CMS-10401 - Appendix A 3Rs

OMB Control Number 0938-1155
Expiration Date: XX/2025

Appendix A
Data Elements for Risk Adjustment and Reinsurance
Data Category

Data Elements

Geographic Data

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•
•
•
•
•

Market Level Data

•
•

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

Submitting Entity

State / Issuer

State

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1155. The time
required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions,
search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance
Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. DO NOT MAIL THIS FORM TO THIS ADDRESS. MAILING YOUR APPLICATION
TO THIS ADDRESS WILL SIGNIFICANTLY DELAY PROCESSING.
You have the right to get your information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if
you feel you’ve been discriminated against. Visit CMS.gov/About-CMS/Agency-Information/Aboutwebsite/CMSNondiscriminationNotice or call
1-800-318-2596. TTY users can call: 1-855-889-4325.

OMB Control Number 0938-1155
Expiration Date: XX/2025

Data Category

Enrollee Level Data

Data Elements
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
• Zip Code
• Race
• Ethnicity
• Subsidy Indicator
• Qualified Small Employer Health
Reimbursement Arrangement Indicator
• Individual Coverage Health Reimbursement
Indicator

Submitting Entity

Issuers

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1155. The time
required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions,
search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance
Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. DO NOT MAIL THIS FORM TO THIS ADDRESS. MAILING YOUR APPLICATION
TO THIS ADDRESS WILL SIGNIFICANTLY DELAY PROCESSING.
You have the right to get your information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if
you feel you’ve been discriminated against. Visit CMS.gov/About-CMS/Agency-Information/Aboutwebsite/CMSNondiscriminationNotice or call
1-800-318-2596. TTY users can call: 1-855-889-4325.

OMB Control Number 0938-1155
Expiration Date: XX/2025

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

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 0938-1155. The time required to complete this information collection is
estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. DO NOT MAIL THIS FORM TO THIS ADDRESS. MAILING YOUR
APPLICATION TO THIS ADDRESS WILL SIGNIFICANTLY DELAY PROCESSING.
You have the right to get your information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel you’ve been
discriminated against. Visit CMS.gov/About-CMS/Agency-Information/Aboutwebsite/CMSNondiscriminationNotice or call 1-800-318-2596. TTY users can call: 1-855889-4325.

OMB Control Number 0938-1155
Expiration Date: XX/2025

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

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 0938-1155. The time required to complete this information collection is
estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. DO NOT MAIL THIS FORM TO THIS ADDRESS. MAILING YOUR
APPLICATION TO THIS ADDRESS WILL SIGNIFICANTLY DELAY PROCESSING.
You have the right to get your information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel you’ve been
discriminated against. Visit CMS.gov/About-CMS/Agency-Information/Aboutwebsite/CMSNondiscriminationNotice or call 1-800-318-2596. TTY users can call: 1-855889-4325.

OMB Control Number 0938-1155
Expiration Date: XX/2025

Data Category

Medical Claims (continued)

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

Submitting Entity
Issuer

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1155. The time required to
complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard,
Baltimore, Maryland 21244-1850. DO NOT MAIL THIS FORM TO THIS ADDRESS. MAILING YOUR APPLICATION TO THIS ADDRESS WILL
SIGNIFICANTLY DELAY PROCESSING.
You have the right to get your information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you
feel you’ve been discriminated against. Visit CMS.gov/About-CMS/Agency-Information/Aboutwebsite/CMSNondiscriminationNotice or call 1-800318-2596. TTY users can call: 1-855-889-4325.

OMB Control Number 0938-1155
Expiration Date: XX/2025

Supplemental Diagnoses

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

Issuer

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1155. The time required to
complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard,
Baltimore, Maryland 21244-1850. DO NOT MAIL THIS FORM TO THIS ADDRESS. MAILING YOUR APPLICATION TO THIS ADDRESS WILL
SIGNIFICANTLY DELAY PROCESSING.
You have the right to get your information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you
feel you’ve been discriminated against. Visit CMS.gov/About-CMS/Agency-Information/Aboutwebsite/CMSNondiscriminationNotice or call 1-800318-2596. TTY users can call: 1-855-889-4325.