Supplemental Diagnosis (153.700(a))

Appendix A

OMB Control Number 0938-1155
Expiration Date: XX/2022

Data Elements for Risk Adjustment and Reinsurance
Data Category

Geographic Data

Market Level Data

Enrollee Level Data

Data Elements
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•
•
•
•
•

Plan ID
Metal Level
Actuarial Value
Benefit Year
Rating Area
Individual or small-group or merged market

State average actuarial risk (HHS-sourced)
State Rating Curve
Includes header, issuer, and enrollee data
elements:
• File ID
• File Execution Zone
• Run Date/Time
• Report Type
• Total Number of Enrollee Records
• Total Number of Enrollment Period Records
• Record ID
• Issuer ID
• Unique Enrollee ID
• Enrollee DOB
• Enrollee Gender
• Subscriber Indicator
• Enrollment Period Activity Indicator
• Subscriber ID
• Plan ID
• Enrollment Start Date
• Enrollment End Date
• Premium Amount
• Rating Area
•
•

Submitting Entity

State / Issuer

State

Issuers

Data Category

Pharmacy Claims

Data Elements
Includes header, issuer, plan and claim data
elements:
• File ID
• Execution Zone
• Run Date/Time
• Report Type
• Total Claims
• Total Plan Paid Amount
• Issuer ID
• Record ID
• Plan ID
• Unique Enrollee ID
• Claim ID
• Claim In-Network or Out-of-Network
Indicator
• Claim Processed Date/Time
• Fill Date
• Paid Date
• Prescription/Service Reference Number
• Product/Service ID Qualifier
• Product/Service ID
• Dispensing Provider Service ID Qualifier
• Dispensing Provider Service ID
• Fill Number
• Days Supply
• Dispensing Status
• Void/Replace Indicator
• Total Allowed Cost
• Derived Amount Indicator
• Plan Paid Amount
• Interface Control Release Number

Submitting Entity

Issuer

Data Category

Data Elements

Submitting Entity

Includes header, issuer, plan and claim header
and claim line data elements:
• File ID
• Execution Zone
• Run Date/Time
• Report Type
• Total Claims
• Total Claim Lines
• Total Plan Paid Amount
• Record ID
• Issuer ID
• Plan ID
• Unique Enrollee ID
• Interface Control Release Number

Medical Claims

Claim Header Level Data Elements:
• Form Type
• Claim ID
• Original Claim ID
• Claim In-Network and Out-of-Network
Indicator
• Claim Processed Date/Time
• Bill Type
• Date Paid
• Void/Replace Indicator
• Discharge Status Code
• Statement Covers From
• Statement Covers Through
• Billing Provider ID Qualifier
• Billing Provider ID
• Total Amount Allowed
• Total Amount Paid
• Derived Amount Indicator
• Diagnosis Code Qualifier
• Diagnosis Code

Issuer

Data Category
Medical Claims (continued)

Supplemental Diagnoses

Data Elements
Claim Line Level Data Elements
• Diagnosis Code Record ID
• Claim Line Sequence Number
• In-Network and Out-of-Network Indicator
• Date of Service - From
• Date of Service - To
• Revenue Code
• Service Code Qualifier
• Service Code
• Service Code Modifier
• Place of Service
• Rendering Provider ID Qualifier
• Rendering Provider ID
• Amount Allowed
• Amount Paid
• Derived Amount Indicator
Includes header, issuer, plan and claim
header and claim line data elements:
• File ID
• Execution Zone
• Total Count of Detail Records
• Run Date/Time
• Report Type
• Record ID
• Issuer ID
• Plan ID
• Unique Enrollee ID
• Supplemental Diagnosis Detail Record ID
• Original Claim ID
• Detail Record Processed Date/Time
• Add/Delete/Void Indicator
• Original Supplemental Diagnosis Detail ID
• Date of Service From - From
• Date of Service - Through
• Supplemental Diagnosis Code Qualifier
• Supplemental Diagnosis Code
• Supplemental Diagnosis Code Source
• Interface Control Release Number

Submitting Entity
Issuer

Issuer