claims data elements - virginiadmasva.dmas.virginia.gov/content_atchs/rfp-lib/reference...

Reference Outputs03/29/2016

Output Reports RF-F-152A CapitationRate Update File

General InformationThis file, created byCapitation Rate Batch Edit program (RFR150), stores valid capitation rateupdates. Once the rates are verified byDMAS, the file would be used to update the Capitation RateTable (RF_CAPITATION)

Subsystem: ReferenceFrequency: RequestedVolume: 500Number of Copies: N/AOutput Form: N/ARetention: N/ADistribution: N/AProgram: N/AConfidential: NoSequence: N/AControl Breaks: N/A

Capitation Rate Update File (RF-F-152A)There is no Sample

Field Definitions# Field Name Data Element Name Element ID Source/CalculationsN/A

Output Reports RF-O-002-01 Pro-cedure Audit Trail- Dental

General InformationThis report is a detail log of dental updates of procedure data. The report displays the original valueand the updated value.

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Daily Log Analyzer Procedure Audit Trail (Dental) (VMPRDL02)Confidential: NoSequence: Log Date

Log TimeControl Breaks: N/A

Procedure Audit Trail- Dental (RF-O-002-01)

Field Definitions# Field Name Data Element Name Element

IDSource/Calculations

1 USER ID LogOperator Iden-tification

DE5706

2 CORRELATIONID (The ID asso-ciated with the DB2thread)

DE0000

3 URID (Unit ofrecovery ID)

DE0000

4 CONNECTION ID(Connection IDused by call attach-ment facility to com-municate withDB2)

DE0000

5 CONNECTIONTYPE (Connectiontype with db2)

DE0000

6 PLAN NAME (Thename of the DB2plan that wasexecuted)

DE0000

7 DATE Log Date DE57048 TIME Log Time DE5705

9 TABLE (Name ofthemodified DB2Table)

DE0000

10 DATABASE(Name of themod-ified Database)

DE0000

11 ACTION TYPE Log Action Type DE570212 NEW (After image

of the changedrow)

DE0000

12.1 OLD (Beforeimage of thechanged row)

DE0000

Output Reports RF-O-002-02 ICD Dia-gnosis Audit Trail

General InformationThis report is a detail log of all updates of the ICD Diagnosis data as a result of batch processing.The report displays the old and new version of the data. The length-of-stay data appears only on thebatch update report. Additionally a sum of all transactions reflected on the report appears as a totalsline at the end of the report.

Subsystem: ReferenceFrequency: AnnualVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: HCIA Diagnosis/LOS (RFA040)Confidential: NoSequence: Diagnosis Code

DateTime

Control Breaks: N/A

ICD Diagnosis Audit Trail (RF-O-002-02)



2 ACTION TYPE Log Action Type DE57023 LOGDATE LogDate DE57044 LOGTIME Log Time DE57058 DIAG Diagnosis Code DE53018.1 ICD Version ICD VERSION

INDICATORDE5341

9 (DIAGNOSISDESCRIPTION)

Diagnosis Name DE5302

10 BEG Diagnosis CoverageBegin Date

DE5318

11 END Diagnosis CoverageEnd Date

DE5319

14 AGEMIN DiagnosisMinimumAge

DE5304

15 (AGE) MAX DiagnosisMaximumAge

DE5305

16 ACUTE/TRAUMA DiagnosisAcute/Trauma Indic-ator

DE5310

18 EFF DT Diagnosis Auto ErrorEffective Date

DE5309

19 SEX Diagnosis SexRestric-tion Code

DE5303

20 FAMPLAN Diagnosis Family Plan-ning Indicator

DE5316

21 PA Diagnosis PriorAuthorization Indic-ator

DE5321

22 EMERGENCY IND Diagnosis EmergencyCode

DE5322

23 EFF DT Diagnosis EmergencyCode Effective Date

DE5342

23.1 EDIT FLAG Diagnosis Edit Flag DE531123.2 COMOFLAG Diagnosis Combo

FlagDE5312

23.3 COMOCODE Diagnosis ComoCode

DE5313

23.4 MDC DiagnosisMDC DE5314

23.5 HCFA Diagnosis HCFA DE531523.6 ORIG DiagnosisOriginal DE531723.7 PCLAS Diagnosis Procedure

Class IndicatorDE5340

24 LOS KEY HCIA LOS Group DE546725 LOS LINK LOS Link DE533026 CURRENT LOS Begin DE532927 PREVIOUS LOS Begin DE532928 (LOS PERCENTILE) LOS Percentile DE532329 (LOS) 00-19 LOS for Age Range

00-19DE5335

30 (LOS) 20-34 LOS for Age Range20-34

DE5336


DE5337


DE5338

33 (LOS) 65 + LOS for Age Range65+

DE5339

34 AVGLOS: SINGLEDX

LOS Average forSingle Diagnosis

DE5327

35 AVGLOS: MULTPDX

LOS Average for Mul-tiple Diagnosis

DE5328

36 AVGLOS: SINGLEDX SURG

LOS Average forSingle DiagnosisWithSurgery

DE5351

37 AVGLOS: MULTPDX SURG

LOS Average for Mul-tiple DiagnosisWithSurgery

DE5349

38 AVGLOS: SINGLEDX NOSURG

LOS Average forSingle DiagnosisWithout Surgery

DE5352

39 AVGLOS: MULTPDX NOSURG

LOS Average for Mul-tiple DiagnosisWithout Surgery

DE5350

40 (LOS PERCENTILE)SINGLE DX

LOS Percentile forSingle Diagnosis

DE5346

41 (LOS PERCENTILE)MULTP DX

LOS Percentile forMultiple Diagnosis

DE5343

42 (LOS PERCENTILE)SINGLE DX SURG

LOS Percentile forSingle DiagnosisWithSurgery

DE5347

43 (LOS PERCENTILE)MULT DX SURG

LOS Percentile forMultiple DiagnosisWith Surgery

DE5344

44 (LOS PERCENTILE)SINGLE DX NOSURG

LOS Percentile forSingle DiagnosisWithout Surgery

DE5348

45 (LOS PERCENTILE)MULTP DX NOSURG

LOS Percentile forMultiple DiagnosisWithout Surgery

DE5345

46 TOTALDIAGNOSISCODES INPUT

Calculated DE0002

47 TOTALDIAGNOSISCODES UPDATED

Calculated DE0002

48 TOTALDIAGNOSISCODES ADDED

Calculated DE0002

49 TOTALDIAGNOSISCODES ENDED

Calculated DE0002

51 Diagnosis Code Diagnosis Code DE530152 Action CD DE000053 ItemDescription DE000054 ItemValue DE000055 ERRORMessage DE000056 Total diagnosis codes

inputDE0000 Calculated

57 Total diagnosis codesin error

DE0000

Output Reports RF-O-002-03 For-mulary Audit Trail - Drug

General InformationThis report is a detail log of drug updates of the Formulary data. The report displays the originalvalue and the updated value.

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Daily Log Analyzer Procedure Formulary Audit Trail (Drug) (VMPRDL04)Confidential: NoSequence: Log Date


Formulary Audit Trail - Drug (RF-O-002-03)




DE5706


DE0000


DE0000


DE0000


DE0000


DE0000

7 DATE Log Date DE57048 TIME Log Time DE57059 TABLE (Name of

themodified DB2Table)

DE0000


DE0000

11 UPDATE Log Action Type DE570212 NEW (After image

of the changedrow)

DE0000

13 OLD (Beforeimage of thechanged row)

DE0000

14 INSERT DE0000

Output Reports RF-O-002-04 Pro-cedure Audit Trail - Medical

General InformationThis report is a detail log of medical updates of the procedure data. The report displays the originalvalue and the updated value.

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Daily Log Analyzer Procedure Audit Trail (Medical) (VMPRDL05)Confidential: NoSequence: Log Date


Procedure Audit Trail - Medical (RF-O-002-04)




DE5706


DE0000


DE0000


DE0000


DE0000


DE0000



DE0000


DE0000


of the changedrow)

DE0000


DE0000

14 INSERT DE0000

Output Reports RF-O-002-05 Pro-cedure Audit Trail - Revenue

General InformationThis report is a detail log of revenue updates of the procedure data. The report displays the originalvalue and the updated value.

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Daily Log Analyzer Procedure Audit Trail (Revenue) (VMPRDL06)Confidential: NoSequence: Log Date


Procedure Audit Trail - Revenue (RF-O-002-05)




DE5706


DE0000


DE0000

4 CONNECTION ID(Connection IDused by call attach-ment facility to com-municate with

DE0000

DB2)5 CONNECTION

TYPE (Connectiontype with db2)

DE0000


DE0000



DE0000


DE0000


of the changedrow)

DE0000


DE0000

14 Insert DE0000

Output Reports RF-O-002-06 Pro-cedure Audit Trail - ICD-10-CM

General InformationThis report is a detail log of all updates of the ICD Procedure data as a result of batch processing.The report displays the old and new version of the ICD-10-CM procedure data. The length-of-staydata appears only on the batch update audit trail report. Additionally a sum of all transactions reflec-ted on the report appears as a totals line at the end of the report.

Subsystem: ReferenceFrequency: AnnualVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: HCIA Diagnosis/LOS (RFA040)Confidential: NoSequence: Log Date

Procedure CodeControl Breaks: N/A

Procedure Audit Trail - ICD-10-CM (RF-O-002-06)




1 (OLD OR NEW) DE00002 ACTION TYPE Log Action Type DE57023 LOGDATE LogDate DE57044 LOGTIME Log Time DE57055 TERM ID Log Terminal Iden-

tificationDE5707

6 OPER ID LogOperator Iden-tification

DE5706

8 REC ID Procedure Code Type DE50019 PROC CD Procedure Code DE500210 (PROCEDURE Procedure Short Name DE5015

NAME)11 BEG Procedure Coverage

Begin DateDE5003

12 END Procedure CoverageEnd Date

DE5004

13 AGEMIN ProcedureMinimumAge Limit

DE5009

14 (AGE) MAX ProcedureMaximumAge Limit

DE5010

15 SEX Valid SexCode DE501116 P/R Procedure Pend

Review IndicatorDE5007

17 UVSP ProcedureMaximumUVSP

DE5016

18 PA: TYPE PA Type Effective Date DE501818.1 EFF Procedure PA Type DE501722 PLACE SERV ClaimProfessional

Place of ServiceDE2173

23 TYPE SERV Claim Type of Service DE207224 TPLCD TPLCode DE542225 X-REF CrossReference Pro-

cedure CodeDE5164

25.1 XREF-DUP-CK CrossReference Pro-cedure DuplicateCheck

DE5139

25.2 XREF-PA CrossReference Pro-cedure Prior Auth Indic-ator

DE5140

43 PROV TYP Provider Type DE400644 PROV SPEC Provider Specialty

CodeDE4007

45 BEGIN DT Procedure Valid Pro-vider Type-SpecialtyBegin Date

DE5173

46 END DT Procedure Valid Pro-vider Type-SpecialtyEnd Date

DE5174

47 FLAG Flag Code DE516548 S/R Flag Date Type Code DE524049 BEGIN DT Flag Begin Date DE524250 END DT Flag End Date DE5243

51 LOS KEY HCIA LOS Group DE546752 (ALL DEFAULT

LOS)DE0000

53 CURRENT LOS Begin DE532954 PREVIOUS LOS Begin DE532955 (LOS

PERCENTILE)LOS Percentile DE5323

56 (LOS) 00-19 LOS for Age Range 00-19

DE5335


DE5336


DE5337


DE5338


DE5339

62 AVGLOS:SINGLE DX


DE5327

63 AVGLOS: MULTPDX

DrugObsolete Date DE5238

64 AVGLOS:SINGLE DXSURG


DE5351



DE5349

66 AVGLOS:SINGLE DX NOSURG


DE5352


LOS Average for Mul-tiple DiagnosisWithoutSurgery

DE5350

68 (LOSPERCENTILE)SINGLE DX


DE5346

69 (LOSPERCENTILE)MULTP DX

LOS Percentile for Mul-tiple Diagnosis

DE5343

70 (LOSPERCENTILE)SINGLE DXSURG


DE5347

71 (LOSPERCENTILE)MULTP DX SURG

LOS Percentile for Mul-tiple DiagnosisWithSurgery

DE5344

72 (LOSPERCENTILE)SINGLE DX NOSURG


DE5348

73 (LOSPERCENTILE)MULTP DX NOSURG

LOS Percentile for Mul-tiple DiagnosisWithoutSurgery

DE5345

74 TOTALRECORDS READ

Calculated DE0002

75 TOTAL ADDRECORDS READ

Calculated DE0002

76 TOTALCHANGERECORDS READ

Calculated DE0002

77 TOTALDELETERECORDS READ

Calculated DE0002

78 TOTALRECORDSWRITTEN

Calculated DE0002

79 Procedure Code Procedure Code 500280 Action CD DE000081 ItemDescription DE000082 ItemValue DE000083 Error Message DE000084 Total procedure

codes inputCalculated DE0002 calculated

85 Total procedurecodes in error

Calculated DE0002 Calculated

Output Reports RF-O-002-07 Pro-cedure Audit Trail - Home Health

General InformationThis report is a detail log of all updates of the HomeHealth procedure data. The report displays theoriginal value and the updated value.

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Daily Log Analyzer Procedure Audit Trail (HomeHealth) (VMPRDL08)Confidential: NoSequence: Log Date


Procedure Audit Trail - Home Health (RF-O-002-07)




DE5706


DE0000


DE0000


DE0000


DE0000


DE0000



DE0000


DE0000


of the changedrow)

DE0000


DE0000

Output Reports RF-O-002-08 Pro-cedure Audit Trail - Hospice

General InformationThis report is a detail log of all updates of the Hospice procedure data. The report displays the ori-ginal value and the updated value.

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Daily Log Analyzer Procedure Audit Trail (Hospice) (VMPRDL09)Confidential: NoSequence: Log Date


Procedure Audit Trail - Hospice (RF-O-002-08)




DE5706


DE0000


DE0000


DE0000


DE0000


DE0000



DE0000


DE0000


of the changedrow)

DE0000


DE0000

14 INSERT DE0000


General InformationThis report is a detail log of all updates of the ICD Diagnosis data. The report displays the old andnew version of the data.

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: On-DemandRetention: 30 DaysDistribution: DMASProgram: Daily Log Analyzer Procedure Audit Trail (ICD Diagnosis) (VMPRDL03)Confidential: NoSequence: Log Date






DE5706


DE0000


DE0000


DE0000


DE0000


DE0000

7 DATE Log Date DE57048 TIME Log Time DE5705

9 TABLE (Name ofthemodified DB2Table)

DE0000


DE0000


of the changedrow)

DE0000


DE0000

Output Reports RF-O-002-10 Pro-cedure Audit Trail - ICD-10-CM

General InformationThis report is a detail log of all updates of the ICD Procedure data. The report displays the old andnew version of the ICD-10-CM procedure data.

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Daily Log Analyzer Procedure Audit Trail(ICD-10-CM) (VMPRDL07)Confidential: NoSequence: Log Date






DE5706


DE0000


DE0000


DE0000


DE0000


DE0000



DE0000


DE0000


of the changedrow)

DE0000


DE0000

Output Reports RF-O-002-11 DRGAudit Trail

General InformationThis report is a detail log of all updates of the DRGdata. The report displays the original value andthe updated value.

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Daily Log Analyzer DRGAudit Trail (RF-O-111) (VMPRDL10)Confidential: NoSequence: Log Date


DRG Audit Trail (RF-O-002-11)




DE5706


DE0000


DE0000


DE0000


DE0000


DE0000



DE0000


DE0000


of the changedrow)

DE0000


DE0000

Output Reports RF-O-003-01 Pro-cedure Listing - Dental

General InformationThis report lists information on individual or all dental procedures depending on the value set mem-ber.

Subsystem: ReferenceFrequency: Monthly / On-DemandVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Procedure File Listing (Dental) (RFR00301)

Procedure File Listing (ALL) (RFR00305)Confidential: NoSequence: Procedure Code: DentalControl Breaks: N/A

Procedure Listing - Dental (RF-O-003-01)

Procedure Listing - Dental (RF-O-003-01)



1 PROC CD Procedure Code DE50022 PROCEDURE

DESCProcedure Short Name DE5015

3 PROC TYPE Procedure Code Type DE50014 PROC TYPE

DESCProcedure Code Type DE5001

5 PROC BEG Procedure CoverageBegin Date

DE5003

6 PROC END Procedure CoverageEnd Date

DE5004

7 AGE: MIN ProcedureMinimumAge Limit

DE5009

8 AGE: MAX ProcedureMaximumAge Limit

DE5010

9 SEX Valid SexCode DE501110 PA TYPE Procedure PA Type DE501711 PA EFF DATE PA Type Effective Date DE501812 PA END DATE PA Type EndDate DE512013 CAT Region Type DE524414 DESCRIPTION Region Name DE525015 INP OUT Procedure Rate Type DE5153 Rate Type 'IP' or 'OP'16 MAX RATE Procedure Amount DE504717 EFF DATE Procedure Amount

Effective DateDE5046

18 END DATE Procedure Rate EndDate

DE5138

19 FLAGCDE (1) Flag Code DE516520 IND (1) Flag Date Type Code DE524021 FLAGBEGIN DT

(1)Flag Begin Date DE5242

22 FLAGEND DT (1) Flag End Date DE524323 FLAGCDE (2) Flag Code DE516524 IND (2) Flag Date Type Code DE524025 FLAGBEGIN DT


26 FLAGEND DT (2) Flag End Date DE5243

27 FLAGCDE (3) Flag Code DE516528 IND (3) Flag Date Type Code DE524029 FLAGBEGIN DT
















58 FLAGEND DT Flag End Date DE5243

Output Reports RF-O-003-03Alpha/Numeric ICD Diagnosis Listing

General InformationThis report is a listing of the Diagnosis data, in alphabetic/numeric order by diagnosis name/ICD.The associated length-of-stay data is also displayed.

Subsystem: ReferenceFrequency: QuarterlyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Alpha/Numeric Diagnosis File Listing (RFR00303)Confidential: NoSequence: Diagnosis NameControl Breaks: N/A

Alpha/Numeric ICD Diagnosis Listing (RF-O-003-03)



1 DIAG Diagnosis Code DE53011.1 ICD VERSION ICD Version Indicator DE53412 (DIAGNOSIS

NAME)Diagnosis Name DE5302

3 BEG Diagnosis CoverageBegin Date

DE5318

4 END Diagnosis CoverageEnd Date

DE5319

7 AGEMIN DiagnosisMinimumAge

DE5304

8 (AGE) MAX DiagnosisMaximumAge

DE5305

9 ACUTE/TRAUMA DiagnosisAcute/Trauma Indic-ator

DE5310

10 AEC ClaimError ESC Code DE550611 EFF DT Diagnosis Auto Error


12 SEX Diagnosis SexRestric-tion Code

DE5303

13 FAMPLAN Diagnosis Family Plan-ning Indicator

DE5316

14 PA Diagnosis Prior Author-ization Indicator

DE5321

15 EMERGENCYIND

Diagnosis EmergencyCode

DE5322

16 EFF DT Diagnosis EmergencyCode Effective Date

DE5342

16.1 EDIT FLAG Diagnosis Edit Flag DE531116.2 COMOFLAG Diagnosis Combo Flag DE531216.3 COMOCODE Diagnosis ComoCode DE531316.4 MDC DiagnosisMDC DE531416.5 HCFA Diagnosis HCFA DE531516.6 ORIG DiagnosisOriginal DE531716.7 PCLAS Diagnosis Procedure

Class IndicatorDE5340

17 LOS KEY HCIA LOS Group DE5467

18 (ALL DEFAULTLOS)

DE0000

19 CURRENT LOS Begin DE532920 PREVIOUS LOS Begin DE532921 (LOS

PERCENTILE)LOS Percentile DE5323


DE5335


DE5336


DE5337


DE5338


DE5339

27 AVGLOS:SINGLE DX


DE5327

28 AVGLOS: MULTPDX


DE5328



DE5351



DE5349

31 AVGLOS:SINGLE NOSURG


DE5352

32 AVGLOS: MULTPNOSURG


DE5350



DE5346



DE5343



DE5347

36 (LOS LOS Percentile for Mul- DE5344

PERCENTILE)MULTP DX SURG

tiple DiagnosisWithSurgery

37 (LOSPERCENTILE)SINGLE NOSURG


DE5348

38 (LOSPERCENTILE)MULTP NOSURG


DE5345

Output Reports RF-O-003-04 For-mulary Listing - Drug

General InformationThis report lists all information for the Formulary with individual or all drug codes, depending on avalue set member.

Subsystem: ReferenceFrequency: On-DemandVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Formulary File Listing (Drug) (RFR00304)Confidential: NoSequence: National Drug Code (NDC)Control Breaks: N/A

Formulary Listing - Drug (RF-O-003-04)



1 NDC Drug Code (NDC) DE52003 BRAND NAME Drug Brand Name DE52084 ADD Drug Record Added

DateDE5300

5 OBS DrugObsolete Date DE52386 BEG Drug Coverage Begin

DateDE5201

7 END Drug Coverage EndDate

DE5202

8 LAST UPDT: CD Drug Last Update Code DE51889 (LAST UPDT) DT Row Update Date DE001110 (LAST UPDT)

TIMERow Update Date DE0011

11 PREV NDC Drug PreviousNationalDrug Code (NDC)

DE5752

12 REPLNDC Drug ReplacementNational Drug Code(NDC)

DE5753

13 GCN DrugGeneric CodeNumber (GCN)

DE5061

14 (GENERICSEQUENCE NO.)

DrugGeneric (GSN)Sequence Number

DE5731

15 (DRUGGENERICNAME)

DrugGeneric Name DE5747

16 STRENGTH Drug Strength Number DE529517 PKGSIZE Drug Package Size DE504118 V/F Drug Virginia Formulary

IndicatorDE5219

19 U/U Drug Unit of Use Code DE519320 BYPASS Drug Update Bypass

IndicatorDE5241

21 DISP UNIT Drug Dispensing Unit DE503122 FFP MFG

REBATEDrug Federal FinancialParticipation (FFP)RebateManufacturerCode

DE5197

23 UNIT DOSE Drug Unit Dose Code DE504224 UNIT Drug Strength Units DE529625 LABELER ID Drug Labeler Identifier

CodeDE5191

26 FORM Drug FormCode DE520627 DEA Drug Enforcement

Administration (DEA)Code

DE5032

28 MAINT DrugMaintenance Code DE528929 STD PKG IND Drug Standard Package

CodeDE5217

30 RBT EFF DT Drug Federal FinancialParticipation (FFP)RebateManufacturerCode Date

DE5216

31 TOP 200 Drug Top 200 Code DE508632 DESC Drug Strength Descrip-

tionDE5070

33 RTE DESC Drug Route Description DE509134 CP Drug Co-pay Indicator DE507135 CAT Drug Category Code DE508836 RTE ADMIN Drug Route of Admin-

istration CodeDE5736

37 GENDER SPEC DrugGender-SpecificCode

DE5297

38 MAX DISP UNITS DrugMaximumDis-pensing Units

DE5209

39 VOLNUM Drug Strength VolumeNumber

DE5194

40 MFG DrugMan-ufacturer/DistributorName

DE5040

41 CLS Drug ClassCode DE505942 DP Drug Direct Price Indic-

atorDE5203

43 INST PROD Drug InstitutionalProduct Code

DE5196

45 MAX QTY DrugMaximumQuantity DE521145.5 SRVC LIMIT Drug Service Limit Code DE507246 VOLUNITS Drug Strength Volume

UnitsDE5195

47 DOSAGE FORM Drug Dosage FormDescription

DE5043

48 THER STD Drug Therapeutic ClassStandard Code

DE5232

49 (THERAPEUTICCLASSDESCRIPTION)

Drug Therapeutic ClassStandard Description

DE5293

50 HCFA APPV DT Drug HCFA ApprovalDate

DE5110

51 ALLERGY CD Drug AllergyCodes DE528552 GEN Drug Therapeutic Class

Generic CodeDE5037


Drug Therapeutic ClassGeneric Description

DE5294

54 HCFA CMPROCCD

Drug HCFA CommonProcedure Code(HCPC)

DE5286

55 HCFA TERMDT Drug HCFA Termination DE5112

Date56 SPEC Drug Therapeutic Class

Specific CodeDE5735


Drug Therapeutic ClassSpecific Description

DE5292

58 HCFA DRUGCAT Drug HCFA Drug Cat-egory Code

DE5104

59 HCFA DESI CD Drug HCFA DESI Code DE510560 AHFS Drug Therapeutic Class

AHFS CodeDE5290


Drug Therapeutic ClassAHFS Description

DE5291

62 HCFA DRUGTYPIND

Drug HCFA Drug TypeCode

DE5113

63 HCFA DESI EFFDT

Drug HCFA DESI Effect-ive Date

DE5288

64 ORANGE BOOKCD

DrugOrange BookCode

DE5754

65 (ORANGE BOOKCDDESCRIPTION)

DrugOrange BookCode Description

DE5755

65.1 HICL Drug HierarchicalIngredient Code List(HICL)

DE5748

65.2 HICL SEQ Drug HierarchicalIngredient Code List(HICL) Sequence Num-ber

DE5218

65.3 SMART KEY Drug Smart KeyCode DE528766 MIN ADULT

DAILY DOSEUNIT

DrugMinimumDailyDose Units

DE5756 Dosage Type '1' (Adult)

67 MIN ADULTDAILY DOSE QTY

DrugMinimumDailyDoseQuantity


68 MIN ADULTDAILY DOSEFORM

DrugMinimumDailyUnits Form


69 MIN ADULTDAILY DOSE QTY

DrugMinimumDailyUnits Quantity


70 MAX ADULTDAILY DOSE

DrugMaximumDailyDose Units


UNIT71 MAX ADULT

DAILY DOSE QTYDrugMaximumDailyDoseQuantity


72 MAX ADULTDAILY DOSEFORM

DrugMaximumDailyUnits Form


73 MAX ADULTDAILY DOSE QTY

DrugMaximumDailyUnits Quantity


74 MIN GER DAILYDOSE UNIT


DE5756 Dosage Type '2' (Geriatric)

75 MIN GER DAILYDOSE QTY



76 MIN GER DAILYDOSE FORM



77 MIN GER DAILYDOSE QTY



78 MAX GER DAILYDOSE UNIT



79 MAX GER DAILYDOSE QTY

DrugMaximumDailyDoseQuantity


80 MAX GER DAILYDOSE FORM



81 MAX GER DAILYDOSE QTY



82 MIN MMAR ABSDAILY DOSEUNIT


DE5756 Dosage Type '3' (MMAR)

83 MIN MMAR ABSDAILY DOSE QTY



84 MIN MMAR ABSDAILY DOSEFORM



85 MIN MMAR ABSDAILY DOSE QTY



86 MAXMMAR ABSDAILY DOSEUNIT



87 MAXMMAR ABSDAILY DOSE QTY



88 MAXMMAR ABSDAILY DOSEFORM



89 MAXMMAR ABS DrugMaximumDaily DE5759 Dosage Type '3' (MMAR)

DAILY DOSE QTY Units Quantity90 MIN MMGR ABS

DAILY DOSEUNIT


DE5756 Dosage Type '4' (MMGR)

91 MIN MMGR ABSDAILY DOSE QTY



92 MIN MMGR ABSDAILY DOSEFORM



93 MIN MMGR ABSDAILY DOSE QTY



94 MAXMMGR ABSDAILY DOSEUNIT



95 MAXMMGR ABSDAILY DOSE QTY



96 MAXMMGR ABSDAILY DOSEFORM



97 MAXMMGR ABSDAILY DOSE QTY



98 REF COST Drug Price Amount DE5220 Proce Type 'REF'99 BEGDATE Drug Price Effective

DateDE5222 Price Type 'REF'

100 SRCE Drug Price Source Code DE5221 Price Type 'REF'101 BRAND NEC Drug Price Amount DE5220 Price Type 'DAW'102 BEGDATE Drug Price Effective

DateDE5222 Price Type 'DAW'

103 SRCE Drug Price Source Code DE5221 Price Type 'DAW'104 DRUGCOST Drug Price Amount DE5220 Price Type 'DC'105 BEGDATE Drug Price Effective

DateDE5222 Price Type 'DC'

106 SRCE Drug Price Source Code DE5221 Price Type 'DC'107 UNIT DOSE Drug Price Amount DE5220 Price Type 'UD'108 BEGDATE Drug Price Effective

DateDE5222 Price Type 'UD'

109 SRCE Drug Price Source Code DE5221 Price Type 'UD'110 FMAC Drug Price Amount DE5220 Price Type 'MAC'111 BEGDATE Drug Price Effective

DateDE5222 Price Type 'MAC'

112 SRCE Drug Price Source Code DE5221 Price Type 'MAC'

113 DIR UNIT PRICE Drug Price Amount DE5220 Price Type 'DUP'114 BEGDATE Drug Price Effective

DateDE5222 Price Type 'DUP'

115 SRCE Drug Price Source Code DE5221 Price Type 'DUP'116 WAC Drug Price Amount DE5220 Price Type 'WAC'117 BEGDATE Drug Price Effective

DateDE5222 Price Type 'WAC'

118 SRCE Drug Price Source Code DE5221 Price Type 'WAC'119 AWP Drug Price Amount DE5220 Price Type 'AWP'120 BEGDATE Drug Price Effective

DateDE5222 Price Type 'AWP'

121 SRCE Drug Price Source Code DE5221 Price Type 'AWP'122 AWP LAST UPDT Drug AverageWhole-

sale Price (AWP) Dateof Last Change

DE5749

123 VMAC (60TH UD) Drug Price Amount DE5220 Price type 'V60'124 BEGDATE Drug Price Effective

DateDE5222 Price type 'V60'

125 VMAC (75THNON-UD)

Drug Price Amount DE5220 Price Type 'V75'

126 BEGDATE Drug Price EffectiveDate

DE5222 Price Type 'V75'

Output Reports RF-O-003-05 Pro-cedure Listing - Medical

General InformationThis report lists information for all medical procedures, depending on the value set member.

Subsystem: ReferenceFrequency: Monthly / On-DemandVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Procedure File Listing (ALL) (RFR00305)Confidential: NoSequence: Procedure Code: Medical CodeControl Breaks: N/A

Procedure Listing - Medical (RF-O-003-05)

Procedure Listing - Medical (RF-O-003-05)




DESCProcedure ShortName

DE5015

3 PROC TYPE Procedure Code Type DE50014 PROC TYPE DESC Procedure Code Type DE50015 PROC BEG Procedure Coverage

Begin DateDE5003


DE5004

7 AGE:MIN ProcedureMinimum DE5009

Age Limit8 AGE:MAX ProcedureMaximum

Age LimitDE5010

9 SEX Valid SexCode DE501110 PA TYPE Procedure PA Type DE501711 PA EFF DATE PA Type Effective

DateDE5018

12 PA END DATE PA Type EndDate DE512013 CAT Region Type DE524414 DESCRIPTION Region Name DE525015 INP OUT Procedure Rate Type DE5153 Rate Type 'IP' or 'OP'16 MAX RATE Procedure Amount DE5047 Rate Type 'OP' or 'IP'17 EFF DATE Procedure Amount


18 END DATE Procedure Rate EndDate

DE5138 Rate Type 'IPPC'

19 PC RATE Procedure Amount DE5047 Rate Type 'IPPC' or 'OPPC'20 PC EFF DATE Procedure Amount


21 PC END DATE Procedure Rate EndDate

DE5138 N/A

22 TC RATE DE0000 MAX RATE - PC RATE. SPACESIF PC RATE = ZERO

23 TC EFF DATE Procedure AmountEffective Date

DE5046 Rate Type 'IP'

24 ANESTHESIOLOGYBASE UNITS (1)

Anesthesiology BaseUnits

DE5050

25 ANESTHESIOLOGYBEGIN DT (1)

Anesthesiology BaseUnits Begin Date

DE5051

26 ANESTHESIOLOGYEND DT (1)

Anesthesiology BaseUnits End Date

DE5163



DE5050



DE5051



DE5163



DE5050



DE5051

32 ANESTHESIOLOGY Anesthesiology Base DE5163

END DT (3) Units End Date33 ANESTHESIOLOGY

BASE UNITS (4)Anesthesiology BaseUnits

DE5050

34 ANESTHESIOLOGYBEGIN DT(4)


DE5051



DE5163



DE5050



DE5051



DE5163

39 FLAGCDE (1) Flag Code DE516540 IND (1) Flag Date Type Code DE524041 FLAGBEGIN DT (1) Flag Begin Date DE524242 FLAGEND DT (1) Flag End Date DE524343 FLAGCDE (2) Flag Code DE516544 IND (2) Flag Date Type Code DE524045 FLAGBEGIN DT (2) Flag Begin Date DE524246 FLAGEND DT (2) Flag End Date DE524347 FLAGCDE (3) Flag Code DE516548 IND (3) Flag Date Type Code DE524049 FLAGBEGIN DT (3) Flag Begin Date DE524250 FLAGEND DT (3) Flag End Date DE524351 FLAGCDE (4) Flag Code DE516552 IND (4) Flag Date Type Code DE524053 FLAGBEGIN DT (4) Flag Begin Date DE524254 FLAGEND DT (4) Flag End Date DE524355 FLAGCDE (5) Flag Code DE516556 IND (5) Flag Date Type Code DE524057 FLAGBEGIN DT (5) Flag Begin Date DE524258 FLAGEND DT (5) Flag End Date DE524359 FLAGCDE (6) Flag Code DE516560 IND (6) Flag Date Type Code DE524061 FLAGBEGIN DT (6) Flag Begin Date DE524262 FLAGEND DT (6) Flag End Date DE524363 FLAGCDE (7) Flag Code DE516564 IND (7) Flag Date Type Code DE5240

65 FLAGBEGIN DT (7) Flag Begin Date DE524266 FLAGEND DT (7) Flag End Date DE524367 FLAGCDE (8) Flag Code DE516568 IND (8) Flag Date Type Code DE524069 FLAGBEGIN DT (8) Flag Begin Date DE524270 FLAGEND DT(8) Flag End Date DE524371 FLAGCDE (9) Flag Code DE516572 IND (9) Flag Date Type Code DE524073 FLAGBEGIN DT (9) Flag Begin Date DE524274 FLAGEND DT (9) Flag End Date DE524375 FLAGCDE (10) Flag Code DE516576 IND (10) Flag Date Type Code DE524077 FLAGBEGIN DT


78 FLAGEND DT (10) Flag End Date DE5243

Output Reports RF-O-003-06 Pro-cedure Listing - Revenue

General InformationThis report lists information for individual or all revenue codes, depending on the value set member.

Subsystem: ReferenceFrequency: Monthly / On-DemandVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Procedure File Listing (ALL) (RFR00305)

Procedure File Listing (Revenue) (RFR00306)Confidential: NoSequence: Procedure Code: Revenue CodeControl Breaks: N/A

Procedure Listing - Revenue (RF-O-003-06)





DESCProcedure Short Name DE5015

3 PROC TYPE Procedure Code Type DE50014 PROC TYPE

DESCProcedure Code Type DE5001

5 PROC BEG Procedure CoverageBegin Date

DE5003


DE5004


DE5009

8 AGE: MAX ProcedureMaximumAge Limit

DE5010

9 SEX Valid SexCode DE5011

10 PA TYPE Procedure PA Type DE501711 PA EFF DATE PA Type Effective Date DE501812 PA END DATE PA Type EndDate DE512013 CAT Region Type DE524414 DESCRIPTION Region Name DE525015 INP OUT Procedure Rate Type DE5153 Rate Type 'IP' or 'OP'16 MAX RATE Procedure Amount DE504717 EFF DATE Procedure Amount


18 END DATE Procedure Amount DE504719 FLAGCDE (1) Flag Code DE516520 IND (1) Flag Date Type Code DE524021 BEGIN DT (1) Flag Begin Date DE524222 END DT (1) Flag End Date DE524323 FLAGCDE (2) Flag Code DE516524 IND (2) Flag Date Type Code DE524025 FLAGBEGIN DT










42 FLAGEND DT (6) Flag End Date DE524343 FLAGCDE (7) Flag Code DE5165

44 IND (7) Flag Date Type Code DE524045 FLAGBEGIN DT








58 FLAGEND DT(10)

Flag End Date DE5243

Output Reports RF-O-003-07 Pro-cedure Listing - ICD-10-CM

General InformationThis report lists information for all ICD-10-CM procedures and associated length of stay.

Subsystem: ReferenceFrequency: On-DemandVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Procedure File Listing (ICD-10-CM) (RFR00307)Confidential: NoSequence: Procedure Code: ICD-10-CMControl Breaks: N/A

Procedure Listing - ICD-10-CM (RF-O-003-07)



1 REC ID Procedure Code Type DE50012 PROC CD Procedure Code DE50023 (PROCEDURE

CODE NAME)Procedure Short Name DE5015

4 BEG Procedure CoverageBegin Date

DE5003


DE5004


DE5009

7 MAX ProcedureMaximumAge Limit

DE5010


9 P/R Procedure PendReview Indicator

DE5007


DE5016

11 PA: TYPE Procedure PA Type DE501712 EFF PA Type Effective Date DE501816 PLACE SERV ClaimProfessional

Place of ServiceDE2173


cedure CodeDE5164


DE5139


DE5140

36 PROV TYP Provider Type DE400637 PROV SPEC Provider Specialty

CodeDE4007


DE5173


DE5174

40 FLAG Flag Code DE516541 S/R Flag Date Type Code DE524042 BEGIN DT Flag Begin Date DE524243 END DT Flag End Date DE524344 LOS KEY HCIA LOS Group DE546745 (ALL DEFAULT

LOS)DE0000

46 CURRENT LOS Begin DE532947 PREVIOUS LOS Begin DE532948 (PERCENTILE) LOS Percentile DE532349 (LOS) 00-19 LOS for Age Range 00-

19DE5335


DE5336


DE5337


DE5338


DE5339

54 AVGLOS:SINGLE DX


DE5327

55 AVGLOS: MULTPDX


DE5328



DE5351



DE5349

58 AVGLOS:SINGLE DX NOSURG


DE5352



DE5350



DE5346



DE5343



DE5347

63 (LOSPERCENTILE)MULTP DX SURG

LOS Percentile for Mul-tiple DiagnosisWithSurgery

DE5344

64 (LOSPERCENTILE)SINGLE DX NOSURG


DE5348

65 (LOSPERCENTILE)MULTP DX NOSURG


DE5345

Output Reports RF-O-003-08 Pro-cedure Listing - Home Health

General InformationThis report lists information for all HomeHealth procedures.

Subsystem: ReferenceFrequency: On-DemandVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Procedure File Listing (HomeHealth) (RFR00308)Confidential: NoSequence: Procedure CodeControl Breaks: N/A

Procedure Listing - Home Health (RF-O-003-08)

Procedure Listing - Home Health (RF-O-003-08)




NAME)Procedure Short Name DE5015


DE5003


DE5004

6 AGE:MIN ProcedureMinimumAge Limit

DE5009


DE5010


9 P/R Procedure PendReview Indicator

DE5007


DE5016

11 PA:TYPE Procedure PA Type DE501712 (PA TYPE) EFF PA Type Effective Date DE501813 (PA TYPE) END PA Type EndDate DE512014 (PA TYPE AGE)

MINReference ProcedurePA Type AgeMinimum

DE5900

15 (PA TYPE AGE)MAX

Reference ProcedurePA Type AgeMax-imum

DE5975

16.1 TDOPROJCODE Reference ProcedureTDOProject Code

DE5890

16.2 BEG Reference ProcedureTDOProject CodeBegin Date

DE5891

16.3 END Reference ProcedureTDOProject Code EndDate

DE5892

17 PLACE SERV ClaimProfessionalPlace of Service

DE2173


cedure CodeDE5164


DE5139


DE5140

20.3 CAT Region Type DE524421 DESCRIPTION Region Name DE525022 IP AREAMAX Procedure Amount DE5047 Rate Type 'IP'23 IP EFF DATE Procedure Amount

Effective DateDE5046 Rate Type 'IP'

24 OP AREAMAX Procedure Amount DE5047 Rate Type 'OP'25 OP EFF DATE Procedure Amount

Effective DateDE5046 Rate Type 'OP'

26 CARRIER Medicare CarrierName

DE5178

27 IP MCAREMAX Medicare Amount DE5175 Rate Type 'IP'28 IP BEGIN DT Medicare Amount

Begin DateDE5176 Rate Type 'IP'

29 IP END DT Medicare Amount EndDate


30 OPMCAREMAX Medicare AmountBegin Date

DE5176 Rate Type 'OP'

31 OP BEGIN DT Medicare AmountBegin Date


32 OP END DT Medicare Amount EndDate


33 IP MCARE PC Medicare Amount DE5175 Rate Type 'IPPC'34 IP BEGIN DT Medicare Amount

Begin DateDE5176 Rate Type 'IPPC'



36 OPMCARE PC Medicare Amount DE5175 Rate Type 'OPPC'37 OP BEGIN DT Medicare Amount

Begin DateDE5176 Rate Type 'OPPC'


DE5177 Rate Type 'OPPC'

39 IP TC DE000040 OP TC DE000041 PROV TYP Provider Type DE400642 PROV SPEC Provider Specialty

CodeDE4007

42.5 CLMTYPE Claim Type DE200243 BEGIN DT Procedure Valid Pro-

vider Type-SpecialtyBegin Date

DE5173


DE5174


Output Reports RF-O-003-09 Pro-cedure Listing - Hospice

General InformationThis report lists information for all Hospice procedures.

Subsystem: ReferenceFrequency: On-DemandVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Procedure File Listing (Hospice) (RFR00309)Confidential: NoSequence: Procedure CodeControl Breaks: N/A

Procedure Listing - Hospice (RF-O-003-09)

Procedure Listing - Hospice (RF-O-003-09)




NAME)Procedure Short Name DE5015


DE5003


DE5004


DE5009


DE5010

8 SEX Valid SexCode DE50119 P/R Procedure Pend

Review IndicatorDE5007


DE5016

11 PA:TYPE Procedure PA Type DE501712 (PA TYPE) EFF PA Type Effective Date DE501813 END PA Type EndDate DE512014 PA AGE: MIN Reference Procedure

PA Type AgeMinimumDE5900

15 MAX Reference ProcedurePA Type AgeMax-imum

DE5975

16.1 TDOPROJCODE Reference ProcedureTDOProject Code

DE5890

16.2 BEG Reference ProcedureTDOProject CodeBegin Date

DE5891

16.3 END Reference ProcedureTDOProject Code EndDate

DE5892

17 PLACE SERV ClaimProfessionalPlace of Service

DE2173


cedure CodeDE5164


DE5139


DE5140

20.3 CAT Region Type DE524421 DESCRIPTION Region Name DE525022 IP AREAMAX Procedure Amount DE5047 Rate Type 'IP'23 IP EFF DATE Procedure Amount

Effective DateDE5046 Rate Type 'IP'

24 OP AREAMAX Procedure Amount DE5047 Rate Type 'OP'25 OP EFF DATE Procedure Amount

Effective DateDE5046 Rate Type 'OP'

26 CARRIER Medicare Carrier DE5178

Name27 IP MCAREMAX Medicare Amount DE5175 Rate Type 'IP'28 IP BEGIN DT Medicare Amount

Begin DateDE5176 Rate Type 'IP'



30 OPMCAREMAX Medicare Amount DE5175 Rate Type 'OP'31 OP BEGIN DT Medicare Amount

Begin DateDE5176 Rate Type 'OP'



33 IP MCARE PC Medicare Amount DE5175 Rate Type 'IPPC'34 IP BEGIN DT Medicare Amount

Begin DateDE5176 Rate Type 'IPPC'



36 OPMCARE PC Medicare Amount DE5175 Rate type 'OPPC'37 OP BEGIN DT Medicare Amount

Begin DateDE5176 Rate Type 'OPPC'



39 IP TC Medicare Amount DE5175 Rate type 'IPTC'40 OP TC Medicare Amount DE5175 Rate type 'OPTC'41 PROV TYP Provider Type DE400642 PROV SPEC Provider Specialty

CodeDE4007


DE5173


DE5174


Output Reports RF-O-008-01 BlueBook Drug Update ComparisonReport

General InformationThis report lists updated drug data before and after actual update.

Subsystem: ReferenceFrequency: WeeklyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Blue BookDrug Update (RFW008)

Blue BookDrug Update - Restart (RFW008A)Confidential: NoSequence: National Drug Code (NDC)Control Breaks: N/A

Blue Book Drug Update Comparison Report (RF-O-008-01)

Field Definitions# Field Name Data Element

NameElementID

Source/Calculations

1 NDC Drug Code (NDC) DE52002 DRUGNAME Drug Brand Name DE52083 ACTION CD DE0000 Add, change, or delete determ-

ined by program.4 ITEMDESCRIPTION DE0000 Description of data element

being added or changed.5 OLD VALUE DE0000 Current value of data element

being added or changed.6 NEWVALUE DE0000 New value of data element

being added or changed.7 NDDF DRUGPRICING

TAPE RECORDS READCalculated DE0002

8 TOTALNDDF ADDRECORDS

Calculated DE0002

9 PROCEDURE/FORMULARYRECORDS CHANGED

Calculated DE0002

10 NDDF DRUGPRICINGRECORDS IN ERROR

Calculated DE0002

11 TOTAL ADDS, CHANGES,AND ERRORS

Calculated DE0002

12 NDDF DRUGRECORDS NOCHANGES

Calculated DE0002

Output Reports RF-O-008-02 BlueBook Drug Error Report

General InformationThis report provides a control listing of all errors encountered during the update to the drug table.



Blue Book Drug Error Report (RF-O-008-02)



1 NDC Drug Code (NDC) DE52002 ACTION CD DE0000 Add, change, or delete determined by

program.3 ITEM

DESCRIPTIONDE0000 Description or data element that is

being determined as an error.4 ITEMVALUE DE0000 Value of data element that is in error.5 ERROR

MESSAGEDE0000 Description of error.

6 NDDF DRUGPRICINGRECORDS INERROR

Calculated DE0002

Output Reports RF-O-008-03 BlueBook Drug Add Report

General InformationThis report provides a control listing of all drug table data which were added to the file.



Blue Book Drug Add Report (RF-O-008-03)



1 NDC Drug Code (NDC) DE52002 ACTION CD DE0000 'Add'3 ITEM

DESCRIPTIONDE0000 Description of data element added.

4 NEWVALUE DE0000 Value of data element added.5 TOTALNDDF

ADD RECORDSCalculated DE0002

Output Reports RF-O-008-04 VirginiaFormulary Drug Prices by NDC

General InformationThis report provides a listing in NDC sequence of all drug prices for Virginia formulary drugs.

Subsystem: ReferenceFrequency: WeeklyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Blue BookDrug Price Changes (RFW00801)Confidential: NoSequence: National Drug Code (NDC)Control Breaks: N/A

Virginia Formulary Drug Prices by NDC (RF-O-008-04)

Virginia Formulary Drug Prices by NDC (RF-O-008-04)



1 NDC Drug Code (NDC) DE52002 BRAND NAME Drug Brand Name DE52083 GENERIC NAME DrugGeneric Name DE57474 MANUFACTURER DrugMan-

ufacturer/DistributorName

DE5040

5 STRENGTH Drug Strength Descrip-tion

DE5070

6 DOSAGE Drug Dosage FormDescription

DE5043

7 ROUTE Drug Route Description DE50918 GEN CODE DrugGeneric Code

Number (GCN)DE5061

9 THERAPEUTICCLASS STD

Drug Therapeutic ClassStandard Code

DE5232

10 THERAPEUTIC Drug Therapeutic Class DE5037

CLASS GEN Generic Code11 THERAPEUTIC

CLASS SPECDrug Therapeutic ClassSpecific Code

DE5735

12 THERAPEUTICCLASS AHFS

Drug Therapeutic ClassAHFS Code

DE5290

13 DEA Drug EnforcementAdministration (DEA)Code

DE5032

14 CLASS Drug ClassCode DE505915 DISP UNIT Drug Dispensing Unit DE503116 CAT CODE Drug Category Code DE508817 PKGSIZE Drug Package Size DE504118 DUP*D1 Drug Price Effective

DateDE5222 Rate Type 'DUP'

19 DUP*P1 Drug Price Amount DE5220 Rate Type 'DUP'20 WAC*D1 Drug Price Effective

DateDE5222 Rate Type 'WAC'

21 WAC*P1 Drug Price Amount DE5220 Rate Type 'WAC'22 AWP*D1 Drug Price Effective

DateDE5222 Rate Type 'AWP'

23 AWP*P1 Drug Price Amount DE5220 Rate Type 'AWP'24 VMAC*D1 Drug Price Effective

DateDE5222 Rate Type 'V60'

25 VMAC*P1 Drug Price Amount DE5220 Rate Type 'V60'26 VMAC*D1 Drug Price Effective


27 VMAC*P1 Drug Price Amount DE5220 Rate Type 'V75'28 FMAC*D1 Drug Price Effective

DateDE5222 Rate Type 'MAC'

29 FMAC*P1 Drug Price Amount DE5220 Rate Type 'MAC'30 RC*D1 Drug Price Effective

DateDE5222 Rate Type 'REF'

31 RC*P1 Drug Price Amount DE5220 Rate Type 'REF'32 SRC Drug Price Source Code DE5221 Rate Type 'REF'33 BN*D1 Drug Price Effective

DateDE5222 Rate Type 'DAW'

34 BN*P1 Drug Price Amount DE5220 Rate Type 'DAW'35 SRC Drug Price Source Code DE5221 Rate Type 'DAW'36 DC*D1 Drug Price Effective

DateDE5222 Rate Type 'DC'

37 DC*P1 Drug Price Amount DE5220 Rate Type 'DC'

38 SRC Drug Price Source Code DE5221 Rate Type 'DC'39 UDP*D1 Drug Price Effective

DateDE5222 Rate Type 'UD'

40 UDP*P1 Drug Price Amount DE5220 Rate Type 'UD'42 SRC Drug Price Source Code DE5221 Rate Type 'UD'

Output Reports RF-O-008-05 VirginiaFormulary Drug Prices by Labeler

General InformationThis report provides a listing in manufacturer labeler sequence of all drug prices for Virginia for-mulary drugs.

Subsystem: ReferenceFrequency: WeeklyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Blue BookDrug Price Changes (RFW00801)Confidential: NoSequence: DrugManufacturer LabelerControl Breaks: N/A

Virginia Formulary Drug Prices by Labeler (RF-O-008-05)

Virginia Formulary Drug Prices by Labeler (RF-O-008-05)



1 NDC Drug Code (NDC) DE52002 BRAND NAME Drug Brand Name DE52083 GENERIC NAME DrugGeneric Name DE57474 MANUFACTURER DrugMan-


DE5040

5 STRENGTHDESC

Drug Strength Descrip-tion

DE5070


DE5043

7 ROUTE DESC Drug Route Description DE50918 GEN CODE DrugGeneric Code

Number (GCN)DE5061

9 THERAPEUTICCLASS STD

Drug Therapeutic ClassStandard Code

DE5232

10 THERAPEUTICCLASS GEN

Drug Therapeutic ClassGeneric Code

DE5037

11 THERAPEUTICCLASS SPEC

Drug Therapeutic ClassSpecific Code

DE5735



DE5290

13 DEA Drug EnforcementAdministration (DEA)Code

DE5032

14 CLASS Drug ClassCode DE505915 DISP UNIT Drug Dispensing Unit DE503116 CAT CODE Drug Category Code DE508817 PKGSIZE Drug Package Size DE504118 DUP*D1 Drug Price Effective

DateDE5222 Rate Type 'DUP'

19 DUP*P1 Drug Price Amount DE5220 Rate Type 'DUP'20 WAC*D1 Drug Price Effective


21 WAC*P1 Drug Price Amount DE5220 Rate Type 'WAC'22 AWP*D1 Drug Price Effective


23 AWP*P1 Drug Price Amount DE5220 Rate Type 'AWP'24 VMAC*D1 Drug Price Effective


25 VMAC*P1 Drug Price Amount DE5220 Rate Type 'V60'26 VMAC*D1 Drug Price Effective


27 VMAC*P1 Drug Price Amount DE5220 Rate Type 'V75'28 FMAC*D1 Drug Price Effective


29 FMAC*P1 Drug Price Amount DE5220 Rate Type 'MAC'30 RC*D1 Drug Price Effective

DateDE5222 Rate Type 'REF'

31 RC*P1 Drug Price Amount DE5220 Rate Type 'REF'32 SRC Drug Price Source Code DE5221 Rate Type 'REF'33 BN*D1 Drug Price Effective

DateDE5222 Rate Type 'DAW'

34 BN*P1 Drug Price Amount DE5220 Rate Type 'DAW'35 SRC Drug Price Source Code DE5221 Rate Type 'DAW'36 DC*D1 Drug Price Effective

DateDE5222 Rate Type 'DC'

37 DC*P1 Drug Price Amount DE5220 Rate Type 'DC'38 SRC Drug Price Source Code DE5221 Rate Type 'DC'39 UDP*D1 Drug Price Effective

DateDE5222 Rate Type 'UD'

40 UDP*P1 Drug Price Amount DE5220 Rate Type 'UD'41 SRC Drug Price Source Code DE5221 Rate Type 'UD'

Output Reports RF-O-008-06 VendorMAC Price Update Listing

General InformationThis report shows the details of each record, the processes done and action taken for each record inthe Vendor MAC. It also contains the old and new values of the price, effective date and source andmessage for errors/discrepancies encountered.

Subsystem: ReferenceFrequency: WeeklyVolume: VariableNumber of Copies: to be determinedOutput Form: StandardRetention: 30 daysDistribution: DMASProgram: Vendor MAC Update of RF_NDC_PRICE (RFW00802)Confidential: NoSequence: N/AControl Breaks: N/A

Vendor MAC Price Update Listing (RF-O-008-06)



1 NDC Drug National DrugCode (NDC) FormatCode

DE5192 Identifies the original ten characterformat of the NDC (DE 5200) and typeof code, i.e. NDC (National DrugCode), UPC (Universal ProductCode), HRI (Health Related ItemCode) and PIN (Personal IdentificationNumber).

2 GCN DrugGeneric CodeNumber (GCN)

DE5061 Random number representing the gen-eric formula of a drug. It is specific togeneric ingredient combination, Routeof Administration (DE 5736), DosageForm (DE 5043) and Drug Strength(DE 5070). It is the same acrossman-ufacturers and/or package sizes.

3 Action DE0000 The action taken for the price of thedrug. The responses for this field are'Initial', 'Changed' 'Bypassed', 'Error' orBlank.

4 Old Price Drug Price Amount DE5220 The previous price amount for thedrug, based on the price type.

5 New Price Drug Price Amount DE5220 The price amount for the drug, based

on the price type.6 Old Date Drug Price Effective

DateDE5222 The previous Effective date of Drug

Price.7 New Date Drug Price Effective

DateDE5222 Effective date of Drug Price.

8 Old/New Source Drug Price SourceCode

DE5221 Source of Drug Price.

9 MAC OVRD Indic-ator

Drug VA MAC Over-ride

DE5095 This field will be used byDMAS toOverrideMAC pricing

10 Message DE0000 This field contains the text that com-poses an error message to be printedon the Report.

Output Reports RF-O-008-07ANDA/NDA Update ComparisonReport

General InformationThis report shows the details of each record, the processes done and action taken for each FDBrecord. It also contains the old and new values of the ANDA/NDA Indicator, andmessage for error-s/discrepancies encountered.

Subsystem: ReferenceFrequency: WeeklyVolume: DiskNumber of Copies: 1Output Form: StdRetention: 100Distribution: N/AProgram: RF_NDC Table Update for NDA/ANDA Indicators (RFW00803)Confidential: NoSequence: N/AControl Breaks: N/A

ANDA/NDA Update Comparision Report (RF-O-008-07)

ANDA/NDA Update Comparision Report (RF-O-008-07)



1 NDC Drug Code (NDC) DE52002 DRUGNAME Drug Brand Name DE52083 ACTION CODE DE0000 Move a value of 'C' to this field.4 ITEM

DESCRIPTIONDE0000 Move the name of the field 'C-DRUG-

NDA' or 'C-DRUG-ANDA' to beupdated to the Report ItemDescrip-tion.

5 OLD VALUE Drug New Drug Applic-ation

DE5098 Current value of C-DRUG-NDA(DE5098) or C-DRUG-ANDA(DE5099) from the NDC Table.

6 NEWVALUE Drug New Drug Applic-ation

DE5098 New value of C-DRUG-NDA(DE5098) or C-DRUG-ANDA(DE5099) from the input file.

7 ANDA/NDARECORDS READ

Calculated DE0002 Number of input records read.

8 ANDA/NDACHANGES

Calculated DE0002 Number of changes that will updatethe RF_NDC table.

9 ANDA/NDAUPDATEERRORS

Calculated DE0002 Number of errors encountered whileupdating table RF_NDC.

10 TOTALCHANGES ANDERRORS

Calculated DE0002 Number of changes and errors whenupdating the RF_NDC table.

11 ANDA/NDA NOCHANGES

Calculated DE0002 Number of input records that did notupdate the RF_NDC table.

Output Reports RF-O-009-01 DrugTrade Name Listing

General InformationThis report is a listing of all drug table data by trade name. The production or this output is controlledby a parmlib member.

Subsystem: ReferenceFrequency: WeeklyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Drug Trade Name Listing (RFW00901)Confidential: NoSequence: Drug Trade Name

NDCControl Breaks: N/A

Drug Trade Name Listing (RF-O-009-01)



1 NDC Drug Code (NDC) DE52002 TRADE NAME Drug Brand Name DE52083 MANUFACTURER DrugMan-


DE5040

4 STRENGTHDESC

Drug Strength Descrip-tion

DE5070

5 DOSE FORM Drug Dosage FormDescription

DE5043

6 DISP UNIT Drug Dispensing Unit DE50317 PKGSIZE Drug Package Size DE50418 THERAPEUTIC

CLASS STDDrug Therapeutic ClassStandard Code

DE5232


Drug Therapeutic ClassGeneric Code

DE5037


Drug Therapeutic ClassSpecific Code

DE5735



DE5290

12 AWP Drug Price Amount DE5220 Rate Type 'AWP'13 AWP DATE Drug Price Effective


14 WAC Drug Price Amount DE5220 Rate Type 'WAC'15 WAC DATE Drug Price Effective


16 FMAC Drug Price Amount DE5220 Rate Type 'MAC'17 FMAC DATE Drug Price Effective


18 DIRECT UNITPRICE

Drug Price Amount DE5220 Rate Type 'DUP'

19 DIRECT UNITDATE

Drug Price EffectiveDate

DE5222 Rate Type 'DUP'

20 VMAC (60th UD) Drug Price Amount DE5220 Rate Type 'V60'21 VMAC DATE Drug Price Effective


22 VMAC (75th NON-UD)

Drug Price Amount DE5220 Rate Type 'V75'

23 VMAC DATE Drug Price EffectiveDate

DE5222 Rate Type 'V75'

24 TOTALDRUGSREPORTED

Calculated DE0002 Count number of NDCs reported.

Output Reports RF-O-009-04 MACDrug Listing

General InformationThis report is a listing of theMAC drug prices.

Subsystem: ReferenceFrequency: On-DemandVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: MAC Drug Listing (RFW00904)Confidential: NoSequence: Therapeutic Class/Drug Trade NameControl Breaks: N/A

MAC Drug Listing (RF-O-009-04)



1 DRUGCODE Drug Code (NDC) DE52002 DRUGNAME Drug Brand Name DE52083 WAC Drug Price Amount DE5220 Rate Type 'WAC'4 AWP Drug Price Amount DE5220 Rate Type 'AWP'5 FMAC Drug Price Amount DE5220 Rate Type 'MAC'6 VMAC (60TH UD) Drug Price Amount DE5220 Rate Type 'V60'7 VMAC (75TH

NON-UD)Drug Price Amount DE5220 Rate Type 'V75'

8 DIRECT PRICE Drug Price Amount DE5220 Rate Type 'DUP'9 TOTALDRUGS

REPORTEDCalculated DE0002

Output Reports RF-O-010 NumericNDC Drug Dosage Report

General InformationThis report provides a listing of all drug procedures including the trade name, strength and genericname.

Subsystem: ReferenceFrequency: QuarterlyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Numeric NDC Drug Dosage Report (RFW010)Confidential: NoSequence: NDCControl Breaks: N/A

Numeric NDC Drug Dosage Report (RF-O-010)



1 NDC CODE Drug Code (NDC) DE52002 TRADE NAME Drug Brand Name DE52083 STRENGTH

DESCDrug Strength Descrip-tion

DE5070

4 GENERIC NAME DrugGeneric Name DE57475 THERAPEUTIC

CLASS STDDrug TherapeuticClass Standard Code

DE5232


Drug TherapeuticClassGeneric Code

DE5037


Drug TherapeuticClass Specific Code

DE5735


Drug TherapeuticClass AHFS Code

DE5290


DE5043

10 TOTALDRUGSREPORTED

Calculated DE0002 Equals number of rows on the NDCtable

Output Reports RF-O-015 Edit Cri-teria Listing

General InformationThis report is a listing of all information on the Edit Criteria and associated tables (RF_EDIT_CRITERIA, RF_EDIT_PARM_SET, RF_EC_VALUE_SET, RF_VALUE_SET, RF_VALUE_SET_RANGE, and RF_EDIT_TEXT).

Subsystem: ReferenceFrequency: OnDemandVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Edit Criteria Listing (RFR015)Confidential: NoSequence: Edit Code within ESC CodeControl Breaks: N/A

Edit Criteria Listing (RF-O-015)



1 ESC ClaimError ESC Code DE55062 EDIT CD Error Text Error Code DE55013 PROG Benefit Definition Plan

ProgramCodeDE3551

4 FORM Claim FormCode DE58765 CLAIM TYPE Claim Type DE20026 CRITERIA TYPE Edit Criteria Set Type DE56837 EDIT TEXT

DESCRIPTIONError Text ShortDescription

DE5513

8 BEG ClaimEdit Code ParmBegin Date

DE5877

9 END ClaimEdit Code Parm DE5878

EndDate10 CRITERION Edit Criteria Criterion DE561411 SEQ# Edit Criteria Sequence

NumberDE5610

12 CRIT SET TYPE Edit Criteria Set Type DE568313 OPTIONS Same/Different/Any

OptionsDE5615

14 INCL EXCL Edit Criteria Exclus-ive/Inclusive (E/I) Code

DE5624

15 TIME SPAN TYPE Edit Criteria Time SpanType

DE5696

16 TIME UNITS Edit Criteria TimeUnits DE569717 TIME TYPE Edit Criteria Time Type DE569818 LIMIT UNIT QTY Edit Criteria Limit Unit

QuantityDE5873

19 LIMIT UNIT TYPE Edit Criteria Limit UnitType

DE5874

20 LIMIT AMOUNTQTY

Edit Criteria LimitAmount Quantity

DE5875

21 A/B/X Edit Criteria A/B/XCode

DE5625

22 BEGDATE Edit Criteria Begin Date DE561623 END DATE Edit Criteria End Date DE561724 BEGIN

EFFECTIVEDATE

Edit Criteria Value SetBegin Date

DE5694

25 END EFFECTIVEDATE

Edit Criteria Value SetEnd Date

DE5695

26 DATA ELEMENTTYPE

Value Set Data Ele-ment Type

DE5395

27 DESCRIPTION Value Set Name DE539228 BEGIN Value Set Effective

Begin DateDE5438

29 END Value Set Effective EndDate

DE5439

30 BEGIN RANGE Value Set Data BeginRange

DE5396

31 END RANGE Value Set Data EndRange

DE5397

32 TYPE Value Set Range Type DE544033 BEGIN Value Set Range Begin

DateDE5441

34 END Value Set Range EndDate

DE5442

Output Reports RF-O-016 Error Textand Disposition/Location Listing

General InformationThis is a list of all the detail data on the Error Text (RF_EDIT_TEXT) and the Error Disposition Loca-tion (RF_ERROR_DISP_LOC) tables.

Subsystem: ReferenceFrequency: OnDemandVolume: VariableNumber of Copies: To be determinedOutput Form: StandardRetention: 30 daysDistribution: To be determinedProgram: Error Text & Disposition/Location List (RFR016)Confidential: NoSequence: Error ESC Code, ProgramCode, FormCode, Claim TypeControl Breaks: N/A

Error Text and Disposition/Location Listing (RF-O-016)



1 ERROR CODE Error Text Error Code DE55012 ERROR ESC Error ESC Code DE56093 SHORT

DESCRIPTIONError Text ShortDescription

DE5513

4 LONGDESCRIPTION

Error Text LongDescription

DE5514

5 BEGIN Error Text Edit BeginDate

DE5503

6 END Error Text Edit EndDate

DE5523

7 EDIT TYPE Edit Error Edit Type DE5680 N/A8 DENY Error Text Deny Indic-

atorDE5517 N/A

9 TAD Error Text Turn AroundDocument (TAD) Indic-ator

DE5516 N/A

10 RES OVR Error Text ResolutionOverride Indicator

DE5504

11 RA PRT Error Text RemittanceAdvice Print Indicator

DE5507 N/A

12 ADJ Edit Text AdjustmentCode

DE5498 N/A

13 CMP Edit Text CompoundCode

DE5681 N/A

14 DISP PRIO Error Text Display Pri-ority

DE5499 N/A

14.1 NCPDP ERROR Error Text NCPDPError Code

DE5522 N/A

15 PROGRAM Benefit Definition PlanProgramCode

DE3551 N/A

16 FORM Claim FormCode DE5876 N/A17 CLMTYP Claim Type DE2002 N/A18 PA OVR Error Text Prior Author-

ization Override Indic-ator

DE5518 N/A

19 CUT BAK Cutback or Reductionin a Provider Payment

DE5607 N/A

20 CRIT EXIST Edit Criteria Exists DE5724 N/A22 END ClaimEdit Code Parm

EndDateDE5878 N/A

23 BEGIN ClaimEdit Code ParmBegin Date

DE5877 N/A

23 MEDIUM Error Text Claim TypeMedia Code

DE5521 N/A

24 CLMMOD Claim TypeModifier DE2003 N/A25 DISPWITH Error Text Disposition

AttachmentsDE5603 N/A

26 LOCWITH Error Text LocationAttachments

DE5605 N/A

27 DISPWITHOUT Error Text Location NoAttachments

DE5606 N/A

28 LOCWITHOUT Error Text DispositionNo Attachments

DE5604 N/A

29 DAT TYP Error Text Ser-vice/Payment DateCode

DE5519 N/A

30 REC DAS Error Text RecycledDays

DE5679 N/A

31 BEGIN Error Text DispositionLocation Effective Date

DE5602 N/A

32 END Disposition LocationEnd Date

DE5682 N/A

33 REASON RESPXREF

Adjustment Reason/Re-sponse CrossRefer-ence

DE5560 N/A

Output Reports RF-O-017 Claimresponse code listing

General InformationThis is a list of all the detail data on the Claims response code table(RF_CLM_RESPONSE_R)

Subsystem: ReferenceFrequency: OnDemandVolume: VariableNumber of Copies: To be determinedOutput Form: StandardRetention: 30 daysDistribution: To be determinedProgram: ClaimResponse Listing (RFR017)Confidential: NoSequence: N/AControl Breaks: N/A

Claim response code listing (RF-O-017)



1 ClaimResponsecode

ClaimResponse Code DE5540

2 ClaimResponseType

ClaimResponse Type DE5541

3 ClaimResponseBegin Date

ClaimResponse BeginDate

DE5544

4 ClaimResponseEnd Date

ClaimResponse EndDate

DE5545

5 ClaimResponseCode StatusCat-egory

ClaimResponse CodeStatusCatalog

DE5548

6 ClaimResponseShort Description

ClaimResponse ShortDescription

DE5549

7 ClaimResponseDescription

ClaimResponseDescription

DE5543

8 Total no of claimsresponse codes

DE0000

Output Reports RF-O-018 ClaimAdjustment Reason codes Listing

General InformationThis is a list of all the detail data on the HIPAA Adjustment Reason code table(RF_HIPAA_ADJ_RSN_R)

Subsystem: ReferenceFrequency: OnDemandVolume: VariableNumber of Copies: To be determinedOutput Form: StandardRetention: 30 daysDistribution: To be determinedProgram: Adjustment Reason Listing (RFR018)Confidential: NoSequence: N/AControl Breaks: N/A

Claim Adjustment Reason codes Listing (RF-O-018)



1 HIPAA AdjustmentReason Code

HIPAA AdjustmentReason Code

DE5580

2 HIPAA AdjustmentReasonGroupCode

HIPAA AdjustmentReasonGroup Code

DE5535

3 HIPAA AdjustmentReason BeginDate

HIPAA AdjustmentReason Begin Date

DE5584

4 HIPAA AdjustmentReason EndDate

HIPAA AdjustmentReason EndDate

DE5585

5 HIPAA AdjustmentReason ShortDescription

HIPAA AdjustmentReason Short Descrip-tion

DE5586

6 HIPAA AdjustmentReason Descrip-tion

HIPAA AdjustmentReason Description

DE5583

7 Total no of adjust-ment reason codes

DE0000

Output Reports RF-O-019 Adjustmentreason and response codes cross ref-erence listing

General InformationThis is a list of all the detail data on the Adjustment reason and response codes table(RF_ADJ_RSN_RSP_XRF)

Subsystem: ReferenceFrequency: OnDemandVolume: VariableNumber of Copies: To be determinedOutput Form: StandardRetention: 30 daysDistribution: To be determinedProgram: Adjustment Reason CrossReference Table Listing (RFR019)Confidential: NoSequence: N/AControl Breaks: N/A

Adjustment reason and response codes cross reference listing (RF-O-019)



1 AdjustmentReason/ResponseCrossReferencecode


DE5560

2 AdjustmentReason/ResponsePayment Code

Adjustment Reason/Re-sponse Payment Code

DE5561

3 HIPAA AdjustmentReason Code

HIPAA AdjustmentReason Code

DE5580

4 HIPAA AdjustmentReasonGroupCode

HIPAA AdjustmentReasonGroup Code

DE5535

5 ClaimResponseCode

ClaimResponse Code DE5540

6 ClaimResponseType

ClaimResponse Type DE5541

7 AdjustmentReason/ResponseBegin Date

Adjustment Reason/Re-sponse Begin Date

DE5562

8 AdjustmentReason/ResponseEnd Date

Adjustment Reason/Re-sponse End Date

DE5563

9 Total no of Xrefcodes

DE0000

Output Reports RF-O-020 ProcedureGEOFEE File Conversion Error/Con-trol Totals Reports

General InformationErrors/Control Totals Report for the conversion of Procedure tables from theGEOFEE File.

Subsystem: ReferenceFrequency: One-TimeVolume: VariableNumber of Copies: 2Output Form: X/PTRRetention: 180 daysDistribution: Test TeamsProgram: N/AConfidential: NoSequence: N/AControl Breaks: N/A

Procedure GEOFEE File Conversion Error/Control Totals Reports (RF-O-020)




1 Source File DE0000 Input Source File Identifier2 Rec Type/Pro-

cedureDE0000 Record Type and Procedure Code of

source record in error.3 CURR VA DE DE0000 Current VMAP Data Element Number.4 Before Image DE0000 Input Source Data in error.5 Error Message DE00006 Disposition DE0000 Fatal or Warning status of source field

in error.7 GEOFEE INPUT

RECORDS READDE0000

8 GEOFEE INPUTBYPASSED

DE0000 Procedures not converted because ofspecific criteria.

9 GEOFEE INPUTRECORD TYPE 0

DE0000

10 BYPASSEDRECORD TYPE 0

DE0000


DE0000


DE0000


DE0000


DE0000


DE0000


DE0000

17 TYPE3Output asTYPE1

DE0000 Procedure Record Type 3 records con-verted as Procedure Record Type 1.


DE0000


DE0000

20 GEOFEERECORDSWRITTEN FORRF_PROCEDURE

DE0000 Total number of records convertedfromGEOFEE File to RF_PROCEDURE table in this program.

21 RF_PROCEDURETYPE 0WRITTEN

DE0000


DE0000


DE0000


DE0000

25 RF_PROCEDURE

DE0000

TYPE 4WRITTEN26 GEOFEE

RECORDSWRITTEN FORRF_PROC_PT_SPEC

DE0000 Total number of records convertedfromGEOFEE File to RF_PROC_PT_SPEC table in this program.

27 RF_PROC_PT_SPEC TYPE 0WRITTEN

DE0000


DE0000


DE0000


DE0000


DE0000

32 GEOFEERECORDSWRITTEN FORRF_PROC_CATG

DE0000 Total number of records convertedfromGEOFEE File to RF_PROC_CATG table in this program.

33 RF_PROC_CATGTYPE 0WRITTEN

DE0000


DE0000


DE0000


DE0000


DE0000

38 GEOFEERECORDSWRITTEN FORRF_PROC_PA_TYPE

DE0000 Total number of records convertedfromGEOFEE File to RF_PROC_PA_TYPE table in this program.

39 RF_PROC_PA_TYPE TYPE 0WRITTEN

DE0000

40 RF_PROC_PA_ DE0000

TYPE TYPE 1WRITTEN


DE0000


DE0000


DE0000

44 GEOFEERECORDSWRITTEN FORRF_PROC_TPL_CODE

DE0000 Total number of records convertedfromGEOFEE File to RF_PROC_TPL_CODE table in this program.

45 RF_PROC_TPL_CODE TYPE 0WRITTEN

DE0000


DE0000


DE0000


DE0000


DE0000

50 GEOFEERECORDSWRITTEN FORRF_PROC_XREF

DE0000 Total number of records convertedfromGEOFEE File to RF_PROC_XREF table in this program.

51 RF_PROC_XREFTYPE 0WRITTEN

DE0000


DE0000


DE0000


DE0000

55 RF_PROC_XREF DE0000

TYPE 4WRITTEN56 GEOFEE

RECORDSWRITTEN FORRF_PROC_NDC_XREF

DE0000 Total number of records convertedfromGEOFEE File to RF_PROC_NDC_XREF table in this program.

57 RF_PROC_NDC_XREF TYPE 0WRITTEN

DE0000


DE0000


DE0000


DE0000


DE0000

62 GEOFEERECORDSWRITTEN FORRF_PROC_ANES_MBASE

DE0000 Total number of records convertedfromGEOFEE File to RF_PROC_ANES_MBASE in this program.

63 RF_PROC_ANES_MBASETYPE 0WRITTEN

DE0000


DE0000


DE0000


DE0000


DE0000

68 GEOFEERECORDSWRITTEN FOR

DE0000 Total number of recordswritten fromGEOFEE File to RF_PROC_BASE_UNITS in this program.

RF_PROC_BASE_UNITS

69 RF_PROC_BASE_UNITSTYPE 0WRITTEN

DE0000


DE0000


DE0000


DE0000

74 GEOFEERECORDSWRITTEN FORRF_PROC_MCARE_CHG

DE0000 Total number of records convertedfromGEOFEE File to RF_PROC_MCARE_CHG table in this program.


DE0000

75 RF_PROC_MCARE_CHGTYPE 0WRITTEN

DE0000


DE0000


DE0000


DE0000


DE0000

80 GEOFEERECORDSWRITTEN FORRF_PROC_RV

DE0000 Total number of records convertedfromGEOFEE File to RF_PROC_RVtable in this program.

81 RF_PROC_RVTYPE 0WRITTEN

DE0000

82 RF_PROC_RV DE0000

TYPE 1WRITTEN83 RF_PROC_RV

TYPE 2WRITTENDE0000


DE0000


DE0000

86 GEOFEERECORDSWRITTEN FORRF_PROC_LAB

DE0000 Total number of records convertedfromGEOFEE File for RF_PROC_LAB table in this program.

87 RF_PROC_LABTYPE 0WRITTEN

DE0000


DE0000


DE0000


DE0000


DE0000

92 GEOFEERECORDSWRITTEN FORRF_PROC_RATES

DE0000 Total number of records convertedfromGEOFEE File to RF_PROC_RATES in this program.

93 RF_PROC_RATES TYPE 0WRITTEN

DE0000


DE0000


DE0000


DE0000


DE0000

98 RF_PROC_RATES FATALERRORS

DE0000 Records that did not convert due tounacceptable data.

99 RATES INPUTFROMRFC020A

DE0000 RF_PROC_RATE records passed tosecond phase of conversion.

100 GEOFEELOOKUPS

DE0000 Selected records in phase 2 thatrequired additional fields from theGEOFEE File.

101 RENTALRFRATEINPUT TYPE 0

DE0000


DE0000


DE0000


DE0000


DE0000

106 TOTALRFRATESOUTPUT FROMRFC020B

DE0000 Total number of records convertedfromGEOFEE File and RFRATErecords passed from phase 1 of thisprogram.

107 TOTALRENTALRF_PROC_RATESWRITTEN

DE0000 Total number of additional Rental Pro-cedure Rates converted fromGEOFEE File to RF_PROC_RATESin this program.


DE0000


DE0000


DE0000


DE0000


DE0000

113 RENTAL XREFSADDED (RF_PROC_XREF)

DE0000 Additional Rental XREF records con-verted fromGEOFEE File to RF_PROC_XREF table in this program.

114 FATALRECORDS

DE0000

WRITTEN FROMRENTALRATES

115 GEOFEE INPUTRECORDS READ

DE0000 TDOProcedure records found onGEOFEE File.

116 RECORDSWRITTEN FORRF_PROC_FLAG_CODES

DE0000 TDO related records converted fromGEOFEE File to RF_PROC_FLAG_CODES in this program.

118 RECORDSWRITTEN FORRF_PROC_TDOPROJ

DE0000 TDOProcedure records convertedfromGEOFEE File to RF_PROC_TDO_PROJ in this program.

119 TDOPROCEDURESNOT FOUND ONGEOFEE

DE0000

Output Reports RF-O-021-04 Edit Cri-teria Audit Trail

General InformationThis is an audit trail report of the on-line changesmade to the Edit Criteria table (RF_EDIT_CRITERIA). 'Before' and 'after' images of the data are displayed on the report.

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Daily Log Analyzer Edit Criteria Audit Trail (RF-O-021-04) (VMPRDL11)Confidential: NoSequence: Log Date

Claim Edit CodeEdit Criteria Number; Log Time

Control Breaks: N/A

Edit Criteria Audit Trail (RF-O-021-04)

Field Definitions# Field Name Data Element Name Element ID Source/Calculations1 User Id LogOperator Iden-

tificationDE5706

2 Correlation ID(The ID asso-ciated with theDB2 Extract)

DEDE0000

3 URID (Unit ofRecovery Id)

DEDE0000

4 Connection ID(Connection IDused byCallAttachment Facil-ity to communicatewith DB2)

DEDE0000

5 Connection Type(Connection Typewith DB2)

DEDE0000

6 Plan Name (Thename of the DB2Plan that wasexecuted)

DEDE0000

7 Date Log Date DE57048 Time Log Time DE57059 Table (Name of

themodified DB2DEDE0000

Table)10 Database (Name

of themodifiedDatabase)

DEDE0000

11 Action Type Log Action Type DE570212 New (After Image

of the changedRow)

DEDE0000

12.1 Old (Before Imageof the changedrow)

DEDE0000

Output Reports RF-O-021-05 ErrorText Audit Trail

General InformationThis is an audit trail report of the on-line changesmade to the Error Text table (RF_EDIT_TEXT).'Before' and 'after' images of the data are displayed on the report.

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: To BeDeterminedProgram: Daily Log Analyzer Error Text Audit Trail (RF-O-021-05) (VMPRDL12)Confidential: NoSequence: N/AControl Breaks: N/A

Error Text Audit Trail (RF-O-021-05)



1 User Id LogOperator Iden-tification

DE5706

2 Correlation ID(The ID associatedwith the DB2Extract)

DE0000


DE0000

4 Connection ID(Connection IDused byCallAttachment Facilityto communicatewith DB2)

DE0000


DE0000


DE0000

7 Date DE00008 Time DE00009 Table (Name of


DE0000

10 Database (Nameof themodifiedDatabase)

DE0000


of the changedRow)

DE0000


DE0000

Output Reports RF-O-021-06 ErrorDisposition/Location Audit Trail

General InformationThis is audit trail report of the on-line changesmade to the Error Dispositions/Locations table (RF_ERROR_DISP_LOC). 'Before' and 'after' images of the data are displayed on the report.

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: To be determinedOutput Form: StandardRetention: 30 daysDistribution: To be determinedProgram: Daily Log Analyzer Error Disposition/Location Audit Trail (RF-O-021-06)

(VMPRDL13)Confidential: NoSequence: Log Date; Error Code; Log TimeControl Breaks: N/A

Error Disposition/Location Audit Trail (RF-O-021-06)




DE5706


DE0000


DE0000


DE0000


DE0000


DE0000



DE0000


DE0000

11 Action Type Log Action Type DE570212 INV TYPE Erwin Element DE206112 New (After Image

of the changedRow)

DE0000


DE0000

Output Reports RF-O-021-07 Adjust-ment Reason/Response Cross-Refer-ence Audit Trail

General InformationThis is audit trail report of the on-line changesmade to the Adjustment Reason/Response Xref table(RF_ADJ_RSN_RSP_UPDT). 'Before' and 'after' images of the data are displayed on the report.

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: DARSOutput Form: StandardRetention: 30 daysDistribution: DMASProgram: Daily Log Analyzer Adjustment Reason Response Xref (RF-O-021-07)

(VMPRDL21)Confidential: NoSequence: N/AControl Breaks: N/A

Adjustment Reason/Response Cross-Reference Audit Trail (RF-O-021-07)



1 User ID LogOperator Iden-tification

DE5706

2 Correlation ID (IDassociated withDB2 Extract)

DE0000

3 URID (Unit ofRecovery ID)

DE0000

4 Connection ID (IDused byCallAttachment Facilityto communicatewith DB2)

DE0000


DE0000


DE0000

7 Date DE00008 Time DE00009 Table (Name of

themodified DB2DE0000

Table)10 Database (Name

of themodifiedDatabase)

DE0000

11 (Action Type) Log Action Type DE570212 New (After Image

of the changedRow)

DE0000


DE0000

Output Reports RF-O-021-08 HIPAAStandard Code Sets MaintenanceAudit Trail

General InformationThis is audit trail report of the on-line changesmade to the HIPAA X.12 UPDATE table (RF_HIPAA_X12_UPDT). 'Before' and 'after' images of the data are displayed on the report.

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: DARSOutput Form: StandardRetention: N/A30 DaysDistribution: DMASProgram: Daily Log Analyzer HIPAA X12Updates (RF-O-021-08) (VMPRDL22)Confidential: NoSequence: N/AControl Breaks: N/A

HIPAA Standard Code Sets Maintenance Audit Trail (RF-O-021-08)



1 User ID LogOperator Iden-tification

DE5706

2 Correlation ID (IDassociated withDB2 Extract)

DE0000

3 URID (Unit ofRecovery ID)

DE0000


DE0000


DE0000


DE0000

7 Date DE00008 Time DE00009 Table (Name of DE0000



DE0000

11 (Action Type) Log Action Type DE570212 New (After Image

of the changedRow)

DE0000


DE0000

Output Reports RF-O-025-01 AuditTrail for Copy ProvType/Specialty

General InformationAudit Trail Report for Program, RFR020. Displays data written to the Procedure Provider Type/Spe-cialty Table (RF_PROC_PT_SPEC). Data is copied from one Procedure Code to another Pro-cedure Code (from the 'COPY' Value Set Type (Copy Provider Type/Specialty rows from the EndRange Procedure Code to the Begin Range Procedure Code)).

Subsystem: ReferenceFrequency: OnRequestVolume:Number of Copies: 1Output Form: StandardRetention: 30 daysDistribution: DMASProgram: Copy Provider Type/Specialty rows from one Procedure Code to another

Procedure Code. (RFR020)Confidential: NoSequence: N/AControl Breaks: N/A

Audit Trail for Copy ProvType/Specialty (RF-O-025-01)



1 (OLD or NEW) DE00002 ACTION TYPE Log Action Type DE5702 N/A3 LOGDATE LogDate DE5704 N/A4 LOGTIME Log Time DE5705 N/A5 PROC TYPE Procedure Code Type DE50016 PROCEDURE

CODE(RECEIVING)

Procedure Code DE5002

7 PROCEDURECODE(SENDING)

Procedure Code DE5002

8 PROV TYPE Provider Type DE40069 SPECIALTY Provider Specialty

CodeDE4007

10 CLAIM TYPE Claim Type DE200211 BEGIN DATE Procedure Valid Pro-

vider Type-SpecialtyBegin Date

DE5173

12 END DATE Procedure Valid Pro- DE5174

vider Type-SpecialtyEnd Date

13 LAST UPDATEDT

Row Update Date DE0011

14 TOTAL VALUESET RANGERECORDS READ

Calculated DE0002

16 TOTAL PROVTYPE/SPECRECORDSWRITTEN

Calculated DE0002

Output Reports RF-O-025-02 ErrorReport (Copy ProvType/Specialty)

General InformationError Report for Program, RFR020. Displays errors discovered from the validation of Value SetRange information for the 'COPY' Value Set Type (Copy Provider Type/Specialty rows from theEnd Range Procedure Code to the Begin Range Procedure Code.

Subsystem: ReferenceFrequency: OnRequestVolume:Number of Copies: 1Output Form: StandardRetention: 30 DaysDistribution: DMASProgram: Copy Provider Type/Specialty rows from one Procedure Code to another

Procedure Code. (RFR020)Confidential: NoSequence: N/AControl Breaks: N/A

Error Report (Copy ProvType/Specialty) (RF-O-025-02)



1 Message DE0000 Program Literal2 Description DE0000 Program Literal3 Value DE0000 Value of Error Field4 TOTAL ACTIVE

VALUE SETRANGERECORDS READ

Calculated DE0002 Displayed from program accumulator.

5 TOTAL ACTIVEVALUE SETRANGERECORDS INERROR

Calculated DE0002 Displayed from program accumulator.

Output Reports RF-O-030-01 TPL Pro-cedure Code Update Report

General InformationReport RF-O-030-01 is produced annually displaying TPLCodes that were added/updated on theRF_PROC_TPL_CODE table.

Subsystem: ReferenceFrequency: AnnualVolume: DiskNumber of Copies: 1Output Form: StdRetention: 365Distribution: N/AProgram: Add/Update CPT/HCPCS TPLCodesWith Selected Values (RFA030)Confidential: NoSequence: Procedure Code

Procedure TypeControl Breaks: N/A

TPL Procedure Code Update Report (RF-O-030-01)

TPL Procedure Code Update Report (RF-O-030-01)



1 ProcCode Procedure Code DE50022 Proc Type Procedure Code Type DE50013 TPLCode TPLCode DE54224 TPL SeqNo Calculated DE0002 when adding a row - TPL-Seq-No = 1.

when updating a row - Add + 1 to TPL-Seq-No.

5 Begin Date Procedure CoverageBegin Date

DE5003

6 EndDate Procedure CoverageEnd Date

DE5004

7 Description DE0000 When adding TPL values, this field willdisplay 'TPL ADDED'. When updatingTPL values, this field will display 'TPLRE-ACTIVATED'.

8 Total ProcedureCodesRead

Calculated DE0002 Increment counter for all ProcedureCodes read.

9 Total ProcedureCodes Processed

Calculated DE0002 Increment counter for ProcedureCodes that will be processed.

10 Total End DatedProceduresBypassed

Calculated DE0002 Increment counter for ProcedureCodes that are end-dated and notselected for processing.

11 Total End DatedProcedures Pro-cessed

Calculated DE0002 Increment counter for ProcedureCodes that are end-dated and selectedfor processing.

12 Total Number ofTPLCodes Added

Calculated DE0002 Increment counter each time a row isadded.

13 Total Number ofTPLCodesReactivated

Calculated DE0002 Increment counter each time a row isupdated.

Output Reports RF-O-031-01 UpdateReport of HIPAA X12 Changes toError Disp Loc

General InformationReport of updatesmade by programRFR030. Displays records updated to RF_ERROR_DISP_LOC tables as result of HIPAA X12 changes.

Subsystem: ReferenceFrequency: OnRequestVolume:Number of Copies: 1Output Form: StandardRetention: 30 daysDistribution: DMASProgram: HIPAA Standard Code SetsMaintenance and Reports (RFR031)Confidential: NoSequence: N/AControl Breaks: N/A

Update Report of HIPAA X12 Changes to Error Disp Loc (RF-O-031-01)



1 ESC CODE ClaimError ESC Code DE55062 EDIT CODE Error Text Error Code DE55013 TYP IND Claim Type Process

IndicatorDE5988 If Drug = 'RX' else = 'HE'

4 ADJGRP HIPAA AdjustmentReasonGroup Code

DE5535 Old ADJGRP

5 ADJRSN HIPAA AdjustmentReason Code

DE5580 Old ADJRSN

6 STATUS ClaimResponse Code DE5540 Old CLAIMSTATUS7 RESP ClaimResponse Code DE5540 Old ClaimRESP8 PEND XREF Adjustment Reason/Re-

sponse CrossRefer-ence

DE5560 Old PEND XREF

9 DENY XREF Adjustment Reason/Re-sponse CrossRefer-ence

DE5560 Old DENY XREF


DE5535 New ADJGRP


DE5580 New ADJRSN

12 STATUS ClaimResponse Code DE5540 New CLAIMSTATUS13 RESP ClaimResponse Code DE5540 New CLAIMRESP14 PEND XREF Adjustment Reason/Re- DE5560 New PEND XREF



DE5560 New DENY XREF

16 EDIT PARMSEQ Reference Data BaseSequential Number

DE5020

17 DISP LOC SEQ Reference Data BaseSequential Number

DE5020

18 NOATTACH CD Error Text Location NoAttachments

DE5606 Indicates type of RESP

19 ADJ-RESP-NO-ATTACH


DE5560

20 ATTACH CD Error Text DispositionAttachments


21 ADJ_RESP_ATTACH


DE5560

22 ADJ-RESP-DENY


DE5560

23 ADJ-RESP-PEND


DE5560

24 TOTALHIPAAX12READ

Calculated DE0002 Maintenance entries read

25 TOTALHIPAAX12UPDATES

Calculated DE0002 Total HIPAA X12 updates

26 TOTALHIPAAX12 ERRORS

Calculated DE0002 Total HIPAA X12 entries with errors

27 TOTALDISP LOCREAD

Calculated DE0002 Total Disp Location entries read forupdate

28 TOTALDISP LOCENTRIESUPDATED

Calculated DE0002

29 TOTALDISP LOCERRORS

Calculated DE0002 Total DISP LOC entries with errors

Output Reports RF-O-031-02 ErrorReport from HIPAA X12 StandardCode Sets - Adj Resp Validation

General InformationListing of Errors encountered while validating Adjudication Responses to proposed HIPAA X12changes

Subsystem: ReferenceFrequency: OnRequestVolume:Number of Copies: 1Output Form: StandardRetention: 30 daysDistribution: DMASProgram: HIPAA Standard Code SetsMaintenance and Reports (RFR031)Confidential: NoSequence: N/AControl Breaks: N/A

Error Report from HIPAA X12 Standard Code Sets - Adj Resp Validation(RF-O-031-02)




IndicatorDE5988 IF Drug = 'RX' else = 'HE'


DE5535 Old ADJGRP


DE5580 Old ADJRSN

6 STATUS ClaimResponse Code DE5540 Old CLAIMSTATUS7 RESP ClaimResponse Code DE5540 Old CLAIMRESP8 PEND XREF Adjustment Reason/Re-






DE5535 New ADJGRP


DE5580 New ADJRSN

12 STATUS ClaimResponse Code DE5540 New CLAIMSTATUS13 RESP ClaimResponse Code DE5540 NEWCLAIMRESP

14 PEND XREF Adjustment Reason/Re-sponse CrossRefer-ence

DE5560 New PEND XREF


DE5020


DE5020

18 NOATTACH IND Error Text Location NoAttachments


19 ADJRESP NOATTACH


DE5560

20 ATTACH IND Error Text DispositionAttachments


21 ADJRESPATTACH


DE5560

22 ADJRESP DENY Adjustment Reason/Re-sponse CrossRefer-ence

DE5560

23 ADJRESP PEND Adjustment Reason/Re-sponse CrossRefer-ence

DE5560

24 TOTAL ESCCODE ERRORS

Calculated DE0002 Total HIPAA X12 entries read witherrors

25 TOTALDISP LOCREAD

Calculated DE0002

26 TOTALMESSAGE LINES

Calculated DE0002

Output Reports RF-O-031-03 ErrorReport from HIPAA X12 StandardCode Sets Validation

General InformationListing of Errors encountered while validating HIPAA X12 changes and Adj Resp

Subsystem: ReferenceFrequency: OnRequestVolume:Number of Copies: 1Output Form: StandardRetention: 30 DaysDistribution: DMASProgram: HIPAA Standard Code SetsMaintenance and Reports (RFR031)Confidential: NoSequence: N/AControl Breaks: N/A

Error Report from HIPAA X12 Standard Code Sets Validation (RF-O-031-03)




IndicatorDE5988 If Drug = 'RX' else = 'HE'


DE5535 Old ADJGRP


DE5580 Old ADJRSN

6 STATUS ClaimResponse Code DE5540 Old CLAIMSTATUS7 RESP HIPAA Adjustment

Reason CodeDE5580 Old CLAIMRESP

8 PEND XREF Adjustment Reason/Re-sponse CrossRefer-ence





DE5535 New ADJGRP


DE5580 New ADJRSN

12 STATUS ClaimResponse Code DE5540 New CLAIMSTATUS

13 RESP ClaimResponse Code DE5540 New CLAIMRESP14 PEND XREF Adjustment Reason/Re-


DE5560 New PEND XREF


DE5560 New DENY XREF


DE5020


DE5020

18 NOATTACH IND Error Text Location NoAttachments


19 ADJRESP NOATTACH


DE5560

20 ATTACH IND Error Text DispositionAttachments


21 ADJRESPATTACH


DE5560

22 ADJRESP DENY Adjustment Reason/Re-sponse CrossRefer-ence

DE5560

23 ADJRESP PEND Adjustment Reason/Re-sponse CrossRefer-ence

DE5560

24 TOTALHIPAAX12 VALIDATEERRORS

Calculated DE0002

25 TOTALDISP LOCERRORS

Calculated DE0002

26 TOTALHIPAAX12 ADJRESPERRORS

Calculated DE0002

Output Reports RF-O-032 EAPGAudit Trail

General InformationThis report provides verification of all batch changesmade to the EAPGdata.

Subsystem: ReferenceFrequency: RequestVolume: VariableNumber of Copies: 1Output Form: StandardRetention: 30 DaysDistribution: DMASProgram: Enhanced Ambulatory Patient Group (EAPG) Update (RFR032)Confidential: NoSequence: N/AControl Breaks: N/A

EAPG Audit Trail (RF-O-032)There is no Sample



1 (OLD OR NEW) Calculated DE00022 LOGACTION

TYPELog Action Type DE5702

3 LOGDATE LogDate DE57044 LOGTIME Log Time DE57055 EAPGCODE EAPGCode DE50646 EAPGWEIGHT EAPGWeight DE50697 EAPGDESC EAPGDescription DE50688 BEGIN DATE EAPGBegin Date DE50669 END DATE EAPGEndDate DE5067

10 LAST UPDATEDATE

Row Update Date DE0011


Calculated DE0002

12 TOTALRECORDSADDED

Calculated DE0002

13 TOTALRECORDSCLOSED

Calculated DE0002


Calculated DE0002

Output Reports RF-O-033 OutpatientEAPG Audit TrailGeneral InformationThis report provides verification of all batch changesmade to the EAPGdata.

Subsystem: ReferenceFrequency: RequestVolume: VariableNumber of Copies: 1Output Form: StandardRetention: 30 DaysDistribution: DMASProgram: Enhanced Ambulatory Patient Group (EAPG) Update (RFR033)Confidential: NoSequence: N/AControl Breaks: N/A

EAPGAudit Trail (RF-O-033)

Field Definitions# Field Name Data Element Name Element ID Source/Calculations1 (OLD OR NEW) Calculated DE00022 LOGACTION TYPE Log Action Type DE57023 LOGDATE LogDate DE57044 LOGTIME Log Time DE57055 EAPGCODE EAPGCode DE50646 EAPGWEIGHT EAPGWeight DE50697 EAPGDESC EAPGDescription DE50688 BEGIN DATE EAPGBegin Date DE50669 END DATE EAPGEndDate DE506710 LAST UPDATE DATE Row Update Date DE001111 TOTALRECORDS READ Calculated DE000212 TOTALRECORDS ADDED Calculated DE0002

13 TOTALRECORDS CLOSED Calculated DE000214 TOTALRECORDSWRITTEN Calculated DE0002

Output Reports RF-O-035 DMAS EDITOVERRIDES REPORTSubsystem: ReferenceFrequency: OnDemandVolume: VariableNumber of Copies: 1Output Form: StandardRetention: 30 DaysDistribution: VAMMISProgram: RFR035Confidential: NoSequence: Procedure CodeControl Breaks: Edit Type

DMAS EDIT OVERRIDES REPORT (RF-0-035)


NameElementID

Source/Calculations

1 PROC CODE1 PROC_COL1 DE50022 PROC CODE2 PROC_COL2 DE50023 EFFECTIVE BEGIN EFFECTIVE_

DATEDE5360

4 EFFECTIVE END DELETION_DATE

DE5361

5 PROC CODMODIND

MOD_IND DE5365

6 LAST UPDATE Calculated DE0002 Based on date of update7 FILE IND FILE_IND DE53588 TOTAL EDIT

OVERRIDESCalculated DE0002 Total # of ProcCodeswith a DMAS Override

Indicator = ‘Y’9 PROC CODE HCPCS_CPT_

CODEDE5002

10MUE UNITS MUE_UNITS DE535911 EFFECTIVE BEGIN EFFECTIVE_

DATEDE5360


DE5361

13 PUBLICATION IND PUBLISH_IND DE536214 LAST UPDATE Calculated DE0002 Based on date of update15 FILE IND FILE_IND DE535816 TOTAL EDIT

OVERRIDESCalculated DE0002 Total # of ProcCodeswith a DMAS Override

Indicator = ‘Y’

Output Reports RF-O-036 BYPASSTABLE MAINTENANCE REPORTSubsystem: ReferenceFrequency: OnDemandVolume: VariableNumber of Copies: 1Output Form: StandardRetention: 30 DaysDistribution: VAMMISProgram: RFR035Confidential: NoSequence: Procedure CodeControl Breaks: Edit Type

BYPASS TABLE MAINTENANCE REPORT (RF-0-036)


NameElementID

Source/Calculations

1 PROC CODE1 PROC_COL1 DE50022 PROC CODE2 PROC_COL2 DE50023 EFFECTIVE BEGIN EFFECTIVE_

DATEDE5360


DE5361

5 PROC CODMOD IND MOD_IND DE53656 LAST UPDATE Calculated DE0002 Based on date of update7 FILE IND FILE_IND DE53588 TOTAL BYPASS

RECORD LOADED Calculated DE0002 Total # of Records to potentially be added

to table9 TOTAL BYPASS

OVERRIDESCalculated DE0002 Total # of rows not updated due to DMA

Override Indicator = to ‘Y’10

TOTAL BYPASSRECORD READ

Calculated DE0002 Total # of Record inserted.

11 PROC CODE HCPCS_CPT_CODE

DE5002

12MUE UNITS MUE_UNITS DE535913 EFFECTIVE BEGIN EFFECTIVE_

DATEDE5360


DE5361

15 PUBLICATION IND PUBLISH_IND

DE5362

16 LAST UPDATE Calculated DE0002 Based on date of update17 FILE IND FILE_IND DE535818 TOTAL BYPASS

RECORD LOADED Calculated DE0002 Total # of Records to potentially be added

to table19 TOTAL BYPASS

OVERRIDESCalculated DE0002 Total # of rows not updated due to DMA

Override Indicator = to ‘Y’20

TOTAL BYPASSRECORD READ

Calculated DE0002 Total # of Record inserted.


General InformationThis report is a detail log of all updates of the ICD Diagnosis data as a result of batch processing.The report displays the old and new version of the data. The length-of-stay data appears only on thebatch update report. Additionally a sum of all transactions reflected on the report appears as a totalsline at the end of the report.

Subsystem: ReferenceFrequency: AnnualVolume: VariableNumber of Copies: To be determinedOutput Form: StandardRetention: 30 daysDistribution: DMASProgram: HCIA Diagnosis/LOS (RFA040)Confidential: NoSequence: Diagnosis Code

DateTime

Control Breaks: N/A




1 (OLD OR NEW) DE00002 ACTION TYPE Log Action Type DE57023 LOGDATE LogDate DE57044 LOGTIME Log Time DE57055 TERM ID Log Terminal Identification DE57076 OPER ID LogOperator Identification DE57068 DIAG Diagnosis Code DE53019 (DIAGNOSIS

DESCRIPTION)Diagnosis Name DE5302

10 BEG Diagnosis Coverage Begin Date DE531811 END Diagnosis Coverage End Date DE531914 AGEMIN DiagnosisMinimumAge DE530415 (AGE) MAX DiagnosisMaximumAge DE530516 ACUTE/TRAUMA Diagnosis Acute/Trauma Indic-

atorDE5310

18 EFF DT Diagnosis Auto Error EffectiveDate

DE5309

19 SEX Diagnosis SexRestriction Code DE530320 FAMPLAN Diagnosis Family Planning Indic-

atorDE5316

21 PA Diagnosis Prior AuthorizationIndicator

DE5321

22 EMERGENCY IND Diagnosis EmergencyCode DE532223 EFF DT Diagnosis EmergencyCode


23.1 EDIT FLAG Diagnosis Edit Flag DE531123.2 COMOFLAG Diagnosis Combo Flag DE531223.3 COMOCODE Diagnosis ComoCode DE531323.4MDC DiagnosisMDC DE531423.5 HCFA Diagnosis HCFA DE531523.6 ORIG Diagnosis Family Planning Indic-

atorDE5316

23.7 PCLAS Diagnosis Procedure Class Indic-ator

DE5340

24 LOS KEY HCIA LOS Group DE546725 LOS LINK LOS Link DE533026 CURRENT LOS Begin DE532927 PREVIOUS LOS Begin DE532928 (LOS PERCENTILE) LOS Percentile DE532329 (LOS) 00-19 LOS for Age Range 00-19 DE533530 (LOS) 20-34 LOS for Age Range 20-34 DE533631 (LOS) 35-49 LOS for Age Range 35-49 DE533732 (LOS) 50-64 LOS for Age Range 50-64 DE533833 (LOS) 65 + LOS for Age Range 65+ DE533934 AVGLOS: SINGLE DX LOS Average for Single Dia-

gnosisDE5327

35 AVGLOS: MULTP DX LOS Average for Multiple Dia-gnosis

DE5328

36 AVGLOS: SINGLE DXSURG

LOS Average for Single Dia-gnosisWith Surgery

DE5351

37 AVGLOS: MULTP DXSURG

LOS Average for Multiple Dia-gnosisWith Surgery

DE5349

38 AVGLOS: SINGLE DX NOSURG

LOS Average for Single Dia-gnosisWithout Surgery

DE5352

39 AVGLOS: MULTP DX NOSURG

LOS Average for Multiple Dia-gnosisWithout Surgery

DE5350

40 (LOS PERCENTILE)SINGLE DX

LOS Percentile for Single Dia-gnosis

DE5346

41 (LOS PERCENTILE) LOS Percentile for Multiple Dia- DE5343

MULTP DX gnosis42 (LOS PERCENTILE)

SINGLE DX SURGLOS Percentile for Single Dia-gnosisWith Surgery

DE5347

43 (LOS PERCENTILE) MULTDX SURG

LOS Percentile for Multiple Dia-gnosisWith Surgery

DE5344

44 (LOS PERCENTILE)SINGLE DX NOSURG

LOS Percentile for Single Dia-gnosisWithout Surgery

DE5348

45 (LOS PERCENTILE)MULTP DX NOSURG

LOS Percentile for Multiple Dia-gnosisWithout Surgery

DE5345

46 TOTALRECORDS READ Calculated DE000247 TOTAL ADD RECORDS

READCalculated DE0002


Calculated DE0002

49 TOTALDELETE RECORDSREAD

Calculated DE0002


Calculated DE0002

51 Diagnosis Code Diagnosis Code DE530152 Action CD DE000053 ItemDescription DE000054 ItemValue DE000055 ERRORMessage DE000056 Total diagnosis codes input DE0000 Calculated57 Total diagnosis codes in error DE0000

Output Reports RF-O-041 RUG AuditTrailGeneral InformationThis report provides verification of all batch changesmade to the RUGdata.

Subsystem: ReferenceFrequency: RequestVolume: VariableNumber of Copies: 1Output Form: StandardRetention: 30 DaysDistribution: DMAS –ReferenceProgram: Resource Utilization Group (RUG) Update (RFR040)Confidential: NoSequence: N/AControl Breaks: N/A

RUG Audit Trail (RF-O-041)

Field Definitions# Field Name Data Element Name Element ID Source/Calculations1 (OLD OR NEW) Calculated2 Log Date Calculated Execution Date3 Log Time Calculated Execution Time4 Rug Type C_RUG_INS_IND DE50245 RugCode C_RUG DE50256 RugDescription T_RUG_DESC DE5029

7 RugWeight N_RUG_WGT DE50308 Begin Date D_RUG_BEGIN DE50279 EndDate D_RUG_END DE502810 Last Update Date H_REC_UPDT DE0011

Output Reports RF-O-060 Home &Community-Based Services AuditTrailGeneral InformationThis report provides a listing of the HCBS data including all rates that weremodified during the exe-cution of programRFR060.

Subsystem: ReferenceFrequency: On-DemandVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Home& Community-Based ServicesUpdate (RFR060)Confidential: NoSequence: N/AControl Breaks: N/A

DRG File Listing (RF-O-060)

Field Definitions# Field Name Data Element Name Element ID Source/Calculations1 C_PROCEDURE_TYPE Procedure Code Type DE5001

2 C_PROCEDURE Procedure Code DE50023 C_PROCEDURE_MOD ClaimsProcedure CodeModifier DE21714 C_REGION_TYPE Region Type DE52445 I_REGION Region Code DE52496 T_PROC_LONG_NAME Procedure Long Name DE50127 N_PROC_RATE Procedure Amount (Old) DE50478 N_PROC_RATE Procedure Amount (New) DE50479 ACTION ACTION Customer Supplied

Output Reports RF-O-085-01 DMERATES UPDATE AUDIT TRAIL

General InformationThis report is the audit trail for the DME Rates update.

Subsystem: ReferenceFrequency: OnDemandVolume:Number of Copies: N/AOutput Form: N/ARetention: N/ADistribution: N/AProgram: N/AConfidential: NoSequence: N/AControl Breaks: N/A

DME RATES UPDATE AUDIT TRAIL (RF-O-085-01)There is no Sample



1 Proc Type Procedure Code Type DE5001

Output Reports RF-O-085-02 DMERATES UPDATE FILE ERRORREPORT

General InformationDME RATES UPDATE FILE ERROR REPORT

Subsystem: ReferenceFrequency: OnDemandVolume:Number of Copies: N/AOutput Form: N/ARetention: N/ADistribution: N/AProgram: N/AConfidential: NoSequence: N/AControl Breaks: N/A

DME RATES UPDATE FILE ERROR REPORT (RF-O-085-02)There is no Sample



1 Proc Type Procedure Code Type DE5001

Output Reports RF-O-100-01 Medi-care/Medicaid Allowance Comparison- Physician Fees

General InformationThis report shows the comparison of Medicare physician fees toMedicaid physician fees for eachcarrier.

Subsystem: ReferenceFrequency: On-DemandVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Medicare/Medicaid Allowance Comparison (RFR10001)Confidential: NoSequence: Procedure CodeControl Breaks: Carrier Code

Medicare/Medicaid Allowance Comparison - Physician Fees (RF-O-100-01)



1 CARRIER TPLCarrier Code DE36572 PROC CD Procedure Code DE50023 MOD Professional Com-

ponent/Technical Com-ponent Code

DE5152

4 LOC MMIS Locality Codebased on Postal Code

DE5254

5 YEAR File Year DE54556 IND Medicare Physician Fee

IndicatorDE5985

7 IP FEE AMT Medicare Amount DE51757.1 OP FEE AMT Medicare Physician

Non-Facility AmountDE5190

8 IP DIFF AMT Calculated DE0002

8.1 OP DIFF AMT Calculated DE00029 IP MAX CHG-1 Procedure Amount DE504710 OPMAX CHG-1 AreaMaximumOut-

patient ChargeDE5169

11 IP MAX DT-1 Procedure AmountEffective Date

DE5046

12 OPMAX DT-1 AreaMaximumOut-patient Charge EffectiveDate

DE5170

13 IP PC CHG-1 Procedure Rate Type DE515314 OP PC CHG-1 Area Professional Com-

ponent (PC) OutpatientCharge

DE5185

15 IP PC DT-1 Area Professional Com-ponent (PC) InpatientCharge Effective Date

DE5154

16 OP PC DT-1 Area Professional Com-ponent (PC) OutpatientCharge Effective Date

DE5186

17 NUMBERMEDICARERECORDSREAD

Calculated DE0002

18 NUMBER OFNONMATCHES

Calculated DE0002

19 TOTALMEDICAID MAXAMT >MEDICARE

Calculated DE0002

Output Reports RF-O-100-02 Medi-caid Fee Greater than MedicareAllowed - Physician Fees

General InformationThis report lists all of theMedicaid fees by Procedure Code greater than the correspondingMedi-care fees allowed for all carriers.

Subsystem: ReferenceFrequency: On-DemandVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: N/AConfidential: NoSequence: Carrier Code

Procedure CodeControl Breaks: N/A

Medicaid Fee Greater than Medicare Allowed - Physician Fees (RF-O-100-02)



1 CARRIER TPLCarrier Code DE36572 PROC Procedure Code DE50023 MOD Professional Com-


DE5152


DE5254

5 YR File Year DE54556 IND Medicare Physician Fee

IndicatorDE5985

7 IP FEE AMT Medicare Amount DE51757.1 OP FEE AMT Medicare Physician

Non-Facility AmountDE5190

8 IP DIFF AMT Calculated DE0002

8.1 OP DIFF AMT Calculated DE00029 IP MAX CHG-1 Procedure Amount DE504710 IP MAX DT-1 Procedure Amount


11 IP PC CHG-1 Procedure Rate Type DE515312 IP PC DT-1 Area Professional Com-

ponent (PC) InpatientCharge Effective Date

DE5154

13 OPMAX CHG-1 AreaMaximumOut-patient Charge

DE5169

14 OPMAX DT-1 AreaMaximumOut-patient Charge EffectiveDate

DE5170

15 OP PC CHG-1 Area Professional Com-ponent (PC) OutpatientCharge

DE5185

16 OP PC DT-1 Area Professional Com-ponent (PC) OutpatientCharge Effective Date

DE5186

17 NUMBERMEDICARERECORDSREAD

Calculated DE0002

18 NUMBER OFNON-MATCHES

Calculated DE0002


Calculated DE0002

Output Reports RF-O-100-03 Medi-care/Medicaid Allowance Comparison- Ambulance and DME Fees

General InformationThis report showsMedicare andMedicaid comparison for ambulance and DME fees by carrier.

Subsystem: ReferenceFrequency: On-DemandVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: N/AConfidential: NoSequence: Carrier Code, Procedure CodeControl Breaks: Carrier Code

Medicare/Medicaid Allowance Comparison - Ambulance and DME Fees(RF-O-100-03)



1 CARRIER TPLCarrier Code DE36572 PROC CD Procedure Code DE50023 MOD FeeModifier DE5023 N/A4 LOC MMIS Locality Code

based on Postal CodeDE5254

5 YR File Year DE54556 IND Professional Com-


DE5152

7 FEE 1 Medicare DME NewPurchase/Ambulance75%Charge

DE5409

8 FEE 2 Medicare DME UsedPurchase/Ambulance50%Charge

DE5410

9 FEE 3 Medicare DMEMonthlyRental/Ambulance Infla-tion Indexed Charge

DE5411

10 MAX CHG1 Procedure Amount DE5047 Inpatient Procedure Amount.11 MAX DT-1 Procedure Amount

Effective DateDE5046 Inpatient Procedure Amount Effective

Date.12 PC CHG-1 Procedure Amount DE5047 This field displays a Procedure Rate

Amount that is identified as In-PatientProfessional Component (IPPC). Theassociated Procedure Amount Effect-ive Date (DE5046) will also be dis-played.

13 PC DT-1 Procedure AmountEffective Date

DE5046 This field displays a Procedure RateAmount Effective Date (identified asIn-Patient Professional Component(IPPC)).

14 MAX CHG2 Procedure Amount DE5047 This field displays a Procedure RateAmount that is identified asOut-Patient MaximumCharge (OP). Theassociated Procedure Amount Effect-ive Date (DE5046) will also be dis-played.

15 MAX DT-2 Procedure AmountEffective Date

DE5046 This field displays a Procedure RateAmount Effective Date for anOut-Patient MaximumCharge.

16 PC CHG-2 Procedure Amount DE5047 This field displays a Procedure RateAmount that is identified asOut-Patient Professional Component(OPPC). The associated ProcedureAmount Effective Date (DE5046) willalso be displayed.


DE5046 This field displays a Procedure RateAmount Effective Date (identified asOut-Patient Professional Component(OPPC)).

18 NUMBER OFMEDICARERECORDSREAD

Calculated DE0002


Calculated DE0002


Calculated DE0002

Output Reports RF-O-100-04 Medi-caid Fee Greater Than MedicareAllowed - Ambulance and DME Fees

General InformationThis report shows theMedicaid fees that are greater than theMedicare amount allowed for all car-riers.

Subsystem: ReferenceFrequency: On-DemandVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: N/AConfidential: NoSequence: Carrier Code

Procedure CodeControl Breaks: Carrier Code

Medicaid Fee Greater Than Medicare Allowed - Ambulance and DMEFees (RF-O-100-04)



1 CARRIER TPLCarrier Code DE36572 PROC Procedure Code DE50023 MOD FeeModifier DE5023 N/A4 LOC MMIS Locality Code

based on Postal CodeDE5254

5 YR File Year DE54556 IND Professional Com-


DE5152

7 FEE 1 Medicare DME NewPurchase/Ambulance75%Charge

DE5409

8 FEE 2 Medicare DME Used DE5410

Purchase/Ambulance50%Charge

9 FEE 3 Medicare DMEMonthlyRental/Ambulance Infla-tion Indexed Charge

DE5411

10 MAX CHG1 Procedure Amount DE5047 Inpatient Procedure Rate Amount.11 MAX DT-1 Procedure Amount


12 PC CHG-1 Procedure Amount DE5047 This field displays a Procedure RateAmount that is identified as In-PatientProfessional Component (IPPC). Theassociated Procedure Amount Effect-ive Date (DE5046) will also be dis-played.


DE5046 This field displays a Procedure RateAmount Effective Date (identified asIn-Patient Professional Component(IPPC).

14 MAX CHG2 Procedure Amount DE5047 This field displays a Procedure RateAmount that is identified asOut-Patient MaximumCharge (OP). Theassociated Procedure Amount Effect-ive Date (DE5046) will also be dis-played.

15 MAX DT-2 Procedure AmountEffective Date

DE5046 This field displays a Procedure RateAmount Effective Date for anOut-Patient MaximumCharge.

16 PC CHG-2 Procedure Amount DE5047 This field displays a Procedure RateAmount that is identified asOut-Patient Professional Component(OPPC). The associated ProcedureAmount Effective Date (DE5046) willalso be displayed.


DE5046 This field displays a Procedure RateAmount Effective Date (identified asOut-Patient Professional Component(OPPC)).

18 NUMBER OFMEDICARERECORDSREAD

Calculated DE0002


Calculated DE0002

20 TOTAL Calculated DE0002

MEDICAID MAXAMT >MEDICARE

Output Reports RF-O-102 ProviderCharges by CPT/HCPCS Code (Dent-al/Revenue/ICD)

General InformationThis report lists provider charges by procedure or revenue code.

Subsystem: ReferenceFrequency: OnRequestVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Provider Charges byHCPCS/Dental/Revenue/ICD (RFR102)Confidential: NoSequence: Procedure Code Range; Provider Type; Provider SpecialtyControl Breaks: N/A

Provider Charges by CPT/HCPCS Code (Dental/Revenue/ICD) (RF-O-102)



1 PROC CDRANGES

Procedure Code DE5002 Data comes fromCAF004 as inputparameter

2 PROV TYPE Provider Type DE40063 PROV SPEC Provider Specialty

CodeDE4007

3.1 AREA MMIS Locality Codebased on Postal Code

DE5254 Data comes fromCAF004 as inputparameter

4 PROC CODE Procedure Code DE50025 PROCEDURE

NAMEProcedure Short Name DE5015

6 COVERAGEDATE BEGIN

Procedure CoverageBegin Date

DE5003

7 COVERAGEDATE END

Procedure CoverageEnd Date

DE5004

8 AGEMIN ProcedureMinimumAge Limit

DE5009

9 AGEMAX ProcedureMaximumAge Limit

DE5010

10 FLAG Flag Code DE516511 S/R Flag Date Type Code DE524012 BEGIN DT Flag Begin Date DE524213 END DT Flag End Date DE524313.1 CAT Region Type DE524414 (DESCRIPTION) Region Name DE525016 IP MAX CHARGE Procedure Amount DE5047 Rate type 'IP'17 OPMAX

CHARGEProcedure Amount DE5047 Rate type 'OP'

18 IP EFF DATE Procedure AmountEffective Date

DE5046 Rate type 'IP'

19 OP EFF DATE Procedure AmountEffective Date

DE5046 Rate type 'OP'

20 IP PREVMAXCHARGE

Procedure Amount DE5047 Rate type 'IP'

21 OP PREVMAXCHARGE

AreaMaximumOut-patient Charge




23 OP EFF DATE AreaMaximumOut-patient Charge Effect-ive Date


24 IP PC CHARGE Procedure Amount DE5047 Rate type 'IPPC'25 OP PC CHARGE Procedure Amount DE5047 Rate type 'OPPC'26 IP EFF DATE Procedure Amount

Effective DateDE5046 Rate type 'IPPC'


DE5046 Rate type 'OPPC'

28 IP PREV PCCHARGE

Procedure Amount DE5047 Rate type 'IPPC'

29 OP PREV PCCHARGE

Procedure Amount DE5047 Rate type 'OPPC'


DE5046 Rate type 'IPPC'


DE5046 Rate type 'OPPC'

Output Reports RF-O-104-01 LocalityRegion Audit Trail

General InformationThis report provides verification of all on-line changesmade to the Region File.

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Daily Log Analyzer Locality Region Audit Trail (RF-O-104-01)

(VMPRDL14)Confidential: NoSequence: Log Date

Region CodeLog Time

Control Breaks: N/A

Locality Region Audit Trail (RF-O-104-01)




DE5706


DE0000


DE0000


DE0000


DE0000


DE0000

7 Date Log Date DE57048 Time Log Time DE57059 Table (Name of DE0000



DE0000


of the changedRow)

DE0000


DE0000

Output Reports RF-O-104-02 LocalityRegion Type Audit Trail

General InformationThis report shows all on-line changes to the Locality Region Type File.

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Daily Log Analyzer Locality Region Type Audit Trail (RF-O-104-02)


Locality Region TypeLog Time

Control Breaks: N/A

Locality Region Type Audit Trail (RF-O-104-02)




DE5706


DE0000


DE0000


DE0000


DE0000


DE0000

7 Date Log Date DE57048 Time Log Time DE5705

9 Table (Name ofthemodified DB2Table)

DE0000


DE0000

11 Action Type DE000012 New (After Image

of the changedRow)

DE0000


DE0000

Output Reports RF-O-104-03 LocalityDetail Audit Trail

General InformationThis report shows all of the on-line changesmade to locality detail data on the Locality File.

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Daily Log Analyzer Locality Detail Audit Trail (RF-O-104-03)


Locality CodeLog Time

Control Breaks: N/A

Locality Detail Audit Trail (RF-O-104-03)




DE5706


DE0000


DE0000


DE0000


DE0000


DE0000



DE0000


DE0000


of the changedRow)

DE0000


DE0000

Output Reports RF-O-104-04 LocalityZip Code Audit Trail

General InformationThis report is an audit trail of all additions and deletions to the Zip Code File.

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Daily Log Analyzer Locality Zip Code Audit Trail (RF-O-104-04)



Locality Zip Code Audit Trail (RF-O-104-04)




DE5706


DE0000


DE0000


DE0000


DE0000


DE0000



DE0000


DE0000


of the changedRow)

DE0000


DE0000

Output Reports RF-O-104-05 RegionType Audit Trail

General InformationThis report shows all of the on-line changesmade to detail data on the Region Type Table.

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Daily Log Analyzer Region Type Audit Trail (RF-O-104-05) (VMPRDL18)Confidential: NoSequence: Log Date


Region Type Audit Trail (RF-O-104-05)




DE5706


DE0000


DE0000


DE0000


DE0000


DE0000



DE0000


DE0000


of the changedRow)

DE0000


DE0000

Output Reports RF-O-104-06 Cap-itation Audit Trail

General InformationThis report shows all of the on-line changesmade to the Capitation table (by Aid Category andRegion).

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 daysDistribution: DMASProgram: N/AConfidential: NoSequence: Log Date

Region TypeRegionCapitation Sequence #Aid CategoryAction Type

Control Breaks: Region Capitation Sequence # Aid Category Action Type

Capitation Audit Trail (RF-O-104-06)There is no Sample



1 (OLD OR NEW) DE00002 ACTION TYPE Log Action Type DE5702 N/A3 LOGDATE LogDate DE5704 N/A4 LOGTIME Log Time DE5705 N/A5 TERM ID Log Terminal Iden-

tificationDE5707 N/A

6 OPER ID LogOperator Iden-tification

DE5706 N/A

7 REGION TYPE Region Type DE5244 N/A8 REGION Region Code DE5249 N/A9 CAP SEQ# Code ID DE0015 N/A10 AID CATEGORY Enrollee Eligibility Aid

CategoryDE3009 N/A

12 BEGIN DATE Capitation Rate Effect-ive Begin Date

DE5478 N/A

13 END DATE Capitation Rate Effect-ive End Date

DE5479 N/A

16 (RATES) UNDER1

Beginning Age Rangefor Capitation

DE5480 N/A

17 (RATES) 1 - 5 Ending Age Range forCapitation

DE5481 N/A

18 (RATES) 6 - 14 Gender that CapitationRate is for

DE5482 N/A

19 (RATES) F 15 - 20 Capitation Rate for AgeandGender

DE5483 N/A

20 (RATES) F 21 - 44 Capitation Rate Type DE5484 N/A21 (RATES) M 15 -

20Capitation Rate forMales 15 - 20

DE5485 N/A

22 (RATES) M 21 -44

Capitation Rate forMales 21 - 44

DE5486 N/A

23 (RATES) OVER44

Capitation Rate forOver 44

DE5487 N/A


Calculated DE0002 Sumof all Reference Sub-system LogFile records read.

25 TOTAL ADDRECORDS READ

Calculated DE0002 Sumof all Reference Sub-system


Calculated DE0002 Sumof all Reference Sub-systemBefore and After Change records readfrom the Log File.


Calculated DE0002 Sumof the Reference Sub-systemLog File records stripped and sortedfor printing.

Output Reports RF-O-105-01 LocalityRegion Listing

General InformationThis report provides a detailed listing of data for all Regions (byRegion Type) and their associatedLocalities.

Subsystem: ReferenceFrequency: On-DemandVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Locality Region Listing (RFR10501)Confidential: NoSequence: Region Type, RegionControl Breaks: Region Type, Region

Locality Region Listing (RF-O-105-01)



1 REGION TYPE Region Type DE52442 (REGION TYPE

NAME)Region Type Name DE5245

3 BEGIN DT Region Type BeginDate

DE5246

4 END DT Region Type EndDate

DE5247

5 END REAS CD Region Type EndReason Code

DE5248

6 (REASON TYPE ENDREASON TEXT)

Region Type EndReason Text

DE5281

7 REGION CD Region Code DE52498 (REGION NAME) Region Name DE5250

9 BEGIN DT Region Begin Date DE525110 END DT Region End Date DE525211 END REAS CD Region End Reason

CodeDE5253

12 (REGION ENDREASON TEXT)

Region End ReasonText

DE5282


DE5254

14 NAME/DESCRIPTION Locality Name DE525515 BEGIN DT Locality/Region Type

Begin DateDE5490 N/A

16 END DT Locality/Region TypeEndDate

DE5491 N/A

17 END REAS CD Region Type LocalityEnd Reason

DE5492 N/A

18 END REAS TEXT Locality/Region TypeEndReason Text

DE5307 N/A

Output Reports RF-O-105-02 LocalityRegion Type Listing

General InformationThis report lists detail Region Type and Locality data from the Locality Region Type file.

Subsystem: ReferenceFrequency: On-DemandVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Locality Region Type Listing (RFR10502)Confidential: NoSequence: Region Type, LocalityControl Breaks: Region Type

Locality Region Type Listing (RF-O-105-02)



1 REGION TYPE Region Type DE5244 RF_REGION_LOC2 (REGION TYPE

NAME)Region Type Name DE5245 RF_REGION_TYPE


DE5246 RF_REGION_TYPE

4 END DT Region Type EndDate

DE5247 RF_REGION_TYPE

4.1 REGION Region Code DE5249 RF_REGION_LOC4.2 (REGION NAME) Region Name DE5250 RF_REGION4.3 BEGIN DT Region Begin Date DE5251 RF_REGION4.4 END DT Region End Date DE5252 RF_REGION5 END REAS CD Region Type Locality

End ReasonDE5492 RF_REGION_LOC

6 (END REASON TEXT) DE00007 LOC CD MMIS Locality Code

based on Postal CodeDE5254 RF_REGION_LOC

8 (LOCALITY NAME) Locality Name DE5255 RF_LOCALITY9 STAT Locality Region Type

StatusCodeDE5271 RF_REGION_LOC

10 EFF DT Locality Region TypeStatus Begin Date

DE5272 RF_REGION_LOC

10.1 BEGIN DATE Locality/Region TypeBegin Date


10.2 END DATE Locality/Region TypeEndDate


13 NAME Locality Region TypeAddressName

DE5264 RF_REG_LOC_ADDR

14 ATTN Locality Region TypeAdditional AddressName


15 ADDR Locality Region TypeStreet Address


16 CITY Locality Region TypeCity Name


17 ST Locality Region TypeState Code


18 ZIP Locality Region TypeZip Code


19 MGMT FEE Locality Region TypeManagement Fee

DE5449 RF_REG_LOC_MGT_FEE

20 (MGMT FEE BEGINDT)

Locality Region TypeManagement FeeBegin Date


21 (MGMT FEE END DT) Locality Region TypeManagement FeeEndDate


22 PRE-ASSIGN Locality Region TypePre-assignment Indic-ator


23 ADJACENTLOCALITY CODES:ORD

Locality Region TypeExtendedOrder Indic-ator

DE5277 RF_REG_LOC_ADJ_EXT

24 ADJACENTLOCALITY CODES:LOC

Locality Region TypeExtended Codes


25 ADJACENT Locality Name DE5255 RF_LOCALITY

LOCALITY CODES:NAME/DESCRIPTION

26 ADJACENTLOCALITY CODES:BEGIN DT

Locality Begin Date DE5256 RF_LOCALITY

27 ADJACENTLOCALITY CODES:END DT

Locality End Date DE5257 RF_LOCALITY

28 EXTENDEDLOCALITY CODES:ORD

Locality Region TypeExtendedOrder Indic-ator


29 EXTENDEDLOCALITY CODES:LOC

Locality Region TypeExtended Codes


30 EXTENDEDLOCALITY CODES:NAME/DESCRIPTION

Locality Name DE5255 RF_LOCALITY

31 EXTENDEDLOCALITY CODES:BEGIN DT

Locality Begin Date DE5256 RF_LOCALITY

32 EXTENDEDLOCALITY CODES:END DT

Locality End Date DE5257 RF_LOCALITY

33 ZIP GROUP Locality Region TypeZip Groups

DE5279 RF_ZIP_GROUP

34 ZIP CODE Locality Region TypeZip Code

DE5269 RF_ZIP_GROUP_ZIP

Output Reports RF-O-105-03 LocalityDetail Listing

General InformationThis report lists all of the detail data on the Locality Table for each locality.

Subsystem: ReferenceFrequency: On-DemandVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Locality Detail Listing (RFR10503)Confidential: NoSequence: Locality CodeControl Breaks: N/A

Locality Detail Listing (RF-O-105-03)



1 LOC CODE MMIS Locality Codebased on PostalCode

DE5254

2 (LOCALITY NAME) Locality Name DE52553 BEGIN DT Locality Begin Date DE52564 END DT Locality End Date DE52577 END REASON CD Locality End Reason

CodeDE5258

8 (END REASON TEXT) Locality End ReasonText

DE5283

9 SIZE INDICATOR Locality Size Code DE526010 INCOME LEVEL Locality Income Level DE5280

Code11 ZIP CODES Locality Zip Codes DE525912 PHYSICALLY

ADJACENTLOCALITY CODES:LOC

Locality PhysicallyAdjacent Codes

DE5262

13 PHYSICALLY ADJLOC CODES:NAME/DESCRIPTION

Locality Name DE5255

14 PHYSICALLY ADJLOC CODES: BEGINDT

Locality Begin Date DE5256

15 PHYSICALLY ADJLOC CODES: END DT

Locality End Date DE5257

16 PHYSICALLYEXTENDEDLOCALITY CODES:LOC

Locality PhysicallyExtended Codes

DE5263

17 PHYSICALLY EXTLOC CODES:NAME/DESCRIPTION


18 PHYSICALLY EXTLOC CODES: BEGINDT

Locality Begin Date DE5256

19 PHYSICALLY EXTLOC CODES: END DT

Locality End Date DE5257

Output Reports RF-O-105-04 LocalityZip Code Listing

General InformationListing of all Zip Codes in Zip Code File.

Subsystem: ReferenceFrequency: OnDemandVolume: To BeDeterminedNumber of Copies: N/AOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Locality Zip Code Listing (RFR10504)Confidential: NoSequence: Zip CodeControl Breaks: N/A

Locality Zip Code Listing (RF-O-105-04)



1 ZIP CODE Locality Zip Codes DE5259

Output Reports RF-O-105-05 RegionType Listing

General InformationThis report shows all the detail data for each Region Type.

Subsystem: ReferenceFrequency: OnRequestVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Region Type Listing (RFR10505)Confidential: NoSequence: Region TypeControl Breaks: N/A

Region Type Listing (RF-O-105-05)



1 REGION TYPE Region Type DE52442 (REGION TYPE)

NAMERegion Type Name DE5245


DE5246

4 END DT Region Type EndDate DE52475 END REAS CD Region Type End

Reason CodeDE5248

6 (END REASTEXT)

Region Type EndReason Text

DE5281

Output Reports RF-O-105-06 Cap-itation Rate Listing

General InformationThis report shows all of the data on the Capitation Table (RF_CAPITATION) byRate Type, Region,Aid Category, andGender/Age Range.

Subsystem: ReferenceFrequency: OnRequestVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 daysDistribution: DMASProgram: Capitation Listing (RFR10506)Confidential: NoSequence: Rate Type

RegionAid CategoryGenderAge Range

Control Breaks: Rate Type Region Aid Category

Capitation Rate Listing (RF-O-105-06)



1 RATE TYPE Capitation Rate Type DE5484 N/A2 DESCRIPTION Code Value Descrip-

tionDE0018 N/A

5 AID CATEGORYGROUP

Enrollee Eligibility AidCategory

DE3009 N/A

6 (AID CATEGORY)DESCRIPTION

Aid Category CodeDescription

DE3301 N/A

7 BEGIN DATE SystemParameterBegin Date

DE5384 N/A

8 END DATE SystemParameterEnd Date

DE5385 N/A

9 REGION Region Code DE5249 N/A

10 (REGION NAME)DESCRIPTION

Region Name DE5250 N/A

11 BEGIN DATE Region Begin Date DE5251 N/A12 END DATE Region End Date DE5252 N/A13.1 SEX Gender that Capitation

Rate is forDE5482 N/A

14 BEGIN AGE Beginning Age Rangefor Capitation

DE5480 N/A

15 END AGE Ending Age Range forCapitation

DE5481 N/A

16 RATE Capitation Rate forAge andGender

DE5483 N/A

17 BEGIN DATE Capitation Rate Effect-ive Begin Date

DE5478 N/A

18 END DATE Capitation Rate Effect-ive End Date

DE5479 N/A

19 TOTALCAPITATIONRATE RECORDSREAD

DE0000 Add 1 to a counter for each recordread.

Output Reports RF-O-105-07 Trans-portation Rate Table Listing

General InformationThis report shows all of the data and rates on the Transportation Rate Table by Procedure Code andby Transportation Rate Type.

Subsystem: ReferenceFrequency: OnRequestVolume: VariableNumber of Copies: To be DeterminedOutput Form: StandardRetention: 30 daysDistribution: DMASProgram: Transportation Rate Listing (RFR10507)Confidential: NoSequence: Procedure Type

Procedure CodeControl Breaks: Procedure Code

Transportation Rate Table Listing (RF-O-105-07)



1 PROCEDURECODE

Procedure Code DE5002 N/A

1.1 TYPE Procedure Code Type DE5001 N/A2 DESCRIPTION Procedure Short Name DE5015 N/A3 BEGIN DATE Procedure Coverage

Begin DateDE5003 N/A

4 END DATE Procedure CoverageEnd Date

DE5004 N/A

5 RATE TYPE Transportation RateType

DE5714 N/A

6 MINIMUMRATE TransportationMin-imumRate

DE5715 N/A

7 MAXIMUMRATE TransportationMax-imumRate

DE5716 N/A

8 BASE RATE Transportation Base DE5717 N/A

Rate9 RATE PER MILE TransRate

Mile/Hour/PassengerDE5718 N/A

10 RATE PERPASSENGER

TransRateMile/Hour/Passenger

DE5718 N/A

11 WAIT RATE TransRateMile/Hour/Passenger

DE5718 N/A

12 MINIMUMMLGRANGE

TransportationMileageRangeMinimum

DE5719 N/A

13 MAXIMUMMLGRANGE

TransportationMileageRangeMaximum

DE5720 N/A

14 ALLOWED HOURS Transportation Allow-ableWait Hours

DE5872 N/A

15 BEGIN DATE(RATE)

Transportation RateBegin Date

DE5712 N/A

16 END DATE (RATE) Transportation RateEnd Date

DE5713 N/A

17 TOTALTRANSPORTATIONRATE RECORDSREAD

DE0000 N/A

Output Reports RF-O-105-08 CCCCapitation Rate Listing Report General InformationThis report shows only the CCC (Commonwealth Coordinated Care) programs on the CapitationTable (RF_CAPITATION) byRate Type, Region, Aid Category, andGender/Age Range. This pro-cesswill NOT include any of the other programs. The CCC programs are identified by the Aid Cat-egories: ‘NFU’, ‘NFO’, ‘CWU’ and ‘CWO’.

Subsystem: ReferenceFrequency: OnRequestVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 daysDistribution: DMASProgram: CCC Capitation Rate Listing (RFR10508)Confidential: NoSequence: Rate Type

RegionAid CategoryGenderAge Range

Control Breaks: Rate Type, Region, Aid Category

Capitation Rate Listing (RF-O-105-08)



1 RATE TYPE C_CAP_RATETYP_CVAL

DE5484 RF_CAPITATION

2 DESCRIPTION T_VALUE_DESC DE0018 GL_CODE_VALUE5 AID CATEGORYGROUP C_AID_CATG DE3009 RS_ENRL_AID_CATG6 (AID CATEGORY)

DESCRIPTIONT_DESC DE3301 RS_AID_CATEGORY_R

7 BEGIN DATE D_SYSPAR_BEGIN DE5384 RF_SYS_PARAMETER8 END DATE D_SYSPAR_END DE5385 RF_SYS_PARAMETER9 REGION C_REGION DE5249 RF_REGION10 (REGION NAME)

DESCRIPTIONT_REGION_DESC DE5250 RF_REGION

11 BEGIN DATE D_REGION_BEGIN DE5251 RF_REGION12 END DATE D_REGION_END DE5252 RF_REGION13.1 SEX C_ENROLLEE_SEX DE5482 RS_PERSON14 BEGIN AGE N_AGE_RNG_BEGIN DE5480 RF_CAPITATION15 END AGE N_AGE_RNG_END DE5481 RF_CAPITATION16 RATE N_CAPITATION_

RATEDE5483 RF_CAPITATION

17 BEGIN DATE D_CAPITATION_BEGIN


18 END DATE D_CAPITATION_END Date


19 TOTALCAPITATIONRATE RECORDS READ

DE0000 Add 1 to a counter for eachrecord read.

Output Reports RF-O-106-01 HCFAHCPCS Update Error Report

General InformationThis report identifies errors that occur during the HCFA HCPCS update.

Subsystem: ReferenceFrequency: AnnualVolume: VariableNumber of Copies: N/AOutput Form: StandardRetention: 30 daysDistribution: DMASProgram: N/AConfidential: NoSequence: N/AControl Breaks: N/A

HCFA HCPCS Update Error Report (RF-O-106-01)



1 PROCEDURE Procedure Code DE50022 ACTION CD DE00003 ITEM

DESCRIPTIONDE0000

4 ITEMVALUE DE00005 ERROR

MESSAGEDE0000

Output Reports RF-O-106 HCFAHCPCS Maintenance Audit TrailReport

General InformationThis report is an audit trail of the batch HCFA HCPCS procedures update.

Subsystem: ReferenceFrequency: AnnualVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: N/AConfidential: NoSequence: Procedure codeControl Breaks: N/A

HCFA HCPCS Maintenance Audit Trail Report (RF-O-106)

HCFA HCPCS Maintenance Audit Trail Report (RF-O-106)



1 PROC CODE Procedure Code DE50022 PROCEDURE

DESCRIPTIONProcedure Short Name DE5015

3 PROCEDUREBEGIN DT

Procedure CoverageBegin Date

DE5003

4 PROCEDUREEND DT

Procedure CoverageEnd Date

DE5004

5 TOS Claim Type of Service DE20726 ANESTHESIA

VALUEMedicare AnesthesiaRelative Value

DE5160

7 ANESTHESIABEGIN DT

Medicare AnesthesiaRelative Value BeginDate

DE5161

8 ANESTHESIAEND DT

Medicare AnesthesiaRelative Value EndDate

DE5162

10 CROSSREFERENCECODES

CrossReference Pro-cedure Code

DE5164

11 LAB CODES Laboratory Code DE5080

Output Reports RF-O-110 HCPCS FileMaintenance - Processing Summary

General InformationSummarizes updates to HCPCS data fromHCFA.

Subsystem: ReferenceFrequency: AnnualVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: N/AConfidential: NoSequence: N/AControl Breaks: N/A

HCPCS File Maintenance - Processing Summary (RF-O-110)



1 RECORD TYPE DE00002 RECORD COUNT Calculated DE00023 TOTAL INPUT Calculated DE00024 TOTAL

RECORDS READCalculated DE0002

5 READ Calculated DE00026 ADDED Calculated DE00027 CHANGED Calculated DE00028 TERMINATED Calculated DE00029 REACTIVATED Calculated DE000210 WRITTEN Calculated DE0002

Output Reports RF-O-111 DRG AuditTrail

General InformationThis report provides verification of all Batch changesmade to the DRGdata.

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: DRGUpdate (RFR030)Confidential: NoSequence: Log Date; Log Time; DRGCodeControl Breaks: N/A

DRG Audit Trail (RF-O-111)



1 (OLD OR NEW) DE00002 ACTION TYPE Log Action Type DE57023 LOGDATE LogDate DE57044 LOGTIME Log Time DE57058 DRGCODE DRG (Diagnosis

RelatedGroup) CodeDE5353

8.1 SOI ClaimDRGSeverity ofIllness

DE2588

9 DRGARITHMEAN LENGTHOF STAY

DRGArithmeticMeanLength of Stay

DE5355

10 DRGDESC DRGDescription DE535611 BEGIN DATE DRGCode Begin Date DE529812 END DATE DRGCode EndDate DE529914 Last Update Date DRGLast Update Date DE535715 DRGRELATIVE

WTDRGRelativeWeight DE5354


Calculated DE0002

17 TOTALRECORDSADDED:

Calculated DE0002

18 TOTALRECORDSCLOSED:

Calculated DE0002

20 TOTALRECORDSWRITTEN:

Calculated DE0002

Output Reports RF-O-112 DRG FileListing

General InformationThis report provides a listing of the DRGdata including all DRGcodes and associated data that areused in claims adjudication.

Subsystem: ReferenceFrequency: On-DemandVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: DRGFile Listing (RFR112)Confidential: NoSequence: DRGCodeControl Breaks: N/A

DRG File Listing (RF-O-112)



1 DRGCODE DRG (DiagnosisRelatedGroup) Code

DE5353

1.1 DRGCODEBEGIN DT

DRGCode Begin Date DE5298

1.2 DRGCODE ENDDT

DRGCode EndDate DE5299

2 DRGARITHMEAN LENGTHOF STAY

DRGArithmeticMeanLength of Stay

DE5355

3 DRGDESCRIPTION

DRGDescription DE5356

4 DRGLASTUPDATE DT

DRGLast Update Date DE5357

5 DRGRELATIVEWEIGHT

DRGRelativeWeight DE5354

Output Reports RF-O-113 HCPCS FileMaintenance - Detail Report

General InformationDetail listing of all updates fromHCFAsHCPCSmaintenance file.

Subsystem: ReferenceFrequency: AnnualVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: N/AConfidential: NoSequence: Procedure CodeControl Breaks: N/A

HCPCS File Maintenance - Detail Report (RF-O-113)



1 PROC CD Procedure Code DE50022 COVERAGE HCPCS Coverage

CodeDE5414

3 MEDICARE RVANES (VALUE)

Medicare AnesthesiaRelative Value

DE5160

5 ADD DT Procedure RecordAdded Date

DE5149

6 TERMDT HCPCS TerminationDate

DE5418

7 ACT DT Available for Use DE50058 ASC GRP HCPCS ASC Payment

Group CodeDE5415

9 (ASC GRP) DATE HCPCS ASC Payment DE5416

Group Effective Date10 BERENSON

EGGERSHCPCS Berenson-Eggers Type of ServiceCode

DE5417

11 LABCERTIFICATION(CODE)

Laboratory Code DE5080

12 HCPCS XREF CrossReference Pro-cedure Code

DE5164

13 MCV REFER HCPCSMedicare Car-riersManual ReferenceSection Number

DE5420

14 COV REFER HCPCS CoverageIssuesManual Refer-ence Section Number

DE5419

15 SHORTDESC Procedure Short Name DE501516 TYPE SERV Claim Type of Service DE207217 PROCESS NOTE HCPCS Processing

Note NumberDE5423

18 COV ISSUE NO HCPCSMedicare Car-riersManual ReferenceSection Number

DE5420

19 LONGDESC Procedure Long Name DE5012

Output Reports RF-O-117 Value SetFile Audit Trail

General InformationThis report is an audit trail report of all changes to Value Set information.

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Daily Log Analyzer Value Set Table Audit Trail (RF-O-117) (VMPRDL19)Confidential: NoSequence: Log Date

Value Set NameLog Time

Control Breaks: N/A

Value Set File Audit Trail (RF-O-117)




DE5706


DE0000


DE0000


DE0000


DE0000


DE0000



DE0000


DE0000


of the changedRow)

DE0000


DE0000

Output Reports RF-O-118 Value SetFile Listing

General InformationThis listing provides value set information including Value Set name, Data Element number, Date ofLast Update, and the Data Ranges from the Value Set tables (RF_VALUE_SET & RF_VALUE_SET_RANGE).

Subsystem: ReferenceFrequency: On-DemandVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Value Set File Listing (RFR118)Confidential: NoSequence: Value Set NameControl Breaks: N/A

Value Set File Listing (RF-O-118)



1 ID Value Set Primary Key DE54432 NAME Value Set Name DE53923 BEGIN DATE Value Set Effective

Begin DateDE5438

4 END DATE Value Set EffectiveEnd Date

DE5439

5 D.E. (TYPE) Value Set Data Ele-ment Type

DE5395

6 A/B Value Set Range Type DE54407 BEGIN RANGE Value Set Data Begin

RangeDE5396

8 END RANGE Value Set Data EndRange

DE5397

9 RANGE BEGIN(DATE)

Value Set Range BeginDate

DE5441

10 RANGE END(DATE)

Value Set Range EndDate

DE5442

Output Reports RF-O-119 SystemParameter File Audit Trail

General InformationThis report shows changesmade to the system parameter table (RF_SYS_PARM_HEADER).

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Daily Log Analyzer SystemParameter Table Audit Trail (RF-O-119)


SystemParameter Name, Log TimeControl Breaks: N/A

System Parameter File Audit Trail (RF-O-119)




DE5706


DE0000


DE0000


DE0000


DE0000


DE0000



DE0000


DE0000


of the changedRow)

DE0000


DE0000

Output Reports RF-O-120 SystemParameter File Listing

General InformationThis report is a listing of all information on the system parameter table (RF_SYS_PARM_HEADER).

Subsystem: ReferenceFrequency: On-DemandVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: SystemParameter File Listing (RFR120)Confidential: NoSequence: SystemParameter ID, SystemParameter Number, Begin DateControl Breaks: N/A

System Parameter File Listing (RF-O-120)



1 SUBSYS SystemParameterSub-System ID

DE5369

2 PARAM ID SystemParameter ID DE53703 SEQ# Reference Data Base

Sequential NumberDE5020

4 BEGIN DATE SystemParameterBegin Date

DE5384

5 END DATE SystemParameter EndDate

DE5385

6 VALUE TYPE SystemParameterValue Type

DE5387

7 LENGTH SystemParameterValue Length

DE5372

8 NUMBERDECIMALS

SystemParameterDecimal Length

DE5373

9 DATE TYPE SystemParameterDate Type

DE5383

9.1 DESCRIPTION SystemParameter DE5382

Description10 DATA VALUE SystemParameter

ValueDE5386

Output Reports RF-O-121 LocalityFile Mailing Labels

General InformationThis report producesmailing labels for local DSS offices, Health Departments, DSS RegionOffices,etc.

Subsystem: ReferenceFrequency: On-DemandVolume: VariableNumber of Copies: 1Output Form: Mailing LabelsRetention: 30 DaysDistribution: DMASProgram: Locality File Mailing Labels (RFR121)Confidential: NoSequence: Locality NameControl Breaks: N/A

Locality File Mailing Labels (RF-O-121)



1 (LOCALITYNAME)


2 (LOCALITYCODE)

MMIS Locality Codebased on Postal Code

DE5254

3 (LOCALITYREGION TYPEADDRESSNAME)

Locality Region TypeAddressName

DE5264

4 (LOCALITYREGION TYPESTREETADDRESS)

Locality Region TypeStreet Address

DE5266

5 (LOCALITYREGION TYPE

Locality Region TypeCity Name

DE5267

CITY NAME)6 (LOCALITY

REGION TYPESTATE CODE)

Locality Region TypeState Code

DE5268

7 (LOCALITYREGION TYPEZIP CODE)

Locality Region TypeZip Code

DE5269

Output Reports RF-O-124 HCPCS Rel-ative Value Report

General InformationLists Procedure HCPCS recordswith a relative value or anesthesia value greater than zero.

Subsystem: ReferenceFrequency: OnRequestVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: HCPCS Relative Value Report (RFR124)Confidential: NoSequence: Procedure CodeControl Breaks: N/A

HCPCS Relative Value Report (RF-O-124)




DESCRIPTIONProcedure Long Name DE5012

3 BEGIN DT Procedure CoverageBegin Date

DE5003

4 END DT Procedure CoverageEnd Date

DE5004

7 RV IP Relative Value Pro-cedure Amount


8 BEGIN DT IP Relative Value Pro-cedure Begin Date


9 END DT IP Relative Value Pro-cedure End Date


10 RV OP Relative Value Pro-cedure Amount


11 BEGIN DTOP Relative Value Pro-cedure Begin Date


12 END DTOP Relative Value Pro-cedure End Date


13 MCARE ANESBASE

Medicare AnesthesiaRelative Value

DE5160

14 (MCARE ANESBASE BEGIN DT)

Medicare AnesthesiaRelative Value BeginDate

DE5161

15 (MCARE ANESBASE END DT)

Medicare AnesthesiaRelative Value EndDate

DE5162

Output Reports RF-O-125-01 RBRVSFee Update Error Report

General InformationThis report identifies errors that occur during the RBRVS Fee update.

Subsystem: ReferenceFrequency: AnnualVolume: VariableNumber of Copies: N/AOutput Form: StandardRetention: 30 daysDistribution: DMASProgram: Procedure RBRVS File Update (RFA080)Confidential: NoSequence: N/AControl Breaks: N/A

RBRVS Fee Update Error Report (RF-O-125-01)



1 PROCEDURE Procedure Code DE50022 ACTION CD DE00003 ITEM

DESCRIPTIONDE0000 Input file field name in Error (i.e. -

INPATIENT RELATIVE VALUE;INPATIENT PROFESSIONALCOMPONENTRV; ...).

4 ITEMVALUE DE0000 The value of the field in error.5 ERROR

MESSAGEDE0000 The error message pertaining to the

input field (i.e. - PROCEDURE CODENOT FOUND; INVALID RATE(RF08-IP-RV); ...).

6 TOTAL ERRORS Calculated DE0002 Total number of transaction errorsencountered.

Output Reports RF-O-125 RBRVS FeeUpdate Audit Trail

General InformationThis report is an audit trail of the procedure fees updated by the RBRVS update file submitted by theCost Settlement and Audit Division of DMAS.

Subsystem: ReferenceFrequency: AnnualVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Procedure RBRVS File Update (RFA080)Confidential: NoSequence: Procedure CodeControl Breaks: N/A

RBRVS Fee Update Audit Trail (RF-O-125)

RBRVS Fee Update Audit Trail (RF-O-125)



1 ACTION TYPE DE00002 DATE DE0000 This is the run date of the batch JOB.2.1 TIME DE0000 This is the time the batch Update Job

started.2.2 PROCEDURE Procedure Code DE50022.3 BEGIN DT Procedure Coverage

Begin DateDE5003

2.4 END DATE Procedure CoverageEnd Date

DE5004

2.5 CAT Region Type DE52443 IP AREAMAX (1) Procedure Amount DE5047 Region 01, Rate Type "IP'4 IP EFF DATE (1) Procedure Amount

Effective DateDE5046 Region 01, Rate Type "IP'

5 OP AREAMAX (1) Procedure Amount DE5047 Region 01, Rate Type 'OP'6 OP EFF DATE (1) Procedure Amount

Effective DateDE5046 Region 01, Rate Type 'OP'

7 IP AREAMAX (2) Procedure Amount DE5047 Region 02, Rate Type 'IP'8 IP EFF DATE (2) Procedure Amount

Effective DateDE5046 Region 02, Rate Type 'IP'

9 OP AREAMAX (2) Procedure Amount DE5047 Region 02, Rate Type 'OP'10 OP EFF DATE (2) Procedure Amount

Effective DateDE5046 Region 02, Rate Type 'OP'

11 IP AREA PC (1) Procedure Amount DE5047 Region 01, Rate Type 'IPPC'12 IP EFF DATE (1) Procedure Amount

Effective DateDE5046 Region 01, Rate Type 'IPPC'

13 OP AREA PC (1) Procedure Amount DE5047 Region 01, Rate Type 'OPPC'14 OP EFF DATE (1) Procedure Amount

Effective DateDE5046 Region 01, Rate Type 'OPPC'

15 IP AREA PC (2) Procedure Amount DE5047 Region 02, Rate Type 'IPPC'16 IP EFF DATE (2) Procedure Amount

Effective DateDE5046 Region 02,Rate Type 'IPPC'

17 OP AREA PC (2) Procedure Amount DE5047 Region 02, Rate Type 'OPPC'18 OP EFF DATE (2) Procedure Amount

Effective DateDE5046 Region 02, Rate Type 'OPPC'

19 IP RV Relative Value Pro-cedure Amount


20 IP BEGIN DT Relative Value Pro-cedure Begin Date


21 IP END DT Relative Value Pro-cedure End Date


22 OP RV Relative Value Pro-cedure Amount


23 OP BEGIN DT Relative Value Pro-cedure Begin Date


24 OP END DT Relative Value Pro-cedure End Date


25 IP PC Relative Value Pro-cedure Amount


26 IP BEGIN DT Relative Value Pro-cedure Begin Date


27 IP END DT Relative Value Pro-cedure End Date


28 OP PC Relative Value Pro-cedure Amount


29 OP BEGIN DT Relative Value Pro-cedure Begin Date


30 OP END DT Relative Value Pro-cedure End Date


Output Reports RF-O-126-01 Medi-care Rate Update Audit Trail - Phys-ician Fee

General InformationMedicare Physician Fee Update Audit Trail report.

Subsystem: ReferenceFrequency: RequestVolume: VariableNumber of Copies: N/AOutput Form: StandardRetention: N/ADistribution: DMASProgram: Medicare Carrier Rates Batch Update (RFR050)Confidential: NoSequence: N/AControl Breaks: N/A

Medicare Rate Update Audit Trail - Physician Fee (RF-O-126-01)



1 Medicare Carrier Medicare Carrier Code DE50902 Medicare Carrier

DescriptionSystemParameterDescription

DE5382

3 Begin Date SystemParameterBegin Date

DE5384

4 EndDate DE0000 Null Value (12/31/9999)5 Procedure Procedure Code DE5002 Input file field RF05-HCPCS-CODE is

5 characters.6 Line Description DE0000 Valid values: CARRIER DATA: OLD

CURRENT: NEWCURRENT: NEW :7 Rate Type Fee Type DE50218 FeeModifier Professional Com-


DE5152

9 Non Facility Amt Medicare PhysicianNon-Facility Amount

DE5190

10 Facility Amt Medicare Amount DE517511 Locality Medicare Physician Fee

Pricing LocalityDE5179

12 BegDate Medicare Amount BeginDate

DE5176

13 EndDate Medicare Amount EndDate

DE5177

14 Message DE0000 Valid values: CARRIER CODE NOTVALID NEWBEGIN DATE <CURRENT BEGIN DATEPROCEDURE CODE NOTONPROCEDURE TABLE

15 Carrier RecordsRead

Calculated DE0002

16 Carrier RecordsRejected

Calculated DE0002

17 Medicare RecordsUpdated

Calculated DE0002

18 Medicare RecordsAdded

Calculated DE0002

Output Reports RF-O-127-01 Medi-care Rate Update Audit Trail -DME/AMBULANCE

General InformationMedicare DME/AMBULANCE Update Audit Trail Report.

Subsystem: ReferenceFrequency: RequestVolume: VariableNumber of Copies: N/AOutput Form: StandardRetention: N/ADistribution: DMASProgram: Medicare Carrier Rates Batch Update (RFR050)Confidential: NoSequence: N/AControl Breaks: N/A

Medicare Rate Update Audit Trail - DME/AMBULANCE (RF-O-127-01)



1 DME orAMBULANCEHeader

DE0000

1.1 Medicare Carrier Medicare Carrier Code DE50902 Medicare Carrier

DescriptionSystemParameterDescription

DE5382

3 Begin Date SystemParameterBegin Date

DE5384

4 EndDate DE0000 Null Value (12/31/9999)5 Procedure Procedure Code DE5002 Input file field RF06-PROC-CODE is

5 characters.6 Line Description DE0000 Valid values: CARRIER DATA: OLD

CURRENT: NEWCURRENT: NEW:

7 Rate Type Fee Type DE50218 FeeModifier FeeModifier DE50239 Fee Amt-1 (Purch) Medicare DME New

Purchase/Ambulance75%Charge

DE5409

10 Fee Amt-2 (Used) Medicare DME UsedPurchase/Ambulance50%Charge

DE5410

11 Fee Amt-3(Rental)

Medicare DMEMonthlyRental/Ambulance Infla-tion Indexed Charge

DE5411

12 Locality MMIS Locality Codebased on Postal Code

DE5254

13 Begin Date Medicare Amount BeginDate

DE5176

14 EndDate Medicare Amount EndDate

DE5177

15 Message DE0000 Valid values: CARRIER CODE NOTVALID NEWBEGIN DATE <CURRENT BEGIN DATEPROCEDURE CODE NOTONPROCEDURE TABLE

16 Carrier RecordsRead

Calculated DE0002

17 Carrier Records Calculated DE0002

Rejected18 Medicare Records

UpdatedCalculated DE0002

19 Medicare RecordsAdded

Calculated DE0002

Output Reports RF-O-150 CapitationRate Updates

General InformationThis report lists all valid regional rates by aid category, gender and age group. These rates will pop-ulate the Capitation Rate Table once the rates are verified.

Subsystem: ReferenceFrequency: Upon RequestVolume:Number of Copies: N/AOutput Form: DARSRetention: 5 yearsDistribution: DMASProgram: Capitation Rate Batch Edit (RFR150)Confidential: NoSequence: N/AControl Breaks: N/A

Capitation Rate Updates (RF-O-150)

Capitation Rate Updates (RF-O-150)



1 RATE TYPE Capitation Rate Type DE54842 BEGIN DATE

(effective)SystemParameterBegin Date

DE5384

3 DESCRIPTION(Aid Category)

Aid Category CodeDescription

DE3301

4 SEX Gender that CapitationRate is for

DE5482

5 BEGIN AGE Beginning Age Rangefor Capitation

DE5480

6 END AGE Ending Age Range forCapitation

DE5481

7 DESCRIPTION(Region Name)

Region Name DE5250

8 RATE Capitation Rate for AgeandGender

DE5483

9 TOTALCAPITATIONRECORDS READ

Calculated DE0002 Add 1 to a counter for each recordread.

10 VALIDCAPITATIONRECORDS

Calculated DE0002 Add 1 to a counter for each validrecord.

Output Reports RF-O-155 CapitationRate File Error Report

General InformationThis report lists all errors in the Capitation Rate Spreadsheet file.

Subsystem: ReferenceFrequency: Upon RequestVolume:Number of Copies: N/AOutput Form: DARSRetention: 5 yearsDistribution: DMASProgram: Capitation Rate Batch Edit (RFR150)Confidential: NoSequence: MCOControl Breaks: N/A

Capitation Rate File Error Report (RF-O-155)



1 SEQUENCENUMBER

Calculated DE0002 Record number in Input File.

2 DESCRIPTION Calculated DE00023 INVALID DATA Calculated DE0002

Output Reports RF-O-160 CapitationRate File Update Report

General InformationThis report indicates successful updates of the Capitation Rate Table. It lists the number of recordsprocessed and updates counts.

Subsystem: ReferenceFrequency: Upon RequestVolume:Number of Copies: N/AOutput Form: DARSRetention: 5 yearsDistribution: DMASProgram: Capitation Rate Batch Update (RFR160)Confidential: NoSequence: MCOControl Breaks: N/A

Capitation Rate File Update Report (RF-O-160)



1 RECORDSPROCESSED

DE0000 Add 1 to a counter for each recordread.

2 RECORDSBYPASSED(SAME ASPRODUCTION)

DE0000 Add 1 to a counter for each recordbypassed.

3 RECORDSUPDATED

DE0000 Add 1 to a counter for each recordupdated.

4 RECORDSINSERTED

DE0000 Add 1 to a counter for each recordinserted.

5 TABLECHANGES: RF_CAPITATION

DE0000 Table changes: RF_CAPITATION.

6 ROWSUPDATED DE0000 Add 1 to a counter for each recordupdated.

7 ROWSINSERTED

DE0000 Add 1 to a counter for each recordinserted.

8 SUCCESSFULCOMPLETIONMESSAGE

DE0000 Message.

Output Reports RF-O-170 HIPP Cap-itation Rate Updates

General InformationThis report is generated by programRFR170. HIPP Rate file is edited in this program for field accur-acy and the records passed through the edits are eligible for update and reported.

Subsystem: ReferenceFrequency: OnRequestVolume: N/ANumber of Copies: N/AOutput Form: OnDemandRetention: 7 yearsDistribution: OnDemandProgram: HIPP Capitation Rate Batch Edit (RFR170)Confidential: YesSequence: N/AControl Breaks: Aid Category

HIPP Capitation Rate Updates (RF-O-170)



1 AID CATEGORY Aid Category CodeDescription

DE3301

2 (SEX) Gender that CapitationRate is for

DE5482 Gender that Capitation Rate is for

3 AGE GROUP(BEGIN AGE)

Beginning Age Rangefor Capitation

DE5480 Beginning age range for Capitation

4 AGE GROUP(END AGE)

Ending Age Range forCapitation

DE5481 Ending age range for Capitation

5 (REGION NAME) Region Name DE52506 (CAPITATION

RATE)Capitation Rate for AgeandGender

DE5483 Capitation Rate for Age andGender

7 CAPITATIONRECORDS READ

Calculated DE0002 CAPITATION RECORDS READ


Calculated DE0002 VALID CAPITATION RECORDS

9 INVALIDCAPITATIONRECORDS

Calculated DE0002 INVALID CAPITATION RECORDS

Output Reports RF-O-171 CCC Cap-itation Rate UpdatesGeneral InformationThis report is generated by programRFR175. CCC Rate file is edited in this program for field accur-acy and the records passed through the edits are eligible for update and reported.

Subsystem: ReferenceFrequency: OnRequestVolume: N/ANumber of Copies: N/AOutput Form: OnDemandRetention: 7 yearsDistribution: OnDemandProgram: CCC Capitation Rate Batch Edit (RFR175)Confidential: YesSequence: MCO

RATE TYPEControl Breaks: MCO

CCC Capitation Rate Updates (RF-O-171)



1 MCO C_CAP_RATETYP_CVAL


2 RATE TYPE Determined based on Nursing Home orCommunitityWellness and age.

3 (SEX) C_SEX_IND_CVAL DE5482 Gender that Capitation Rate is for4 AGE GROUP Age range for Capitation5 CENTRAL VA

REGION 1 CAPITATIONAMOUNT

Capitation rate for this region.

6 NORTHERN VAREGION 2 CAPITATIONAMOUNT


7 TIDEWATERREGION 3 CAPITATIONAMOUNT


8 WESTERNREGION 4 CAPITATIONAMOUNT


9 ROANOKEREGION 5 CAPITATIONAMOUNT


10 WINCHESTERREGION 6 CAPITATIONAMOUNT


11 LYNCHBURG /DANVILLEREGION 7 CAPITATIONAMOUNT


12 SOUTHWESTREGION 8 CAPITATIONAMOUNT


13 CAPITATIONRECORDSREAD

Calculated DE0002 CAPITATION RECORDS READ


Calculated DE0002 VALID CAPITATION RECORDS

15 INVALIDCAPITATIONRECORDS

Calculated DE0002 INVALID CAPITATION RECORDS

Output Reports RF-O-175 HIPP Cap-itation Rate File Error Report

General InformationThis report lists all errors in the Capitation Rate Spreadsheet file.

Subsystem: ReferenceFrequency: OnRequestVolume:Number of Copies: N/AOutput Form: OnDemandRetention: 7 yearsDistribution: OnDemandProgram: HIPP Capitation Rate Batch Edit (RFR170)Confidential: YesSequence: N/AControl Breaks: N/A

HIPP Capitation Rate File Error Report (RF-O-175)

Field Definitions# Field Name Data Element Name Element Source/Calculations

ID1 INPUT RECORD Calculated DE0002 SEQUENCE NUMBER OF INPUT

RECORD2 DATA

DESCRIPTIONCalculated DE0002 DATA DESCRIPTION

3 INVALID DATA Calculated DE0002 INVALID DATA4 TOTAL

CAPITATIONRECORDS READ

Calculated DE0002 TOTALCAPITATION RECORDSREAD

5 TOTALCAPITATIONRECORDS INERROR

Calculated DE0002 TOTALCAPITATION RECORDS INERROR

Output Reports RF-O-176 CCC Cap-itation Rate File Error ReportGeneral InformationThis report lists all errors in the Capitation Rate Spreadsheet file.

Subsystem: ReferenceFrequency: OnRequestVolume:Number of Copies: N/AOutput Form: OnDemandRetention: 7 yearsDistribution: OnDemandProgram: CCC Capitation Rate Batch Edit (RFR175)Confidential: YesSequence: N/AControl Breaks: N/A

CCC Capitation Rate File Error Report (RF-O-176)


NameElementID

Source/Calculations

1 INPUT RECORD Calculated DE0002 SEQUENCE NUMBER OF

INPUT RECORD2 DATA DESCRIPTION Calculated DE0002 DATA DESCRIPTION3 INVALID DATA Calculated DE0002 INVALID DATA4 TOTALCAPITATIONRECORDS READ

Calculated DE0002 TOTALCAPITATION RECORDSREAD

5 TOTALCAPITATIONRECORDS IN ERROR

Calculated DE0002 TOTALCAPITATION RECORDSIN ERROR

Output Reports RF-O-180 HIPP Cap-itation Rate File Update Report

General InformationThis report indicates successful updates of the Capitation Rate Table. It lists the number of recordsprocessed and the updated counts.

Subsystem: ReferenceFrequency: OnRequestVolume:Number of Copies: N/AOutput Form: OnDemandRetention: 7 yearsDistribution: OnDemandProgram: HIPP Capitation Rate Batch Update (RFR180)Confidential: NoSequence: N/AControl Breaks: N/A

HIPP Capitation Rate File Update Report (RF-O-180)



1 RECORDSPROCESSED


2 RECORDSBYPASSED(Same as pro-duction)

Calculated DE0002 Add 1 to a counter of each recordbypassed.

3 RECORDSUPDATED

Calculated DE0002 Add 1 to a counter for each recordupdated.

4 RECORDSINSERTED

Calculated DE0002 Add 1 to a counter for each recordinserted

5 TABLECHANGES: RF_CAPITATION

Calculated DE0002 Table changes: RF_CAPITATION.

6 ROWSUPDATED Calculated DE0002 Add 1 to a counter for each recordupdated

7 ROWSINSERTED

Calculated DE0002 Add 1 to a counter for each recordinserted

8 SUCCESSFULCOMPLETION

Calculated DE0002 Message

Output Reports RF-O-185 CCC Cap-itation Rate File Update ReportGeneral InformationThis report indicates successful updates of the CCC Capitation Rate Table. It lists the number ofrecords processed and the updated counts.

Subsystem: ReferenceFrequency: OnRequestVolume:Number of Copies: N/AOutput Form: OnDemandRetention: 7 yearsDistribution: OnDemandProgram: CCC Capitation Rate Batch Update (RFR185)Confidential: NoSequence: N/AControl Breaks: N/A

CCC Capitation Rate File Update Report (RF-O-185)


NameElementID

Source/Calculations

1 RECORDSPROCESSED


2 RECORDSBYPASSED (Same asproduction)

Calculated DE0002 Add 1 to a counter of each recordbypassed.

3 RECORDS UPDATED Calculated DE0002 Add 1 to a counter for each recordupdated.

4 RECORDS INSERTED Calculated DE0002 Add 1 to a counter for each recordinserted

5 ROWSUPDATED Calculated DE0002 Add 1 to a counter for each recordupdated

6 ROWS INSERTED Calculated DE0002 Add 1 to a counter for each recordinserted

Output Reports RF-O-200-01 TP LogUnidentified Records

General InformationLists records that have been written to the TP Log file and cannot be identified as belonging to anySub-System.

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: To be determinedOutput Form: StandardRetention: 30 daysDistribution: To be determinedProgram: N/AConfidential: NoSequence: Log Date

Log TimeLog Program IDTerminal ID

Control Breaks: N/A

TP Log Unidentified Records (RF-O-200-01)



1 LOGDATE LogDate DE57042 LOGTIME Log Time DE57053 PROGRAM ID Log Program ID DE57104 TERMINAL ID Log Terminal Iden-

tificationDE5707

5 TRANS CODE Log Transaction Code DE56996 SUB SYS Log Transaction Strip

CodeDE5701

7 TABLE/FILE ID Log Table-File ID DE57118 ACTION TYPE Log Action Type DE57029 RECORD DATA LogRecord Data DE5708

Output Reports RF-O-200-02 TP LogSplit Control Totals by Subsystem

General InformationPrints totals by Subsystem of ADDs, CHANGEs, and DELETEs logged to the TP Log File (RF-F-100).

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: To be determinedOutput Form: StandardRetention: 30 daysDistribution: To be determinedProgram: N/AConfidential: NoSequence: Sub-SystemControl Breaks: Sub-System

TP Log Split Control Totals by Subsystem (RF-O-200-02)



1 SUBSYSTEM Log Transaction StripCode

DE5701

2 TOTAL ADDS Calculated DE00023 TOTALDELETES Calculated DE00024 TOTAL

CHANGES(BEFORE)

Calculated DE0002

5 TOTALCHANGES(AFTER)

Calculated DE0002

6 TOTAL Calculated DE00027 GRAND TOTAL Calculated DE0002

Output Reports RF-O-206 RUG List-ingGeneral InformationThis report all RUGcurrent and historical data.

Subsystem: ReferenceFrequency: RequestVolume: VariableNumber of Copies: 1Output Form: StandardRetention: 30 DaysDistribution: DMAS –ReferenceProgram: Resource Utilization Group (RUG) Listing (RFR113)Confidential: NoSequence: C_RUG_INS_IND (Asc), C_RUG (Asc), D_RUG_Begin (Desc)Control Breaks: N/A

RUG Audit Trail (RF-O-206)

Field Definitions# Field Name Data Element Name Element ID Source/Calculations1 RUGTYPE C_RUG_INS_IND DE50242 RUGCODE C_RUG DE50253 Begin Date D_RUG_BEGIN DE50274 EndDate D_RUG_END DE50285 RugDescription T_RUG_DESC DE50296 RugWeight N_RUG_WGT DE5030

7 Last Update Date H_REC_UPDT DE0011 Date portion only

Output Reports RF-O-310 Drug Prices> $9999.99999 ListingGeneral InformationThis report lists all drug unit prices from the RF_NDC_PRICE (Reference Drug Pricing) table wherethe drug unit price amount is greater than $9999.99999. The report is ordered byNDC (internalordering in the program) and the drug pricing type (explicit order based on the index of the table).

Subsystem: ReferenceFrequency: On-DemandVolume: VariableNumber of Copies: To BeDeterminedOutput Form: StandardRetention: 30 DaysDistribution: DMASProgram: Drug Price > $9999.99999 Listing (RFR00310)Confidential: NoSequence: National Drug Code (NDC)Control Breaks: N/A

NDC Drug Prices > $9999.99999 Listing (RF-O-310)

Field Definitions# Field Name Data Element Name Element ID Source/Calculations1 NDC Drug Code (NDC) DE52002 DRUGNAME Drug Brand Name DE52083 DRUGPRICE Drug Price Amount DE5220

4 EFFECTIVEDATE

Drug Price Effective Date DE5222

5 TYPE Drug Price Type DE5205

Output Reports RF-O-500 HIPAA X.12Maintenance Table Listing

General InformationOn-Request report detailing contents of RF_HIPAA_X12_UPDT Table.

Subsystem: ReferenceFrequency: OnRequestVolume:Number of Copies: N/AOutput Form: StandardRetention: 18monthsDistribution: DARSProgram: Report of HIPAA StandardsCode SetsMaintenance fromRF_HIPAA_

X12_UPDT table (RFR500)Confidential: NoSequence: N/AControl Breaks: N/A

HIPAA X.12 Maintenance Table Listing (RF-O-500)



1 ESC CODE ClaimError ESC Code DE55062 TYP CLM IND Claim Type Process

IndicatorDE5988

3 BEGIN DATE Error Text DispositionLocation Effective Date

DE5602

4 END DATE Disposition LocationEnd Date

DE5682

5 SEQ DE00006 CUR ADJGRP HIPAA Adjustment

ReasonGroup CodeDE5535

7 CUR ADJRSN HIPAA AdjustmentReason Code

DE5580

8 CURR STATUS ClaimResponse Code DE55409 CURR RESP ClaimResponse Code DE554010 CURR PEND

XREFAdjustment Reason/Re-sponse CrossRefer-ence

DE5560

11 CURR DENYXREF


DE5560

12 NEWADJGRP HIPAA AdjustmentReasonGroup Code

DE5535

13 NEWADJRSN HIPAA AdjustmentReason Code

DE5580

14 NEWSTATUS ClaimResponse Code DE554015 NEWRESP ClaimResponse Code DE554016 NEWPEND

XREFAdjustment Reason/Re-sponse CrossRefer-ence

DE5560

17 NEWDENYXREF


DE5560

18 LAST UPDATERESULT:

HIPAA Standard CodeSets Update LastUpdate Results

DE5986

19 OVERRIDE IND: HIPAA Standard CodeSets Update CurrentProcess Indicator

DE5987

20 LAST CHGD BYUSERID:

User/Operator ID DE0012

21 DATE/TIME: Row Update Date DE0011

Output Reports RF-O-800 IRP Refer-ence Procedure Control Report

General InformationThis report is produced by themonthly IRP extract program, RFR800, which extracts procedurecode data from the procedure reference tables and creates the IRP files for loading to the IRP. Thereport gives the total number of procedure data extracted from each of the procedure tables and thetotal number written to the files.

Subsystem: ReferenceFrequency: MonthlyVolume:Number of Copies: N/AOutput Form: OnDemandRetention: 7 yearsDistribution: OnDemandProgram: IRP REFERENCE PROCEDURE EXTRACT (RFR800)Confidential: NoSequence: N/AControl Breaks: N/A

IRP REFERENCE PROCEDURE CONTROL REPORT (RF-O-800)



1 Count of pro-cedures selected


2 Count of pro-cedure flags selec-ted


3 Count of pro-cedure lab cat-egories selected


4 Count of pro-cedure xref codesselected


5 Count of relativevalues selected


6 Count of trans-portation ratesselected


7 Count of anes-thesia base unitsselected

Calculated DE0002

8 Count of TPL Calculated DE0002

codes selected9 Count of pro-

cedure rates selec-ted

Calculated DE0002

10 Count of pro-cedure PA typesselected

Calculated DE0002

11 Count of pro-cedure data writtento RF-F-800

Calculated DE0002


Calculated DE0002


Calculated DE0002


Calculated DE0002


Calculated DE0002

Output Reports RF-O-810 IRP Refer-ence NDC Control Report

General InformationThis report is produced by themonthly IRP extract program, RFR810, which extracts NDC datafrom the reference tables and creates the IRP file for loading to the IRP. The report gives the totalnumber of NDC data extracted from each of the reference tables and the total number written to thefile.

Subsystem: ReferenceFrequency: MonthlyVolume:Number of Copies: N/AOutput Form: OnDemandRetention: 7 yearsDistribution: OnDemandProgram: IRP REFERENCE NDC EXTRACT (RFR810)Confidential: NoSequence: N/AControl Breaks: N/A

IRP REFERENCE NDC CONTROL REPORT (RF-O-810)



1 Count of NDCsselected

Calculated DE0002

2 Count of NDCs notselected

Calculated DE0002

3 Count of drugHCFA data selec-ted

Calculated DE0002

4 Count of drugHCFA data notselected

Calculated DE0002

5 Count of drug gen-eric codes selected

Calculated DE0002

6 Count of drug gen-eric codes notselected

Calculated DE0002

7 Count of Va spe-cific NDC infoselected

Calculated DE0002

8 Count of Va spe-cific NDC info notselected

Calculated DE0002

9 Count of drugman-ufacturer name/re-

Calculated DE0002

bate code selected10 Count of drugman-

ufacturer name/re-bate code notselected

Calculated DE0002

11 Count of HICLinformation selec-ted

Calculated DE0002

12 Count of HICLinformation notselected

Calculated DE0002

13 Count of NDCdata written to RF-F-803

Calculated DE0002

Output Reports RF-O-820 IRP Refer-ence Diagnosis Control Report

General InformationThis report is produced by themonthly IRP extract program, RFR820, which extracts diagnosesfrom the diagnosis reference table and creates the IRP file for loading to the IRP. The report givesthe total number of diagnoses extracted from the table and the total number written to the file.

Subsystem: ReferenceFrequency: MonthlyVolume:Number of Copies: N/AOutput Form: OnDemandRetention: 7 yearsDistribution: OnDemandProgram: IRP REFERENCE DIAGNOSIS EXTRACT (RFR820)Confidential: NoSequence: N/AControl Breaks: N/A

IRP REFERENCE DIAGNOSIS CONTROL REPORT (RF-O-820)



1 Count of dia-gnoses selected

Calculated DE0002

2 Count of dia-gnoses historybypassed

Calculated DE0002

3 Count of dia-gnoseswritten toRF-F-806

Calculated DE0002

Output Reports RF-O-868 OutpatientEAPG Monthly Savings SummaryReportGeneral InformationThis report prints a summary listing of Outpatient EAPGclaims activity for current processingmonth.Subsystem: ClaimsFrequency: MonthlyVolume: VariableNumber of Copies: 1Output Form: StandardRetention: 30 DaysDistribution: VAMMISProgram: Outpatient EAPGMonthly SavingsReport (CPR868)Confidential: NoSequence: N/AControl Breaks: N/A

OUTPATIENT EAPG MONTHLY SAVINGS REPORT (CP-O-868)

Field Definitions# Field Name Data Ele-

mentName

ElementID

Source/Calculations

01 # CLAIMS Calculated DE0002 Number of claims for each reason code forthe day.

02 DOLLARS Calculated DE0002 Total savings dollar amount for eachreason code for the day. This will includesavings for voided, denied, reduced paidand fully paid claims.

03 NON-NCCI TOTALDAILYSAVINGS AMOUNT

Calculated DE0002 Sumof savings for all NON-NCCI claimsfor the day.

04 NCCI TOTALDAILYSAVINGS AMOUNT

Calculated DE0002 Sumof savings for all NCCI claims for theday.

05 GRAND TOTALDAILYSAVINGS AMOUNT

Calculated DE0002 Sumof NON-NCCI and NCCI Savings forthe day.

06 PTP SAVINGS-PRACTITIONER &AMBULATORY SURGICALCENTER SERVICES

Calculated DE0002 Sumof savings for Practitioner and ASCServices relating to NCCI PTP denial.

07 PTP SAVINGS-OUTPATIENT HOSPITAL

Calculated DE0002 Sumof savings for Outpatient Hospital Ser-vices relating to NCCI PTP denial.

SERVICES08 PTP SAVINGS-DURABLE

MEDICAL EQUIPMENTCalculated DE0002 Sumof savings for DurableMedical Equip-

ment relating to NCCI PTP denial.09 MUE SAVINGS-

PRACTITIONER &AMBULATORY SURGICALCENTER SERVICES

Calculated DE0002 Sumof savings for Practitioner and ASCServices relating to NCCI MUE denial.

10 MUE SAVINGS-OUTPATIENT HOSPITALSERVICES

Calculated DE0002 Sumof savings for Outpatient Hospital Ser-vices relating to NCCI MUE denial.

11 MUE SAVINGS-DURABLEMEDICAL EQUIPMENT

Calculated DE0002 Sumof savings for DurableMedical Equip-ment relating to NCCI MUE denial.

Output Reports RF-O-869 OutpatientEAPG Quarterly Savings SummaryReportGeneral Information This report prints a summary listing of Outpatient EAPGclaims activity for current processingquarter.Subsystem: ClaimsFrequency: QuarterlyVolume: VariableNumber of Copies: 1Output Form: StandardRetention: 30 DaysDistribution: VAMMISProgram: Outpatient EAPGQuarterly SavingsReport (CPR869)Confidential: NoSequence: N/AControl Breaks: N/A

OUTPATIENT EAPG QUARTERLY SAVINGS REPORT (CP-O-869)


ment NameElementID

Source/Calculations











07 PTP SAVINGS-OUTPATIENT HOSPITALSERVICES

Calculated DE0002 Sumof savings for Outpatient HospitalServices relating to NCCI PTP denial.

08 PTP SAVINGS-DURABLEMEDICAL EQUIPMENT

Calculated DE0002 Sumof savings for DurableMedical Equip-ment relating to NCCI PTP denial.

09 MUE SAVINGS-PRACTITIONER &AMBULATORY SURGICALCENTER SERVICES



Calculated DE0002 Sumof savings for Outpatient HospitalServices relating to NCCI MUE denial.



Output Reports RF-O-869 OutpatientEAPG Quarterly Savings SummaryReportGeneral InformationThis report prints a summary listing of Outpatient EAPGclaims activity for current processingquarter.

Subsystem: ClaimsFrequency: QuarterlyVolume: VariableNumber of Copies: 1Output Form: StandardRetention: 30 DaysDistribution: VAMMISProgram: Outpatient EAPGQuarterly SavingsReport (CPR869)Confidential: NoSequence: N/AControl Breaks: N/A

OUTPATIENT EAPG QUARTERLY SAVINGS REPORT (CP-O-869)


ment NameElementID

Source/Calculations











07 PTP SAVINGS-OUTPATIENT HOSPITALSERVICES

Calculated DE0002 Sumof savings for Outpatient HospitalServices relating to NCCI PTP denial.

08 PTP SAVINGS-DURABLEMEDICAL EQUIPMENT

Calculated DE0002 Sumof savings for DurableMedical Equip-ment relating to NCCI PTP denial.

09 MUE SAVINGS-PRACTITIONER &AMBULATORY SURGICALCENTER SERVICES



Calculated DE0002 Sumof savings for Outpatient HospitalServices relating to NCCI MUE denial.



Output Reports RF-O-900 Letter PrintUpdate Control Report

General InformationControl Totals of the physically printed letters requested from all MMIS subsystems.

Subsystem: ReferenceFrequency: DailyVolume: VariableNumber of Copies: 1Output Form: OnDemandRetention: 30 DaysDistribution: DARSProgram: LETTER PRINT PROGRAM (RFD900)Confidential: NoSequence: N/AControl Breaks: Subsystem

Letter Print Update Control Report (RF-O-900)



1 SUBSYSTEMNAME

Calculated DE0002 Value depends on the Letter Sub-systemOwner (DE 0014) in theRFF902 file: PROVIDER (if 'PR'),RECIPIENT (if 'RS'), FINANCE (if'FN' or 'AS'), EPSDT (if 'EP' or 'MI'),CLAIMS (if 'CL'), SURS (if 'SU')

2 LETTER TYPE CorrespondenceOut-put Identifier

DE3905

3 DESCRIPTION Description DE39074 NO. OF RECS

READCalculated DE0002 Total number of requested letters.

5 LETTERSWRITTEN

Calculated DE0002 Total number of printed letters.

6 LETTERSREJECTED

Calculated DE0002 Total number of rejected letters.

7 SUBSYSTEM Calculated DE0002 Value depends on the Letter Sub-

systemOwner in the RFF902 file:PROVIDER (if 'PR'), RECIPIENT (if'RS'), FINANCE (if 'FN' or 'AS'),EPSDT (if 'EP' or 'MI'), CLAIMS (if'CL'), SURS (if 'SU')

Output Reports RF-O-901 Letter Out-puts

General InformationThis is the control/error report produced by programRFR900which is processed on request toupdate the production Letter Text File (RF-F-900) with new, modified, or deleted letters. The reportindicateswhat letter ids were processed, their status (updated, added, or deleted), and any errorsthat may have occurred.

Subsystem: ReferenceFrequency: DailyVolume:Number of Copies: N/AOutput Form: OnDemandRetention: 7 yearsDistribution: OnDemandProgram: LETTER TEXT UPDATE (RFR900) (RFR900)Confidential: NoSequence: N/AControl Breaks: N/A

Letter Outputs (RF-O-901)



1 Letter ID CorrespondenceOut-put Identifier

DE3905 The ID of the letter being updated,added, or deleted.

2 Process Status Correspondence Vari-able Data

DE3987

3 Error Description Correspondence Vari-able Data

DE3987

Output Reports RF-O-902 Letter PrintError Report

General InformationThis is the error report produced by programRFD900which is run daily at the end of the batch workto process and physically print all of the letter requests from all of the sub-systemswithin theMMIS. Itreports the correspondence ID, the provider ID, the reason the letter was not produced, and the datethe error occurred. There is also a place for corrective action to be written.

Subsystem: ReferenceFrequency: DailyVolume:Number of Copies: N/AOutput Form: OnDemandRetention: 7 yearsDistribution: OnDemandProgram: LETTER PRINT PROGRAM (RFD900)Confidential: NoSequence: N/AControl Breaks: N/A

Letter Print Error Report (RF-O-902)



1 CorrespondenceID

Correspondence Iden-tifier

DE3906

2 Provider ID Provider IdentificationNumber

DE4002

3 Rejection Reason Correspondence Vari-able Data

DE3987

4 Occurrence Date Calculated DE00025 Corrective Action Correspondence Vari-

able DataDE3987

Output Reports RF-O-950 Letter PrintControl Report

General InformationThis report reports the total number of letters and total number of pages for each letter id produced.It also gives the grand total number of letters and pageswritten.

Subsystem: ReferenceFrequency: DailyVolume:Number of Copies: N/AOutput Form: OnDemandRetention: 7 yearsDistribution: OnDemandProgram: Letter Consolidation (RFD950)Confidential: NoSequence: N/AControl Breaks: N/A

Letter Print Control Report (RF-O-950)



1 Letter ID CorrespondenceOut-put Identifier

DE3905 The id of the letter being produced.

2 Letter Description Description DE39073 LettersWritten Calculated DE0002 The total number of letters written for

each letter ID and the grand total of let-ters written for all letter IDs.

4 PagesWritten Calculated DE0002 The total number of pageswritten foreach letter ID and the grand total ofpageswritten for all letter IDs.

claims data elements - virginiadmasva.dmas.virginia.gov/content_atchs/rfp-lib/reference...

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