the monthly total rated premiumcharged by the issuer for a subscriber, including the

Advance Premium Tax Credit (APTC) amount. ThePremium Amount may include more than the amountcharged directly to a subscriber. The Premium Amountdoes not represent an amount paid by a subscriber.

CREATN_DT DATETIME Null Date and time when this row was created in the database.

INACTIVATION_DT DATETIME NullDate and time when this policy was inactivated, null ifpolicy is active.

LAST_CNFRMED_DT DATETIME NullDate and time the policy data on this row was last updated.It is the generation date and time from inbound XML file.

LAST_MDFYD_DT DATETIME Null Date and time when this row was modified in the database.



ENRLMT_MNT_TYPE_CD VARCHAR(6) Not Null

Identifies the type of activity associated with the creation ofan enrollment period.Valid values are:

• ‘021028’ – Initial issuance of the policy

• ‘001’ – Modification of existing policy

• ‘021EC’ – Addition of member to an existingpolicy

• ‘021041’ – Renewal of an existing policy for thenext year

PLCY_RATG_AREA_CD VARCHAR(15) Not NullRating Area used for the enrollee in the plan. If enrollee isnot rated, use the subscriber Rating Area.

INSRD_MMBR_STUS_CD CHAR(2) Not Null





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Table Name : MMBR_INSRNC_PLCY_CVRG (Cont.)

Group: Member Table

Category: Ingested Data TableTable Definition: This table has the ingested enrollee polic y/enrollment period infor mation.


INSRD_MMBR_ID INT(10) Not NullForeign key to the enrollee table to identify the associatedmember.

SBSCBR_IND CHAR(1) Null

Indicates when the enrollee linked to this enrollmentperiod record is also the subscriber. A subscriber isdefined as the primary insured party. Valid values are:

• ‘S’ – Subscriber

• Null or Blank – Non-subscriber

SBSCBR_ID CHAR(80) Null

This ID represents a Unique Enrollee ID who is identifiedas the primary insured party. This represents a MASKEDidentifier, not a medical record number or cardholder ID.If SBSCBR_IND is Null or Blank, this field must bepopulated.

RCRD_IDNTFR BIGINT(19) Not Null Unique identifier for each record in enrollment file.

RI_FLAG VARCHAR(1) Null RI claim selection flag to indicate if claim qualifies for RI.

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12. MMBR_INSRNC_PLCY_CVRG_CRSS_YR_HSTYTable Name : MMBR_INSRNC_PLCY_CVRG_CRSS_YR_HSTY

Group: Member Table

Category: Association TableTable Definition: This table host s the system generated cross-year enrollment periods for each RA run.


UID BIGINT(19) Not Null The UID.


MEDICAL_CLAIM_UID BIGINT(19) Null The medical claim UID.



Unique identifier for insurance plan offered by issuer thatthe enrollee is covered under. The Plan ID will correspondto the HIOS Standard Component ID. The Plan ID includesthe CSR variant.




The Premium Amount is the monthly total rated premiumcharged by the issuer for a subscriber, including the APTCamount. The Premium Amount may include more than theamount charged directly to a subscriber. The Premium

Amount does not represent an amount paid by asubscriber.










• ‘001’ – Modification of existing policy• ‘021EC’ – Addition of member to an existing

policy



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Table Name : MMBR_INSRNC_PLCY_CVRG_CRSS_YR_HSTY (Cont.)

Group: Member Table

Category: Association TableTable Definition: This table host s the system generated cross-year enrollment periods for each RA run.













This ID represents a Unique Enrollee ID who is identifiedas the primary insured party. This represents a MASKEDidentifier, not a medical record number or cardholder ID.

If SBSCBR_IND is Null or Blank, this field must bepopulated.



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13. MMBR_INSRNC_PLCY_CVRG_PROFILE_ASCTNTable Name : MMBR_INSRNC_PLCY_CVRG_PROFILE_ASCTN

Group: Member Table

Category: Association TableTable Definition: This table stores mapping between polic y ID and insured m ember policy coverage ID.


MMBR_INSRNC_PLCY_CVRG_ID_PK_FK BIGINT(19) NOT NULL Primary key for the Member Insurance Policy ID.

POLICY_ID BIGINT(19) NOT NULLGenerated Policy ID for the Member Insurance PolicyCoverage ID.

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14. PHARMACY_CLAIMTable Name : PHARMACY _CLAIM

Group: Claim Table

Category: Ingested Data TableTable Definition: This table has the ingested pharmacy claim data.


ID INT(10) Not Null Unique database row identifier.

JOBID BIGINT(19) Not Null Reference to the job that inserted the record.

RECEIVED_INSURED_MEMBER_ID VARCHAR(80) NullUnique identifier of enrollee. This represents aMASKED identifier; not a medical record number orcardholder ID.

CLAIM_IDENTIFIER VARCHAR(50) NullUnique number generated by issuer adjudicationsystem to uniquely identify the transaction.

CLAIM_PROCESSED_DATETIME DATETIME NullThe date and time when the claim was adjudicatedand resulted in a paid amount or reported

encounter.

PRESCRIPTION_FILL_DATE DATE Not NullIndicates the date that the prescription wasdispensed by the dispensing pharmacy.

ISSUER_CLAIM_PAID_DATE DATE Null

The date a check or electronic funds transfer wasissued by the insurance company/issuer to thevendor for paid claims. For encounters, the datepaid means the date of claim adjudication.

PRESCRIPTION_FILL_NUMBER INT(10) NullCode identifying whether the prescription is anoriginal (01) or refill (02-99).

PRESCRIPTION_SERVICE_REFERENCE_NUMBER

VARCHAR(255) NullUnique number assigned by the pharmacy to thedispensed prescription.

NATIONAL_DRUG_CODE VARCHAR(255) NullUnique ID of the product or service dispensed

[National Drug Code (NDC) code].

DISPENSING_PROVIDER _IDENTIFIER

VARCHAR(255) NullThe Dispensing Provider's identification number(NPI or unique Issuer assigned Provider ID).

DISPENSING_PROVIDER_ID_QUALIFIER

VARCHAR(255) NullIdentifies the type of dispensing provider ID beingsubmitted in the Dispensing Provider ID field.

DISPENSING_STATUS_CODE VARCHAR(1) Null

Indicates if the prescription was a partial or thecompletion of a partial fill. Valid values are:

• Null, Empty – Complete fill

• ‘P’ – Partial fill

• ‘C’ – Completion of a previous partial fill

POLICY_PAID_AMOUNT DECIMAL(18,2) NullThe total cost of the product/service paid by theplan.

DERIVED_SERVICE_CLAIM_INDICATOR

VARCHAR(1) Null

Indicator used to distinguish between fee-for-serviceclaims and claims covered under capitation. Validvalues are:

• ‘Y’ – Capitated

• ‘N’ – Fee-for-Service

INSURANCE_PLAN_IDENTIFIER VARCHAR(80) Null Unique insurance plan identif ier covering this claim.

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Table Name : PHARMACY _CLAIM (Cont.)

Group: Claim Table

Category: Ingested Data TableTable Definition: This table has the ingested pharmacy claim data.


ISSUER_IDENTIFIER VARCHAR(80) Null Unique HIOS Issuer ID.

VOID_REPLACE_CODE VARCHAR(1) Null

Identifies if a previously accepted claim isto be voided or replaced. Valid values are:

• ‘V’ – Void

• ‘R’ – Replace

• Null, Empty – Original

ALLOWED_TOTAL_COST_AMOUNT DECIMAL(18,2) NullRepresents the sum of allowed charges foringredient cost, dispensing fee, and salestax.

CREATION_DATE DATETIME NullDate when this row/claim was created inthe database.

LAST_MODIFIED_DATE DATETIME NullDate when this row/claim was modified inthe database.

CREATED_BY VARCHAR(255) NullUser ID that created this row/claim in thedatabase.

MODIFIED_BY VARCHAR(255) NullUser ID that modified this row/claim in thedatabase.

LAST_CONFIRMED_DATE DATETIME NullDate when this claim was last updated byan inbound XML file.

INACTIVATION_DATE DATETIME NullDate when this claim was inactivated, nullif claim active.

CLAIM_TRANSACTION_TYPE VARCHAR(1) Not Null

Indicates claim type. Valid values are:

• ‘V’ – Void

• ‘R’ – Replace

• ‘O’ – Original

BENEFIT_YEAR VARCHAR(4) Not Null Benefit year of the pharmacy claim.

RI_FLAG VARCHAR(1) NullRI claim selection flag to indicate if claimqualifies for RI.

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15. PRM_STBLZN_SUBMSN_STUSTable Name : PRM_STBLZN_SUBMSN_STUD

Group: Member Table

Category: Transitional TableTable Definition: This table has meta information about the file ingest processes run by the system.


RCVD_SUBMSN_ID BIGINT(19) Not Null The unique Job ID for the batch job.

RCVD_SUBMSN_DT_TIME DATETIME NullDate and time of the inbound XML filesubmission.

ISSR_PROCD_RUN_DT DATETIME NullDate and time when the inbound XML filewas generated.

CREATN_DT DATETIME Null Creation date of this row in the database.

FIL_ID VARCHAR(12) NullUnique file identifier from the inbound XMLfile.

SBMTTING_ORG_ID VARCHAR(5) Null Unique HIOS Issuer ID.

ZN_CD VARCHAR(1) Null

Indicator to denote which environment the

inbound XML file is intended. Valid valuesare:

• ‘T’ – Test

• ‘P’ – Production

SUBMSN_STUS_CD VARCHAR(1) Null Deprecated.

SUBMSN_TYPE_CD VARCHAR(1) Null

Submission type code. Valid values are:





EXCTN_STUS_CD VARCHAR(2) Null Deprecated.

PRCSG_STUS_CD VARCHAR(2) Null

Status of the job. Valid values are:

• ‘01’ – In Progress

• ‘02’ – Failed

• ‘03’ – Completed successfully

FIL_STUS_CD VARCHAR(2) Null

Status of the inbound file. Valid values are:

• ‘04’ – Header validation failed

• ‘05’ – File accepted

• ‘06’ – File rejected

FIL_NM VARCHAR(34) Null Inbound XML file name.

GENERIC_INFO BLOB Null Deprecated.

VERSION VARCHAR(25) Null EDGE server version information.

INBOUND_FILE_HASH VARCHAR(100) Null MD5 hash of the inbound XML file.

DETAIL_REPORT_HASH VARCHAR(100) Null MD5 hash of the detail error report.

JOB_END_DT DATETIME NullDate and time when file processingcompleted.

RA_PROCESSED BIT(1) TRUEFlag to indicate if record was included forrisk assurance.

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16. RECORD_LEVEL_HIERTable Name : RECORD_LEVEL_HIER


Category: Transitional Table (internal application table)Table Definition: The table is used to verify record level hierarchy reference codes, and used as the basis for fil e ingestion errorreports.



JOBID BIGINT(19) Not NullReference to the job that inserted therecord.

RECORDID BIGINT(19) Not NullUnique identifier for each record in thereceived file.

PARENT_RECORDID BIGINT(19) NullParent record identifier, internally used bythe application for report generation.

RECORDLEVEL VARCHAR(45) Not Null

The record level is used to record thedifferent levels in the file. For instance,issuer level, plan level, enrollee level,enrollment period level, claim detail level,and claim service line level, etc.

CURRENT_ELEMENTID VARCHAR(100) NullCurrent Element ID Value, internally usedby the application for report generation.

SUBMISSIONTYPE VARCHAR(80) Null

Describes the type of inbound XML filesubmitted. Valid values are:





STATUS_TYPE CHAR(2) Not Null

Describes the status type of the processeddata element in a received inbound file.Valid values are:

• ‘A’ – Accept

• ‘R’ – Reject

•

‘I’ – Informational (Accepted withwarning message)

CLAIM_FORM_TYPE CHAR(1) Null

Indicator for claim form type. Only used formedical claims.Valid values are:

• ‘I’ – Institutional

• ‘P’ – Professional

CLAIM_REFDATE VARCHAR(80) NullInternally used for reporting. Claimreference date to reference current andprevious claims.

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17. RISKSCORETable Name : RISKSCORE

Group: Member Table

Category: Risk Score Report TableTable Definition: This table stores data from r isk sco re report.

Column Name Data TypeNull OptionType

Column Definition

MMBR_INSRNC_PLCY_CVRG_ID BIGINT(19) Not Null Member Enrollee Policy Coverage ID (Primary Key).

JOB_ID BIGINT(19) Not Null Job ID of the process run (Primary Key).

MODEL_SCORE DECIMAL(33,15) Not Null Model score.

CSR_SCORE DECIMAL(33,15) Not Null CSR factor quantity.

DEMOGRAPHIC_SCORE DECIMAL(33,15) Not Null Demographic factor quantity.

RA_SCORE DECIMAL(33,15) Not Null Risk assurance quantity.

CC_FLAG VARCHAR(1) Not Null Conditional category code flag.

MODEL_TYPE VARCHAR(20) Not Null

Age model type valid values are:• Adult

• Child

• Infant

MAX_PERIOD_DATE DATETIME Not Null Enrollment End Date.

RA_CLAIM_COUNT INT(10) Not Null Risk assurance claim counts.

TOTAL_PLAN_PAID VARCHAR(33) Not Null Total number of paid plans.

DX_TO_CC_UNIQUE_COUNT INT(10) Not NullUnique Diagnosis Code to Condition Code (CC) codecount.

DX_TO_CC_COUNT INT(10) Not Null Total Diagnosis Code to CC code count.

DX_UNIQUE_COUNT INT(10) Not Null Unique Diagnosis Code count.

DX_COUNT INT(10) Not Null Diagnosis Code count.

CC_UNIQUE_COUNT INT(10) Not Null Unique CC code count.

HCC_UNIQUE_COUNT INT(10) Not NullHolds the unique number of Hierarchal ConditionCategory (HCC) codes.

V3_INDICATOR VARCHAR(10) Not Null'Y' or 'N' depending if there is a severity interactionindicator.

SEVERITY_INTER_GRP VARCHAR(10) Not NullThe severity level interaction level either 'M' for mediumor 'H' for high or blank for no severity interaction.

INSRNC_PLAN_ID_REP VARCHAR(14) Not Null Unique insurance plan identif ier with 14 digits.

PLCY_RATG_AREA_CD VARCHAR(15) Not Null Rating Area code.


MMBR_MNTHS DECIMAL(33,15) Null The number of enrollment months for the current period.

UTILIZER_IND VARCHAR(1) Null An indicator that indicates whether the enrollee is autilizer.

CROSS_YEAR_CLAIM_UID BIGINT(19) Null The medical claim UID.

GNDR_CD VARCHAR(1) Null




• ‘U’ – Unknown (accepted only for newborns)

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Table Name : RISKSCORE (Cont .)

Group: Member Table

Category: Risk Score Report TableTable Definition: This table stores data from r isk sco re report.

Column Name Data Type Null OptionType Column Definition

ARF_AGE INT(10) Null The allowable rating factor (ARF) age of the enrollee.

LAST_AGE INT(10) Null The age of the enrollee in the last day of enrollment.

INFANT_HCC_SEVERITY VARCHAR(3) Null HCC severity code for infants.

INFANT_HCC_MATURITY VARCHAR(3) Null Maturity code for infants.

RCVD_INSRD_MMBR_ID VARCHAR(80) Not NullUnique identifier of enrollee. This represents a MASKEDidentifier; not a medical record number or cardholder ID.

CVRG_EFCTV_STRT_DT DATE Not NullThe date when the enrollment coverage for the enrolleebecame effective for the associated plan.

CVRG_EFCTV_END_DT DATE Not Null The date when the enrollment coverage for the enrollee isno longer effective for the associated plan.

MTL_LVL VARCHAR(2) Not Null Metal Level Code.

EXCHANGE_TYPE VARCHAR(25) Not Null

Exchange Type. Values are:

• On the exchange

• Off the exchange

MARKET_TYPE VARCHAR(20) Not Null

Market type describes where the plan is offered forpurchase. Valid values are:

• '1' – Individual

• '2' – Small group

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18. RISKSCORE_REMOTETable Name : RISKSCORE_REMOTE

Group: Member Table

Category: Risk Score Report TableTable Definition: This table stores data from risk score report. It is prepared for RADV 15.0.

Column Name Data TypeNull OptionType

Column Definition

MMBR_INSRNC_PLCY_CVRG_ID BIGINT(19) Not Null Member Enrollee Policy Coverage ID (Primary Key).

JOB_ID BIGINT(19) Not Null Job ID of the process run (Primary Key).

MODEL_SCORE DECIMAL(33,15) Not Null Model score.

CSR_SCORE DECIMAL(33,15) Not Null CSR factor quantity.

DEMOGRAPHIC_SCORE DECIMAL(33,15) Not Null Demographic factor quantity.

RA_SCORE DECIMAL(33,15) Not Null Risk assurance quantity.

CC_FLAG VARCHAR(1) Not Null Conditional category code flag.

MODEL_TYPE VARCHAR(20) Not Null

Age model type valid values are:• Adult

• Child

• Infant

MAX_PERIOD_DATE DATETIME Not Null Enrollment End Date.

RA_CLAIM_COUNT INT(10) Not Null Risk assurance claim counts.

TOTAL_PLAN_PAID VARCHAR(33) Not Null Total number of paid plans.

DX_TO_CC_UNIQUE_COUNT INT(10) Not Null Unique Diagnosis Code to CC code count.

DX_TO_CC_COUNT INT(10) Not Null Total Diagnosis Code to CC code count.

DX_UNIQUE_COUNT INT(10) Not Null Unique Diagnosis Code count.



HCC_UNIQUE_COUNT INT(10) Not Null Holds the unique number of HCC codes.

V3_INDICATOR VARCHAR(10) Not Null'Y' or 'N' depending if there is a severity interactionindicator.

SEVERITY_INTER_GRP VARCHAR(10) Not NullThe severity level interaction level either 'M' for mediumor 'H' for high or blank for no severity interaction.

INSRNC_PLAN_ID_REP VARCHAR(14) Not Null Unique insurance plan identif ier with 14 digits.

PLCY_RATG_AREA_CD VARCHAR(15) Not Null Rating Area code.


MMBR_MNTHS DECIMAL(33,15) Null The number of enrollment months for the current period.

UTILIZER_IND VARCHAR(1) Null An indicator that indicates whether the enrollee is autilizer.

CROSS_YEAR_CLAIM_UID BIGINT(19) Null The medical claim UID.

GNDR_CD VARCHAR(1) Null




• ‘U’ – Unknown (accepted only for newborns)

ARF_AGE INT(10) Null The ARF age of the enrollee.

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Table Name : RISKSCORE_REMOTE (Cont .)

Group: Member Table

Category: Risk Score Report TableTable Definition: This table stores data from risk score report. It is prepared for RADV 15.0.

Column Name Data Type Null OptionType Column Definition

LAST_AGE INT(10) Null The age of the enrollee in the last day of enrollment.

INFANT_HCC_SEVERITY VARCHAR(3) Null HCC severity code for infants.

INFANT_HCC_MATURITY VARCHAR(3) Null Maturity code for infants.

RCVD_INSRD_MMBR_ID VARCHAR(80) Not NullUnique identifier of enrollee. This represents a MASKEDidentifier; not a medical record number or cardholder ID.

CVRG_EFCTV_STRT_DT DATE Not NullThe date when the enrollment coverage for the enrolleebecame effective for the associated plan.

CVRG_EFCTV_END_DT DATE Not NullThe date when the enrollment coverage for the enrollee isno longer effective for the associated plan.

MTL_LVL VARCHAR(2) Not Null Metal Level Code.

EXCHANGE_TYPE VARCHAR(25) Not Null

Exchange Type. Values are:

• On the exchange

• Off the exchange

MARKET_TYPE VARCHAR(20) Not Null

Market type describes where the plan is offered forpurchase. Valid values are:

• '1' – Individual

• '2' – Small group

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19. STNG_ENRLMT_SUBMSNTable Name : STNG_ENRLMT_SUBMSN


Category: Transitional Data Table (for application internal use only)Table Definition: This is a table used by the application to int ernally stage the enrollment submiss ion files. It should not bemodified.



UID BIGINT(19) Not Null Unique row identif ier.

FILEIDENTIFIER VARCHAR(80) Not Null Unique identifier for each inbound XML enrollment file.

EXECUTIONZONECODE VARCHAR(80) Not Null

Indicator to denote the environment the file is submitted. Validvalues are:



GENERATIONDATETIME VARCHAR(80) Not Null The date indicat ing when the issuer generated the file.

SUBMISSIONTYPECODE VARCHAR(80) Not Null

Type of the inbound XML file. Valid values are:


• ‘P’ – Pharmacy Claim• ‘E’ – Enrollment


INSUREDMEMBERTOTALQUANTITY

VARCHAR(80) Not NullTotal count of enrollee records included in the submittedenrollment file.

INSUREDMEMBERPROFILETOTALQUANTITY

VARCHAR(80) Not NullTotal count of enrollment period records for all enrolleessubmitted in the enrollment file.

ISSUERRECORDIDENTIFIER VARCHAR(80) Null Unique identif ier for each record in the enrollment file.

ISSUERIDENTIFIER VARCHAR(80) Null Unique HIOS Issuer ID.

ISSUERINSUREDMEMBERTOT ALQUANTITY

VARCHAR(80) NullTotal count of enrollee records included in the submittedenrollment file for the issuer.

ISSUERINSUREDMEMBERPROFILETOTALQUANTITY VARCHAR(80) Null

Total count of enrollment period records for all enrolleessubmitted by the Issuer in the enrollment file.

ENROLLEEREOCRDIDENTIFIER

VARCHAR(80) Null Unique identifier for each record in enrollment file.

INSUREDMEMBERIDENTIFIER VARCHAR(80) Null

Unique identifier for the enrollee. This represents a MASKEDidentifier, not a medical record number or cardholder ID.Issuers should use the same Unique Enrollee ID if the enrolleeswitches plans within the issuer.

INSUREDMEMBERBIRTHDATE VARCHAR(80) Null Date of birth of enrollee.

INSUREDMEMBERGENDERCODE

VARCHAR(80) Null Gender of enrollee.

ENROLLMENTPERIODRECORDIDENTIFIER

VARCHAR(80) Null Unique identifier for each record in enrollment file.

SUBSCRIBERINDICATOR VARCHAR(80) Null Indicates when the enrollee linked to this enrollment periodrecord is also the subscriber. A subscriber is defined as the

primary insured party.

SUBSCRIBERIDENTIFIER VARCHAR(80) Null The identifier of the subscriber on the policy.

INSURANCEPLANIDENTIFIER VARCHAR(80) Null

Unique identifier for insurance plan offered by issuer that theenrollee is covered under. The Plan ID will correspond to theHIOS Standard Component ID. The Plan ID includes the CSRvariant.

COVERAGESTARTDATE VARCHAR(80) Null The date when the enrollment coverage for the enrolleebecame effective for the associated plan.

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Table Name : STNG_ENRLMT_SUBMSN (Cont.)


Category: Transitional Data Table (for application internal use only)Table Definition: This is a table used by the application to int ernally stage the enrollment submiss ion files. It should not bemodified.

Column Name Data Type

Null

OptionType

Column Definition

COVERAGEENDDATE VARCHAR(80) Null The date when the enrollment coverage for theenrollee is no longer effective for the associated plan.

INSURANCEPLANPREMIUMAMOUNT VARCHAR(80) Null

The Premium Amount is the monthly total ratedpremium charged by the issuer for a subscriber,including the APTC amount. The Premium Amountmay include more than the amount charged directly toa subscriber. The Premium Amount does not representan amount paid by a subscriber.

RATEAREAIDENTIFIER VARCHAR(80) Null Rating Area used for the enrollee in the plan.If enrollee is not rated, use the subscriber Rating Area.

PRCSG_STUS CHAR(1) Null Status of the processing row.

VALIDATIONFLAG CHAR(1) Not Null Flag indicating the validation status of the claim.

INTERFACECONTROLRELEASENUMBER VARCHAR(80) Null

Denotes the version number of the Interface ControlDocument (ICD) that the file corresponds to asidentified on page 1 of this document. A file must havethe latest version number to be accepted. The last two(2) digits of the version, however, reflect a cosmeticchange to the ICD and are not validated.

ENROLLMENTMAINTENANCETYPECODE VARCHAR(80) Null Identifies the type of activity associated with thecreation of an enrollment period.

VALIDATIONDATE VARCHAR(80) Null Date this enrollee was last val idated.

POLICYID VARCHAR(80) Null Policy ID.

POLICYSTARTDATE VARCHAR(80) Null Policy start date.

POLICYENDDATE VARCHAR(80) Null Policy end date.

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20. STNG_INSRD_MMBR_CC_ASSOCTable Name : STNG_INSRD_MMBR_CC_ASSOC


Category: Transitional Data Table (for application internal use only)Table Definition: This is an association table between INSRD_MMBR_ID and associated Conditional Category calculated in RiskScore calculation. It is used for application to internally stage the data. It should not be modified.



INSRD_MMBR INT(10) Not NullForeign key to the enrollee table to identifythe associated member.

CC VARCHAR(30) Not NullThe associated CC code per uniqueidentifier of enrollee.

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21. STNG_INSRD_MMBR_DGNS_ASSOC_ACCEPTable Name : STNG_INSRD_MMBR_DGNS_ASSOC_ACCEP


Category: Transitional Data Table (for application internal use only)Table Definition: This is an association table between INSRD_MMBR_ID and associated Diagnosis Codes that have been mappedto CC codes on RA eligible claims. It is used for application to i nternally stage the data. It should no t be modified.




DGNS VARCHAR(30) Not NullThe associated Diagnosis Code perunique identifier of enrollee.

MEDICAL_CLAIM_UID VARCHAR(50) Not NullThe unique medical Claim ID theDiagnosis Code came from.

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22. STNG_INSRD_MMBR_DGNS_UTI_ASSOCTable Name : STNG_INSRD_MMBR_DGNS_UTI_ASSOC


Category: Transitional Data Table (for application internal use only)Table Definition: This is an association table between INSRD_MMBR_ID and associated Diagnosis Codes on RA eligible claims. Itis used for application to internally stage the data. It should not be modified.




DGNS VARCHAR(30) Not NullThe associated Diagnosis Code perunique identifier of enrollee.

MEDICAL_CLAIM_UID VARCHAR(50) Not NullThe unique medical Claim ID theDiagnosis Code came from.

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23. STNG_INSRD_MMBR_DROP_HCC_ASSOCTable Name : STNG_INSRD_MMBR_DROP_HCC_ASSOC


Category: Transitional Data Table (for application internal use only)Table Definition: This is an association table between INSRD_MMBR_ID and associated HCC Codes that were dropped during RiskScore. It is used for application t o internally stage the data. It should not be modi fied.



INSRD_MMBR_ID INT(10) Not NullForeign key to the enrollee table to identifythe associated member.

DROPPED_HCC_CD VARCHAR(30) Not NullThe dropped HCC code per uniqueidentifier of enrollee.

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24. STNG_INSRD_MMBR_HCC_ASSOCTable Name : STNG_INSRD_MMBR_HCC_ASSOC


Category: Transitional Data Table (for application internal use only)Table Definition: This is an association table between INSRD_MMBR_ID and associated HCC Codes calculated in Risk Scorecalculation. It is used for application to int ernally stage the data. It should no t be modified.




HCC VARCHAR(30) Not NullThe associated HCC code per uniqueidentifier of enrollee.

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25. STNG_INSRD_MMBR_HCC_GROUP_ASSOCTable Name : STNG_INSRD_MMBR_HCC_GROUP_ASSOC


Category: Transitional Data Table (for application internal use only)Table Definition: This is an association table between INSRD_MMBR_ID and associated HCC Group Codes. It is used forapplication to in ternally stage the data. It should not be modified.




HCC_GROUP VARCHAR(45) Not Null The associated HCC Group Code.

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26. STNG_MDCL_SUBMSNTable Name : STNG_MDCL_SUBMSN


Category: Transitional Data Table (for application internal use only)Table Definition: This is a table used for application to internally stage the medical submission data. It should not be modified.

Column Name Data TypeNullOptionType

Column Definition



FILEIDENTIFIER VARCHAR(80) Not Null Unique identifier for each inbound medical file.


Indicator to denote for which environment the file isintended. Valid values are:



GENERATIONDATETIME VARCHAR(80) Not Null The date indicating when the issuer generated the file.


Type of the inbound XML file. Valid values are:


• ‘P’ – Pharmacy Claim• ‘E’ – Enrollment


CLAIMDETAILTOTALQUANTITY VARCHAR(80) Not Null Total count of claims in the file.

CLAIMSERVICELINETOTALQUANTITY VARCHAR(80) Not Null Total count of claim lines in the file.

INSURANCEPLANPAIDONFILETOTALAMOUNT VARCHAR(80) Not Null Total amount paid for all claims on the file.

ISSUERRECORDIDENTIFIER VARCHAR(80) NullUnique identifier for each record in the medical claimfile.


ISSUERCLAIMDETAILTOTALQUANTITY VARCHAR(80) Null Total count of claims on the file for the issuer.

ISSUERCLAIMSERVICELINETOTALQUANTITY VARCHAR(80) Null Total count of claim lines for all claims for the issuer.

ISSUERPLANPAIDTOTALAMOUNT VARCHAR(80) Null Total amount paid by issuer for claims on this file.

PLANRECORDIDENTIFIER VARCHAR(80) Null Unique identifier for each record in the medical claimfile.

INSURANCEPLANIDENTIFIER VARCHAR(80) Null Unique identifier for insurance plan offered by issuerthat the enrollee is covered under. The Plan IDincludes the CSR variant.

INSURANCEPLANCLAIMDETAILTOTALQUANTITY

VARCHAR(80) Null Total count of claims for this plan.

INSURANCEPLANCLAIMSERVICELINETOTALQUANTITY

VARCHAR(80) Null Total count of claim lines for all claims for the plan.

INSURANCEPLANPAIDTOTALAMOUNT VARCHAR(80) Null Total amount paid for all claims by the plan.

MEDICALHEADERRECORDIDENTIFIER VARCHAR(80) Null Unique identifier for each record in medical claim file.

INSUREDMEMBERIDENTIFIER VARCHAR(80) Null

Unique identifier for the enrollee. This represents aMASKED identifier; not a medical record number orcardholder ID. Issuers should use the same UniqueEnrollee ID if the enrollee switches plans within theissuer.

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27. STNG_MMBR_INSRNC_PLCY_CVRG_CRSS_YRTable Name : STNG_MMBR_INSRNC_PLCY_CVRG_CRSS_YR


Category: Transitional Data Table (for application internal use)Table Definition: This is a table used by the application to int ernally stage the cross-year enrollment submission files. It should notbe modified.



MEDICAL_CLAIM_UID BIGINT(19) Null The medical claim UID.



Unique identifier for insurance plan offered by issuer thatthe enrollee is covered under. The Plan ID will correspondto the HIOS Standard Component ID. The Plan ID includesthe CSR variant.




The Premium Amount is the monthly total rated premiumcharged by the issuer for a subscriber, including the APTCamount. The Premium Amount may include more than theamount charged directly to a subscriber. The Premium

Amount does not represent an amount paid by asubscriber.










• ‘001’ – Modification of existing policy

• ‘021EC’ – Addition of member to an existingpolicy



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Table Name : STNG_MMBR_INSRNC_PLCY_CVRG_CRSS_YR (Cont.)


Category: Transitional Data Table (for application internal use)Table Definition: This is a table used by the application to int ernally stage the cross-year enrollment submission files. It should notbe modified.













This ID represents a Unique Enrollee ID who is identifiedas the primary insured party. This represents a MASKEDidentifier, not a medical record number or cardholder ID.If SBSCBR_IND is Null or Blank, this field must bepopulated.



INSRNC_PLAN_ID_REP VARCHAR(14) Not Null Unique insurance plan identifier with 14 digits.

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28. STNG_MMBR_INSRNC_PLCY_CVRG_PROFILE_ASCTNTable Name : STNG_MMBR_INSRNC_PLCY_CVRG_PROFILE_ASCTN


Category: Transitional Data Table (for application internal use only)Table Definition: This is a table used by the application to internally stage the policy ID and insured member polic y coverage ID forcross-year enrollment submission files. It should not be modified.


MMBR_INSRNC_PLCY_CVRG_ID_PK_FK BIGINT(19) NOT NULL Primary key for the Member Insurance Policy ID.

POLICY_ID BIGINT(19) NOT NULLGenerated Policy ID for the Member Insurance PolicyCoverage ID.

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29. STNG_PHRMCY_SUBMSNTable Name : STNG_PHRMCY_SUBMSN


Category: Transitional Data Table (for application internal use only)Table Definition: This is a table used by the application to internally stage the pharmacy submission data. It should not bemodified.


Column Definition

RCVD_SUBMSN_ID BIGINT(19) Not NullReference to the job that is inserted intothe record.


FILEIDENTIFIER VARCHAR(80) Not NullUnique identifier for each inboundpharmacy file.


Indicators to denote which environment thefile is intended. Valid values are:




Denotes the version number of the ICDthat the file corresponds to as identified onpage 1 of this document. A file must havethe latest version number to be accepted.The last two (2) digits of the version,however, reflect a cosmetic change to theICD and are not validated.

GENERATIONDATETIME VARCHAR(80) Not NullThe date and time that the claimsubmission was generated.


Type of the inbound file. Valid values are:





CLAIMDETAILTOTALQUANTITY VARCHAR(80) Not Null

The total number of claim details that exist

for a given claim.

INSURANCEPLANPAIDONFILETOTALAMOUNT VARCHAR(80) Not Null Total amount paid for all claims on this file.

ISSUERRECORDIDENTIFIER VARCHAR(80) Null The record identif ier of the issuer.


ISSUERCLAIMDETAILTOTALQUANTITY VARCHAR(80) NullThe total number of claim details for agiven issuer.

ISSUERPLANPAIDTOTALAMOUNT VARCHAR(80) NullThe total amount that was paid to a givenissuer and insurance plan.

PLANRECORDIDENTIFIER VARCHAR(80) Null The record identif ier for the insurance plan.

INSURANCEPLANIDENTIFIER VARCHAR(80) Null The identifier for the insurance plan.

INSURANCEPLANCLAIMDETAILTOTALQUANTITY VARCHAR(80) NullThe total number of claim details for agiven insurance plan.

POLICYPAIDTOTALAMOUNT VARCHAR(80) NullThe total amount was paid to a givenpolicy.

PHARMACYDETAILRECORDIDENTIFIER VARCHAR(80) NullThe record identifier for the pharmacydetail record.

INSUREDMEMBERIDENTIFIER VARCHAR(80) Null The identifier for a given insured member.

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Table Name : STNG_PHRMCY_SUBMSN (Cont.)


Category: Transitional Data Table (for application internal use only)Table Definition: This is a table used by the application to internally stage the pharmacy submission data. It should not bemodified.


Null

OptionType

Column Definition

CLAIMIDENTIFIER VARCHAR(80) Null The identifier for a given claim.

CLAIMPROCESSEDDATETIME VARCHAR(80) NullThe date and time that the claim was beingprocessed.

PRESCRIPTIONFILLDATE VARCHAR(80) Null The date the prescript ion was filled.

ISSUERCLAIMPAIDDATE VARCHAR(80) Null The date the issuer claim was paid.

INSUREDMEMBERCLAIMPAIDDATE VARCHAR(80) NullThe date the insurance member claim waspaid.

PRESCRIPTIONSERVICEREFERENCENUMBER VARCHAR(80) NullUnique number assigned by the pharmacyto the dispensed prescription.

NATIONALDRUGCODE VARCHAR(80) NullUnique ID of the product or servicedispensed (NDC code).

DISPENSINGPROVIDERIDQUALIFIER VARCHAR(80) NullIdentifies the qualifier of the DispensingProvider Identifier being submitted in theDispensing Provider ID field.

DISPENSINGPROVIDERIDENTIFIER VARCHAR(80) NullIdentifies the type of Dispensing ProviderID being submitted in the DispensingProvider ID field.

PRESCRIPTIONFILLNUMBER VARCHAR(80) NullCode identifying whether the prescriptionis an original or refill.

DISPENSINGSTATUSCODE VARCHAR(80) NullIndicates if the prescription was a partial fill(P) or the completion of a partial fill (C).

VOIDREPLACECODE VARCHAR(80) NullIdentifies if a claim is to be voided orreplaced.

ALLOWEDTOTALCOSTAMOUNT VARCHAR(80) NullRepresents the sum of allowed charges foringredient cost, dispensing fee and salestax.

POLICYPAIDAMOUNT VARCHAR(80) NullThe total cost of the product/service paidby the plan for a given policy.

DERIVEDSERVICECLAIMINDICATOR VARCHAR(80) NullIndicator used to distinguish between fee-for-service claims and claims coveredunder capitation.

PRCSG_STUS CHAR(1) Null The processing status.

VALIDATIONFLAG BIGINT(19) NullThe flag for the validation, either valid orinvalid.

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30. STNG_RADV_POPULATIONTable Name : STNG_RADV_POPULATION


Category: RADV Population Report TableTable Definition: This table stores data on processing RADV population report.


INSRD_MMBR_ID INT(10) Not Null Insured Member ID (Primary Key).

RISK_SCORE_AVG DECIMAL(65,30) Not Null Risk score average.

MODEL_TYPE VARCHAR(20) Not Null Model type.

CC_FLAG VARCHAR(1) Not Null Condition category flag.

STRATUM VARCHAR(45) Null Statistical categories e.g. 1, 2…, 9, 10.

MAX_PERIOD_DATE VARCHAR(45) Not Null Enrollment period end date.

RA_CLAIM_COUNT INT(10) Not Null Number of risk assurance claim counts.

TOTAL_PLAN_PAID VARCHAR(45) Not Null Total plans that were paid.

DX_TO_CC_UNIQUE_COUNT INT(10) Not Null Unique Diagnosis Code to CC code.

DX_TO_CC_COUNT INT(10) Not Null Total Diagnosis Code to CC code.

DX_UNIQUE_COUNT INT(10) Not Null Diagnosis Code to CC code count.



TOTAL_PREMIUM_AMT VARCHAR(100) Null Total plan premium amount paid.

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31. STNG_REINSURANCETable Name : STNG_RADV_POPULATION


Category: Staging Table for ReinsuranceTable Definition: This table has t emporary Reinsurance data.


UID INT(10) Not Null Unique ID.

INSRD_MMBR_ID VARCHAR(80) Null Insured Member ID.

MEMBER_MONTHS VARCHAR(80) Null Member months.

CSR_MOOP_ADJ VARCHAR(80) Null CSR factor MOOP adjustment factor.

COINSURANCE_ADJ_TOTAL_RI_PAYMENT

VARCHAR(80) NullCoinsurance adjustment total risk RIpayment.

INSRNC_PLAN_ID VARCHAR(16) Not Null Insurance Plan ID.

CLAIM_ID VARCHAR(50) Null Claim ID.

CLAIM_PAID_AMOUNT VARCHAR(80) Null Claim paid amount.

CLAIM_ALLOWED_AMOUNT VARCHAR(80) Null Claim allowed amount.

PERIOD_START_DATE DATETIME Null Enrollment period start date.

PERIOD_END_DATE DATETIME Null Enrollment period end date.

SUB_POLICY_ID BIGINT(19) Null Sub policy ID.

CLAIM_TYPE VARCHAR(1) NullSignifies the claim type of the claim, e.g.“M”, “P”

CLAIM_FROM_DATE DATETIME Null Claim from date.

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32. STNG_SPLMNTL_SUBMSNTable Name : STNG_SPLMNTL_SUBMSN


Category: Transitional Data Table (for application internal use only)Table Definition: This is a table used by the application to internally stage the supplemental submission data. It should not bemodified.


Column Definition

RCVD_SUBMSN_ID BIGINT(19) Not Null Reference to the job that is inserted intothe record.


FILEIDENTIFIER VARCHAR(80) Not Null Unique identifier for each inboundsupplemental file.


Indicators to denote which environment thefile is intended. Valid values are:




Denotes the version number of the ICDthat the file corresponds to as identified onpage 1 of this document. A file must havethe latest version number to be accepted.The last two (2) digits of the version,however, reflect a cosmetic change to theICD and are not validated.

GENERATIONDATETIME VARCHAR(80) Not Null The date and time that the claimsubmission was generated.


Type of the inbound file. Valid values are:





FILEDETAILTOTALQUANTITY VARCHAR(80) Not Null Total amount paid for all claims on this file.

ISSUERRECORDIDENTIFIER VARCHAR(80) Null The record identifier of the issuer.


ISSUERFILEDETAILTOTALQUANTITY VARCHAR(80) Null The total number of claim details for agiven issuer.

PLANRECORDIDENTIFIER VARCHAR(80) Null The record identifier for the insurance plan.

INSURANCEPLANIDENTIFIER VARCHAR(80) Null The identifier for the insurance plan.

INSURANCEPLANFILEDETAILTOTALQUANTITY VARCHAR(80) Null The total number of claim details for agiven insurance plan.

DETAILRECORDIDENTIFIER VARCHAR(80) Null The record identifier for the supplementaldetail record.

INSUREDMEMBERIDENTIFIER VARCHAR(80) Null The identifier for a given insured member.

SUPPLEMENTALDIAGNOSISDETAILRECORDIDENTI

FIERVARCHAR(80) Null The ID associated with the supplemental

claim.

ORIGINALCLAIMIDENTIFIER VARCHAR(80) NullThe Claim ID submitted on a previousclaim file that the issuer intends to void orreplace.

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Table Name : STNG_SPLMNTL_SUBMSN (Cont.)


Category: Transitional Data Table (for application internal use only)Table Definition: This is a table used by the application to internally stage the supplemental submission data. It should not bemodified.


Null

OptionType

Column Definition

DETAILRECORDPROCESSEDDATETIME VARCHAR(80) NullThe date and time when the supplementaldiagnosis detail record was created by theissuer.

ADDDELETEVOIDCODE VARCHAR(80) Null Identifies if a previously accepted claim isto be void or deleted.

ORIGINALSUPPLEMENTALDETAILID VARCHAR(80) Null The Claim ID submitted on a previousclaim file that the issuer intends to void.

SERVICEFROMDATE VARCHAR(80) NullIndicates the first day the service occurredthat supports the submission of asupplemental diagnosis.

SERVICETODATE VARCHAR(80) NullIndicates the last day the service occurredthat supports the submission of asupplemental diagnosis.

DIAGNOSISTYPECODE VARCHAR(80) Null Indicates if the Diagnosis Code is ICD-9 orInternational.

SOURCECODE VARCHAR(80) Null

Identifies the source of the supplementaldiagnosis. Valid values are:

• ‘MR’– Medical record

• ‘EDI’ – Electronic datainterchange

PRCSG_STUS CHAR(1) Null The processing status.

VALIDATIONFLAG INT(10) Null The flag for the validation, either valid or

invalid.

SUPPLEMENTALDIAGNOSISCODE VARCHAR(80) Null

Code value for the Diagnosis Code asdetermined by classification ofInternational Classification of Diseases.Saved as a Blob in database.

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33. SUB_PLCYTable Name : SUB_PLCY

Group: Member Table

Category: Sub Policy Table for Risk Score and ReinsuranceTable Definition: This table has the sub policy inf ormation.


UID BIGINT(19) NOT NULL Unique ID.

MMBR_INSRNC_PLCY_CVRG_ID_FK BIGINT(19) NOT NULL Coverage ID of member insurance policy.

SUB_PLCY_STRT_DT DATETIME NOT NULL Sub policy start date.

SUB_PLCY_END_DT DATETIME NOT NULL Sub policy end date.

SUB_PLCY_ID BIGINT(19) NOT NULL Sub policy ID.

POLICY_ID_FK BIGINT(19) NOT NULL Policy ID Foreign key.

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34. SUPPLEMENTAL_CLAIMTable Name: SUPPLEMENTAL_CLAIMGroup: Claim Table

Category: Ingested Data TableTable Definition: This table stores the in formation related to supplemental claims.


UID INT(10) NOT NULL Unique identifier of the database row.

BENEFIT_YEAR VARCHAR(4) NOT NULLThe benefit year based for this claim, based on theStatement Covers To Date.

SUPPLEMENTAL_DETAIL_ID VARCHAR(50) NULL The ID associated with the supplemental claim.

JOB_ID BIGINT(19) NOT NULL Reference to the job that inserted this record.

DETAIL_RECORD_PROCESSED_DATETIME

DATETIME NULL The date and time when the supplemental diagnosisdetail record was created by the issuer.

SERVICE_FROM_DATE DATE NULLIndicates the first day the service occurred thatsupports the submission of a supplemental diagnosis.

SERVICE_TO_DATE DATE NULLIndicates the last day the service occurred thatsupports the submission of a supplemental diagnosis.

ISSUER_IDENTIFIER VARCHAR(80) NULL Unique HIOS I

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