CRX.002.056

PLAN-ID-NUMBER

Data Element

DE Number

CRX056

System DE Number

CRX.002.056

File Name

CRX - CLAIM PHARMACY

File Segment Number

CRX00002

File Segment Name

CLAIM-HEADER-RECORD-RX

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans.
Size	X(12)
FLF Start Position	345
FLF Stop Position	356
Segment Key Field Identifier	Not Applicable
Coding Requirements	1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional 4. Value must match Managed Care Plan ID (ELG.014.192) 5. Value must match State Plan ID Number (MCR.002.019) 6. Value should be populated when Type of Claim (CRX.002.029) is in [3,C,W,2,B,V] 7. When Type of Claim in [3,C,W,2,B,V] value must have a Managed Care Enrollment (ELG.014) for the beneficiary where the Prescription Fill Date (CRX.002.085) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198) 8. When Type of Claim in [3,C,W,2,B,V] value must have a Managed Care Main Record (MCR.002) for the plan where the Prescription Fill Date (CRX.002.085) occurs between the managed care contract eff/end dates (MCR.002.020/021)

Valid Value Code Set	Valid Value Code	Valid Value Name	Valid Value Description	Effective Start Date	Effective End Date

RULE ID	RULE Definition
RULE-1817	If the plan ID number is populated on a non-denied claim from an RX file, then the plan ID number reported must not contain any pipe or asterisk characters.
RULE-1818	If a claim is a non-denied non-encounter claim from an RX file, then the plan ID must be null.
RULE-6121	If a claim is a non-denied claim from an RX file, then the plan ID number value reported must be compatible with specified T-MSIS picture format: X(12).
RULE-7197	If plan ID is populated on a non-denied Medicaid, S-CHIP, or Other encounter from an RX file, then the plan ID must be equal to the plan ID on a managed care participation segment from an ELG file with the same MSIS ID and where the prescription fill date on the claim is within the effective and end dates of the managed care participation segment.
RULE-7201	If plan ID is populated on a non-denied Medicaid, S-CHIP, or Other encounter from an RX file, then the plan ID must be equal to the plan ID on a managed care main segment from an MCR file where the prescription fill date is within the contract effective and end dates on the managed care main segment.

Measure ID	Measure Name
MCR-54-010-10	# of plans where MC plan type does not match EL plan type
RULE-7201	% of claim headers with a valid value for Plan ID Number that do not have a corresponding MCR Managed Care Main segment for the same time period
RULE-7197	% of claim headers with a valid value for Plan ID Number that do not have a corresponding ELG Managed Care Participation segment for the same time period
MCR-27-002-2	Encounters (by Claims file type) by Plan ID (non-PCCM)
EL-8-001-1	Enrollment, capitation payments, and encounters by Plan Type
MIS-85-020-20	% missing: PLAN-ID-NUMBER (CRX00002)
MIS-27-002-20	% missing: PLAN-ID-NUMBER (CRX00002)
MIS-8-020-20	% missing: PLAN-ID-NUMBER (CRX00002)
MCR-55-003-3	PACE capitation ratio
MCR-55-002-2	Enhanced PCCM capitation ratio
MCR-55-001-1	Traditional PCCM capitation ratio
EL-8-002-2	Enrollment, capitation payments, capitation ratios, encounters (by claim file type) and encounter ratios (by claim file type) by plan ID with plan ID linking to MC file
MCR-54-009-9	# of plans with at least 100 enrollments, capitations, or encounters, that do not have a managed care record
MCR-54-005-5	# of plans with at least 100 capitations or 100 encounters, 0 enrollments
MCR-54-004-4	# of plans with at least 100 enrollments and some capitations that have capitation ratios outside of the expected range (0.7 - 1.3)
MCR-54-003-3	# of plans with at least 100 enrollments or 100 encounters, 0 capitations
MCR-54-002-2	# of plans with at least 100 enrollments or 100 capitations, 0 encounters
MCR-54-001-1	# of plans with at least 100 enrollments, 0 capitations, 0 encounters
MCR-53-003-3	Total # of managed care encounters
MCR-53-002-2	Total # of managed care capitations
MCR-53-001-1	Total # of managed care enrollments

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CIP130	CIP.002.130	PLAN-ID-NUMBER	CIP00002	CLAIM-HEADER-RECORD-IP
CLT080	CLT.002.080	PLAN-ID-NUMBER	CLT00002	CLAIM-HEADER-RECORD-LT
COT066	COT.002.066	PLAN-ID-NUMBER	COT00002	CLAIM-HEADER-RECORD-OT