ELG.005.085

DUAL-ELIGIBLE-CODE

Data Element

DE Number

ELG085

System DE Number

ELG.005.085

File Name

ELG - ELIGIBLE

File Segment Number

ELG00005

File Segment Name

ELIGIBILITY-DETERMINANTS

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	Indicates coverage for individuals entitled to Medicare (Part A and/or B benefits) and eligible for some category of Medicaid benefits.
Size	X(2)
FLF Start Position	56
FLF Stop Position	57
Segment Key Field Identifier	Not Applicable
Coding Requirements	1. Value must be in Dual Eligible Code List (VVL) 2. If value is "05", then Eligibility Group (ELG.005.087) must be "24" 3. If value is "06", then Eligibility Group (ELG.005.087) must be "26" 4. If Dual Eligible Code (ELG.005.085) is "01", "02", "03", 04", 05", "06", "08", "09", or "10", then Primary Eligibility Group Indicator (ELG.005.086) must be "1" (Yes) 5. Mandatory 6. A partial dual eligible (values="01', "03", "05" or "06") then Restricted Benefits Code (ELG.005.097) must be "3" 7. (Not Dual Eligible) if value = "00", then associated Medicare Beneficiary Identifier (ELG.003.051) value must not be populated. 8. Value must be 2 characters 9. If value is in ["08", "10"] then Restricted Benefits Code (ELG.005.097) must be "1" 10. If value is "09", then Eligibility Group (ELG.005.087) and Restricted Benefits Code (ELG.005.097) must not be populated 11. If value equals "10", then CHIP Code (ELG.003.054) must be "03" (S-CHIP) and Medicare Beneficiary Identifier (ELG.003.051) must be populated 12. If value is "01", then Eligibility Group (ELG.005.087) must be "23" 13. If value is "03", then Eligibility Group (ELG.005.087) must be "25"

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

RULE ID	RULE Definition
RULE-7984	If a claim in a non-denied, original or adjustment FFS crossover claim from an RX file, and the MSIS ID is populated and the presription fill date is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
RULE-7983	If a claim in a non-denied, original or adjustment FFS crossover claim from an OT file, and the MSIS ID is populated and the beginning date of service is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
RULE-7982	If a claim in a non-denied, original or adjustment FFS crossover claim from an LT file, and the MSIS ID is populated and the beginning date of service is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
RULE-7981	If a claim in a non-denied, original or adjustment FFS crossover claim from an IP file, and the MSIS ID is populated and the admission date is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
RULE-7744	If a claim in a non-denied, original or adjustment Encounter crossover claimfrom an IP file, and the MSIS ID is populated and the admission date is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01','02', '04', '08'
RULE-7743	If a claim in a non-denied, original or adjustment Encounter crossover claim from an LT file, and the MSIS ID is populated and the beginning date of service is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
RULE-7742	If a claim in a non-denied, original or adjustment Encounter crossover claim from an RX file, and the MSIS ID is populated and the presription fill date is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
RULE-7741	If a claim in a non-denied, original or adjustment Encounter crossover claim from an OT file, and the MSIS ID is populated and the beginning date of service is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
RULE-2126	If dual eligible code is populated on an eligibility determinants segment from an ELG file, then the dual eligible code value reported must be in the list of valid values for dual eligible code.
RULE-2131	If the restricted benefits code is equal to '3' on an eligibility determinants segment from an EL file, then the value for dual eligible code must be one of the following: '01', '03', '05', '06'.
RULE-6213	If a segment is an eligibility determinants segment from an ELG file, the dual eligible code value reported must be compatible with the specified T-MSIS picture format: X(2).
RULE-7297	#N/A
RULE-7412	If a claim in a non-denied, original or adjustment FFS or Encounter crossover claim from an IP file, and the MSIS ID is populated and the admission date is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01','02', '04', '08'
RULE-7413	If a claim in a non-denied, original or adjustment FFS or Encounter crossover claim from an LT file, and the MSIS ID is populated and the beginning date of service is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01','02', '04', '08'
RULE-7414	If a claim in a non-denied, original or adjustment FFS or Encounter crossover claim from an RX file, and the MSIS ID is populated and the prescription fill date is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
RULE-7419	If a segment is an eligibility determinants segment from an ELG file, and the MSIS ID is populated and the eligibility group has a value of '23', '24', '25', or '26' and the primary eligibility group indicator is equal to '1', and the eligibility determinant effective and end dates overlap with the reported enrollment effective and end dates, then the dual eligible code is one of the following values: '01', '02', '03', '04', '05', '06', '08', '09', '10'.
RULE-7420	If a segment is an eligibility determinants segment from an ELG file, and the MSIS ID is populated and the restricted benefits code is equal to '3' and the primary eligibility group indicator is equal to '1', and the eligibility determinant effective and end dates overlap with the reported enrollment effective and end dates, then the dual eligible code is equal to one of the following values: '01', '03', '05', '06'.
RULE-7424	If a claim in a non-denied, original or adjustment FFS or Encounter crossover claim from an OT file, and the MSIS ID is populated and the beginning date of service is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
RULE-7641	If a segment is an eligibility determinants segment from an ELG file, and the dual eligible code is '01', '02', '03', '04', '05', '06', '08', '09', or '10', and the eligibility determinants end date is greater than or equal to the TMSIS cutover date, and the primary eligibility group indicator is '1', then the MBI or the Medicare Hic number are populated and the effective and end dates on the eligibility determinants segment fall within the effective and end dates of one or more continuous variable demographic segments.
RULE-7677	If a segment is a variable demographic eligibility segment from an ELG file, and the medicare beneficiary identifier or the medicare hic num are populated, and the variable demographic element end date is greater than or equal to the TMSIS cutover date, and the primary eligibility group indicator is '1', then the dual eligible code are equal to one of the following values '01', '02', '03', '04', '05', '06', '08', '09', or '10' and the effective and end dates on the variable demographic eligibility segment fall within the effective and end dates of one or more continuous eligibility determinants segments.
RULE-7768	If the restricted benefits code is equal to 'G' (Medicare Part B-ID ESRD Benefit) on an eligibility determinants segment from an ELG file, then the value for dual eligible code must be one of the following: '01', '03', '06'.

Measure ID	Measure Name
MIS-1-023-23	% distinct MSIS IDs with only missing values in any active segment: DUAL-ELIGIBLE-CODE (ELG00005)
EL-6-014-14	# of SLMB only duals (DUAL-ELIGIBLE-CODE = 03)
EL-6-015-15	# of SLMB plus duals (DUAL-ELIGIBLE-CODE = 04)
EL-6-016-16	# of QDWI duals (DUAL-ELIGIBLE-CODE = 05)
EL-6-017-17	# of QI-1 duals (DUAL-ELIGIBLE-CODE = 06)
EL-6-018-18	# of Other duals (DUAL-ELIGIBLE-CODE = 08)
EL-6-019-19	# of Other - specific CMS approval duals (DUAL-ELIGIBLE-CODE = 09)
EL-6-020-20	# of MSIS IDs in S-CHIP entitled to Medicare (DUAL-ELIGIBLE-CODE = 10)
EL-6-026-26	% of RBC duals (RESTRICTED-BENEFITS-CODE = 3 or G) without a partial dual code (DUAL-ELIGIBLE-CODE not 01, 03, 05, 06)
EL-6-027-27	% of partial duals (DUAL-ELIGIBLE-CODE = 01, 03, 05, 06) without an RBC of dual (RESTRICTED-BENEFITS-CODE not 3 or G)
EL-S-002-2	Total # of duals
EL-6-013-13	# of QMB plus duals (DUAL-ELIGIBLE-CODE = 02)
EL-6-036-36	% of duals missing Medicare Beneficiary Identifier
RULE-7553	% of record segments with DUAL-ELIGIBLE-CODE = 1 (QMB only) that do not have ELIGIBILITY-GROUP = 23 (Qualified Medicare Beneficiaries)
RULE-7554	% of record segments with DUAL-ELIGIBLE-CODE = 5 (QDWI) that do not have ELIGIBILITY-GROUP = 24 (Qualified Disabled and Working Individuals)
RULE-7555	% of record segments with DUAL-ELIGIBLE-CODE = 3 (SLMB only) that do not have ELIGIBILITY-GROUP = 25 (Specified Low Income Medicare Beneficiaries)
RULE-7556	% of record segments with DUAL-ELIGIBLE-CODE = 6 (QI) that do not have ELIGIBILITY-GROUP = 26 (Qualifying Individuals)
RULE-7559	% of record segments with Dual Eligible Code indicating dual status where Medicare Beneficiary Identifier and Medicare HIC Number are missing
RULE-7641	% of record segments with a valid Dual Eligible Code that have a missing value for Medicare HIC Number and Medicare Beneficiary Identifier for the same period of time
RULE-7419	% of segments with ELIGIBILITY-GROUP = 23 through 26 (QMB, QDWI, SLMB or QI) without valid DUAL-ELIGIBLE-CODE 01 through 10
RULE-7420	% of segments (RESTRICTED-BENEFITS-CODE = 3) without a partial dual code (DUAL-ELIGIBLE-CODE not 01, 03, 05, 06)
RULE-7421	% of segments (DUAL-ELIGIBLE-CODE = 01, 03, 05, 06) without an RBC of dual (RESTRICTED-BENEFITS-CODE not 3)
EL-15-005-5	% difference between T-MSIS QMB-plus duals count and MMA QMB-plus duals count (Dual Code=02)
ALL-14-002-2	% of MSIS IDs on crossover claim headers not enrolled as duals (QMB, QMB Plus, SLMB Plus, Other) on Beginning Date of Service
ALL-14-003-3	% of MSIS IDs on crossover claim headers not enrolled as duals (QMB, QMB Plus, SLMB Plus, Other) on Beginning Date of Service
ALL-14-004-4	% of MSIS IDs on crossover claim headers not enrolled as duals (QMB, QMB Plus, SLMB Plus, Other) on Prescription Fill Date
ALL-14-005-5	% of MSIS IDs on crossover claim headers enrolled as premium only dual groups (SLMB, QI, QDWI) on Admission Date
ALL-14-006-6	% of MSIS IDs on crossover claim headers enrolled as premium only dual groups (SLMB, QI, QDWI) on Beginning Date of Service
ALL-14-007-7	% of MSIS IDs on crossover claim headers enrolled as premium only dual groups (SLMB, QI, QDWI) on Beginning Date of Service
ALL-14-008-8	% of MSIS IDs on crossover claim headers enrolled as premium only dual groups (SLMB, QI, QDWI) on Prescription Fill Date
EL-11-001-1	% of full duals (DUAL-ELIGIBLE-CODE = 02, 04, and 08) receiving private health insurance (TPL-HEALTH-INSURANCE = 1)
EL-15-003-3	% difference between total T-MSIS duals count and total MMA duals count
EL-15-004-4	% difference between T-MSIS QMB-only duals count and MMA QMB-only duals count (Dual Code=01)
ALL-14-001-1	% of MSIS IDs on crossover claim headers not enrolled as duals (QMB, QMB Plus, SLMB Plus, Other) on Admission Date
EL-15-006-6	% difference between T-MSIS SLMB-only duals count and MMA SLMB-only duals count (Dual Code=03)
EL-15-007-7	% difference between T-MSIS SLMB-plus duals count and MMA SLMB-plus duals count (Dual Code=04)
EL-15-008-8	% difference between T-MSIS QDWI duals count and MMA QDWI duals count (Dual Code=05)
EL-15-009-9	% difference between T-MSIS QI duals count and MMA QI duals count (Dual Code=06)
EL-15-010-10	% difference between T-MSIS Other duals count and MMA Other duals count (Dual Code=08)
EL-15-011-11	% difference between T-MSIS Other - specific CMS approval duals and MMA Other - specific CMS approval duals (Dual Code=09)
EL-3-002-7	% of MSIS IDs in ELIGIBILITY-GROUP = 23 through 26 (QMB, QDWI, SLMB or QI) with valid DUAL-ELIGIBLE-CODE 01 through 10
EL-3-003_1-15	% of MSIS IDs that are duals
EL-3-003-11	% of MSIS IDs with age 65+ that are duals
EL-6-012-12	# of QMB only duals (DUAL-ELIGIBLE-CODE = 01)

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
05/31/2023	3.8.0	ELG.005.085	UPDATE	Necessity	Conditional	Mandatory
05/31/2023	3.8.0	ELG.005.085	UPDATE	Coding requirement	1. Value must be in Dual Eligible Code List (VVL)2. If value is "05", then Eligibility Group (ELG.005.087) must be "24"3. If value is "06", then Eligibility Group (ELG.005.087) must be "26"4. If Dual Eligible Code (ELG.005.085) is "01", "02", "03", 04", 05", "06", "08", "09", or "10", then Primary Eligibility Group Indicator (ELG.005.086) must be "1" (Yes)5. Conditional6. A partial dual eligible (values="01', "03", "05" or "06") then Restricted Benefits Code (ELG.005.097) must be "3"7. (Not Dual Eligible) if value = "00", then associated Medicare Beneficiary Identifier (ELG.003.051) value must not be populated.8. Value must be 2 characters9. If value is in ["08", "10"] then Restricted Benefits Code (ELG.005.097) must be "1"10. If value is "09", then Eligibility Group (ELG.005.087) and Restricted Benefits Code (ELG.005.097) must not be populated11. If value equals "10", then CHIP Code (ELG.003.054) must be "03" (S-CHIP) and Medicare Beneficiary Identifier (ELG.003.051) must be populated12. If value is "01", then Eligibility Group (ELG.005.087) must be "23"13. If value is "03", then Eligibility Group (ELG.005.087) must be "25"	1. Value must be in Dual Eligible Code List (VVL)2. If value is "05", then Eligibility Group (ELG.005.087) must be "24"3. If value is "06", then Eligibility Group (ELG.005.087) must be "26"4. If Dual Eligible Code (ELG.005.085) is "01", "02", "03", 04", 05", "06", "08", "09", or "10", then Primary Eligibility Group Indicator (ELG.005.086) must be "1" (Yes)5. Mandatory6. A partial dual eligible (values="01', "03", "05" or "06") then Restricted Benefits Code (ELG.005.097) must be "3"7. (Not Dual Eligible) if value = "00", then associated Medicare Beneficiary Identifier (ELG.003.051) value must not be populated.8. Value must be 2 characters9. If value is in ["08", "10"] then Restricted Benefits Code (ELG.005.097) must be "1"10. If value is "09", then Eligibility Group (ELG.005.087) and Restricted Benefits Code (ELG.005.097) must not be populated11. If value equals "10", then CHIP Code (ELG.003.054) must be "03" (S-CHIP) and Medicare Beneficiary Identifier (ELG.003.051) must be populated12. If value is "01", then Eligibility Group (ELG.005.087) must be "23"13. If value is "03", then Eligibility Group (ELG.005.087) must be "25"