Form Approved
OMB No. 0920-New
Expiration Date: XX/XX/XXXX
Using Real-time Prescription and Insurance Claims Data to Support the HIV Care Continuum
Attachment 3
Virginia Medicaid data abstraction
Public reporting burden of this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)
Virginia Medicaid data abstraction
MSIS Identification Number
Indicator for AIMS Enrollee
Indicator for Provider Intervention
Indicator for Patient Intervention
Year Date
FFS Indicator
Medicaid Managed Care Organization (MCO)
MCO Program Name
Recipient First Name*
Recipient Last Name*
Recipient Social Security Number*
Recipient Street Address*
Recipient Residence Zip Code*
Recipient Residence County Code*
Recipient Birth Date*, ** (only month and year will be sent to CDC)
Recipient Sex Code*, **
Recipient Race*, **
Recipient Ethnicity*, **
Recipient Date of Death*, ** (only month and year will be sent to CDC)
Recipient Date(s) of Enrollment **
Recipient Date(s) of Disenrollment **
Recipient Eligibility Code – Most Recent **
Recipient Months of Eligibility – Annual **
Recipient Third-Party Insurance Months Count – Annual **
Recipient Third-Party Insurance Name **
Recipient Third-Party Insurance Type **
Recipient Third-Party Insurance Begin Date **
Recipient Third-Party Insurance End Date **
Medicare Dual Code – Annual **
Medicare Beneficiary Months Count – Annual **
Eligible Dual Eligibility **
Eligible CMCP Months Count **
Type of Claim Code **
Procedure (Service) Code **
Procedure (Service) Coding System Code **
Procedure (Service) Begin Date **
Procedure (Service) End Date **
Type of Service Code **
Primary Diagnosis Code **
Secondary Diagnosis Code **
Other Diagnosis Codes **
Place of Service Code **
Prescription Prescribed Date **
National Drug Code **
New or Refill Indicator **
Mail-Order Indicator **
Prescription Fill Date **
Quantity of Service **
Days Supply **
Prescribing Provider National Provider Identifier (NPI)
Prescribing Provider Specialty Code **
Prescribing Provider Address
Prescribing Provider Zip Code
Prescribing Provider County
Prescribing Provider Telephone Number
Prescribing Provider Specialty Code
Medicaid Member Count per Prescribing Provider
Medicaid Member with HIV Count per Prescribing Provider
Medicaid Member Claim Count per Prescribing Provider
Health Care Facility Name – Prescribing Provider
Health Care Facility Address – Prescribing Provider
Health Care Facility Zip Code – Prescribing Provider
Health Care Facility County – Prescribing Provider
Health Care Facility Telephone Number – Prescribing Provider
Servicing Provider National Provider Identifier (NPI)
Servicing Provider Specialty Code
Servicing Provider Address
Servicing Provider Zip Code
Servicing Provider County
Servicing Provider Telephone Number
Servicing Provider Specialty Code **
Medicaid Member Count per Servicing Provider
Medicaid Member with HIV Count per Servicing Provider
Medicaid Member Claim Count per Servicing Provider
Health Care Facility Name – Servicing Provider
Health Care Facility Address – Servicing Provider
Health Care Facility Zip Code – Servicing Provider
Health Care Facility County – Servicing Provider
Health Care Facility Telephone Number – Servicing Provider
Inpatient Admission Begin Date **
Inpatient Admission End Date **
Discharge Status Code **
Diagnosis Related Group (DRG) Code **
Viral load lab test results **
* indicates data variables that we be used to match individuals within the Medicaid database and Virginia Care Marker databases
** indicates data variables that will be sent to CDC
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | April Kimmel |
| File Modified | 0000-00-00 |
| File Created | 2021-10-20 |