ELG.005.086

PRIMARY-ELIGIBILITY-GROUP-IND

Data Element

DE Number

ELG086

System DE Number

ELG.005.086

File Name

ELG - ELIGIBLE

File Segment Number

ELG00005

File Segment Name

ELIGIBILITY-DETERMINANTS

Last updated

09/12/2024

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	A flag indicating the eligibility record is the primary eligibility in cases where there are multiple eligibility records submitted with overlapping or concurrent eligibility determinant effective and end dates. It is expected that an enrollee's eligibility group assignment (ELG087 - ELIGIBILITY-GROUP) will change over time as his/her situation changes. Whenever the eligibility group assignment changes (i.e., ELG087 has a different value), a separate ELIGIBILITY-DETERMINANTS record segment must be created. In such situations, there would be multiple ELIGIBILITY-DETERMINANTS record segments, each covering a different effective time span. In such situations, the value in ELG087 would be the primary eligibility group for the effective date span of its respective ELIGIBILITY-DETERMINANTS record segment, and the PRIMARY-ELIGIBILITY-GROUP-IND data element on each of these segments would be set to "1"(YES). Should a situation arise where a Medicaid/CHIP enrollee has been assigned both a primary and one or more secondary eligibility groups, there would be two or more ELIGIBILITY-DETERMINANTS record segments with overlapping effective time spans - one segment containing the primary eligibility group and the other(s) for the secondary eligibility group(s). To differentiate the primary eligibility group from the secondary group(s), only one segment should be assigned as the primary group using PRIMARY-ELIGIBILITY-GROUP-IND = "1"; the others should be assigned PRIMARY-ELIGIBILITY-GROUP-IND = "0".
Size	X(1)
FLF Start Position	58
FLF Stop Position	58
Segment Key Field Identifier	4
Coding Requirements	1. Value must be in Primary Eligibility Group Indicator List (VVL) 2. Value must be 1 character 3. Value must be in [0,1] 4. Mandatory

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Valid Value Code Set	Valid Value Code	Valid Value Name	Valid Value Description	Effective Start Date	Effective End Date
PRIMARY-ELIGIBILITY-GROUP-IND	0	NO		01/01/0001	12/31/9999
PRIMARY-ELIGIBILITY-GROUP-IND	1	YES		01/01/0001	12/31/9999

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RULE ID	RULE Definition
RULE-2132	If the primary eligibilty group indicator is populated on a eligibility determinants file, then the primary eligibilty group indicator reported must be found in the list of valid values.
RULE-2133	If there is only one eligibility determinants segment, with segment keys submitting state, MSIS ID and MSIS case number, then the primary eligibility group indicator is equal to '1'
RULE-6899	If a segment is an eligibility determinants segment, the primary eligibility group indicator value reported must be compatible with the specified T-MSIS picture format: X(1).
RULE-7409	If a segment is a variable demographics eligibility segment from an ELG file, and the chip code is M-CHIP, then the max(variable demographics eligibility effective date, 2015-01-01) is greater than or equal to eligibility determinants effective date and the variable demographics eligibility end date is less than or equal to eligibility determinants end date and the eligibility determinants end date is greater than or equal to '2015-01-01' and the primary eligibility group indicator is equal to '1' and the eligibility group is equal to '07', '31', or '61'
RULE-7410	If a segment is a variable demographics eligibility segment from an ELG file, and the chip code is for S-CHIP, then the max(variable demographics eligibility effective date, 2015-01-01) is greater than or equal to eligibility determinants effective date and the variable demographics eligibility end date is less than or equal to eligibility determinants end date and the eligibility determinants end date is greater than or equal to '2015-01-01' and the primary eligibility group indicator is equal to '1' and the eligibility group is equal to '61', '62', '63', '64', '65', '66', '67' or '68'
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-7422	If a segment is a variable demographics eligibility segment from an ELG file, and the chip code is for Medicaid, then the max(variable demographics eligibility effective date, 2015-01-01) is greater than or equal to eligibility determinants effective date and the variable demographics eligibility end date is less than or equal to eligibility determinants end date and the eligibility determinants end date is greater than or equal to '2015-01-01' and the primary eligibility group indicator is equal to '1' and the eligibility group is not equal to '61', '62', '63', '64', '65', '66', '67' or '68'
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-7427	If a segment is a waiver participation segment from an ELG file, and the waiver participation segment has a family planning demonstration waiver type and the effective and end dates on the waiver participation segment fall within the effective and end dates of one or more continuous eligibility determinants segments, and the eligibility determinants has a primary eligibility group indicator equal to '1', then the restricted benefits code is equal to '6'.
RULE-7428	If restricted benefits code is for S-CHIP dental on an eligibility determinants segment from an ELG file, and the eligibility determinants has a primary eligibility group indicator equal to '1', then the effective date and end date on the eligibility determinants segment must fall within the effective and end dates of one or more continuous variable demographics eligibility segments and the CHIP code must be for S-CHIP for the month on the variable demographic eligibility segment.
RULE-7429	If MSIS ID is populated on an mfp information segment from an ELG file, then the effective date and end date on the mfp information segment must fall within the effective and end dates of one or more continuous eligibility determinants segments and the primary eligibility group indicator is equal to '1' and the restricted benefits code must be for Medicaid Money Follows the Person (MFP) rebalancing demonstration on the eligibility determinants segment.
RULE-7529	If restricted benefits code is for restricted benefits based on noncitizen status on an eligibility determinants segment from an ELG file, and eligibility determinants has a primary eligibility group indicator equal to '1' then the effective date and end date on the eligibility determinants segment must fall within the effective and end dates of one or more continuous variable demographics eligibility segments and the immigration status must be for a noncitizen on the variable demographics eligibility segment.
RULE-7540	If MSIS ID is populated on an enrollment time span segment from an ELG file, then the effective date and end date on the enrollment time span segment must fall within the effective and end dates of one or more continuous eligibility determinants segments and the MSIS ID is populated in the eligibility determinants segment.
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-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-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-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-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-7810	If restricted benefits code is for Money Follows the Person (MFP) on an eligibility determinants segment from an ELG file, and the primary eligibility group indicator is equal to '1', then the effective date and end date on the eligibility determinants segment must fall within the effective and end dates of one or more continuous mfp information segments.
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-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-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-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'

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Measure ID	Measure Name
MIS-1-031-31	% distinct MSIS IDs with only missing values in any active segment: PRIMARY-ELIGIBILITY-GROUP-IND (ELG00005)

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DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
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Published Date	Data Guide Version	Data Element	Action	Field	Before	After
09/12/2024	3.29.0	ELG.005.086	UPDATE	Definition	A flag indicating the eligibility record is the primary eligibility in cases where there are multiple eligibility records submitted with overlapping or concurrent eligibility determinant effective and end dates. It is expected that an enrollee's eligibility group assignment (ELG087 - ELIGIBILITY-GROUP) will change over time as his/her situation changes. Whenever the eligibility group assignment changes (i.e., ELG087 has a different value), a separate ELIGIBILITY-DETERMINANTS record segment must be created. In such situations, there would be multiple ELIGIBILITY-DETERMINANTS record segments, each covering a different effective time span. In such situations, the value in ELG087 would be the primary eligibility group for the effective date span of its respective ELIGIBILITY-DETERMINANTS record segment, and the PRIMARY-ELIGIBILITY-GROUP-IND data element on each of these segments would be set to '1' (YES). Should a situation arise where a Medicaid/CHIP enrollee has been assigned both a primary and one or more secondary eligibility groups, there would be two or more ELIGIBILITY-DETERMINANTS record segments with overlapping effective time spans - one segment containing the primary eligibility group and the other(s) for the secondary eligibility group(s). To differentiate the primary eligibility group from the secondary group(s), only one segment should be assigned as the primary group using PRIMARY-ELIGIBILITY-GROUP-IND = 1; the others should be assigned PRIMARY-ELIGIBILITY-GROUP-IND = 0.	A flag indicating the eligibility record is the primary eligibility in cases where there are multiple eligibility records submitted with overlapping or concurrent eligibility determinant effective and end dates. It is expected that an enrollee's eligibility group assignment (ELG087 - ELIGIBILITY-GROUP) will change over time as his/her situation changes. Whenever the eligibility group assignment changes (i.e., ELG087 has a different value), a separate ELIGIBILITY-DETERMINANTS record segment must be created. In such situations, there would be multiple ELIGIBILITY-DETERMINANTS record segments, each covering a different effective time span. In such situations, the value in ELG087 would be the primary eligibility group for the effective date span of its respective ELIGIBILITY-DETERMINANTS record segment, and the PRIMARY-ELIGIBILITY-GROUP-IND data element on each of these segments would be set to "1"(YES). Should a situation arise where a Medicaid/CHIP enrollee has been assigned both a primary and one or more secondary eligibility groups, there would be two or more ELIGIBILITY-DETERMINANTS record segments with overlapping effective time spans - one segment containing the primary eligibility group and the other(s) for the secondary eligibility group(s). To differentiate the primary eligibility group from the secondary group(s), only one segment should be assigned as the primary group using PRIMARY-ELIGIBILITY-GROUP-IND = "1"; the others should be assigned PRIMARY-ELIGIBILITY-GROUP-IND = "0".
09/12/2024	3.29.0	ELG.005.086	UPDATE	Coding requirement	1. Value must be in Primary Eligibility Group Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1]4. Mandatory	1. Value must be in Primary Eligibility Group Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1]4. Mandatory
09/21/2023	3.13.0	ELG.005.086	UPDATE	Segment key field identifier	Not Applicable	4
08/01/2023	3.11.0	ELG.005.086	UPDATE	Coding requirement	1. Value must be in Primary Eligibility Group Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. Value must be 1 character5. Mandatory	1. Value must be in Primary Eligibility Group Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1]4. Mandatory
01/07/2022	3.0.0	ELG086	ADD	Data Dictionary	N/A	\|DE NO\| DATA ELEMENT NAME\| DEFINITION\| NECESSITY \|CODING REQUIREMENT\| \|ELG086\|PRIMARY-ELIGIBILITY-GROUP-IND\| Not Applicable \|Not Applicable \|A person enrolled in Medicaid/CHIP should always have a primary eligibility group classification for any given day of enrollment. (There may or may not be a secondary eligibility group classification for that same day.) It is expected that an enrollee's eligibility group assignment (ELG087 - ELIGIBILITY-GROUP) will change over time as his/her situation changes. Whenever the eligibility group assignment changes (i.e., ELG087 has a different value), a separate ELIGIBILITY-DETERMINANTS record segment must be created. In such situations, there would be multiple ELIGIBILITY-DETERMINANTS record segments, each covering a different effective time span. In such situations, the value in ELG087 would be the primary eligibility group for the effective date span of its respective ELIGIBILITY-DETERMINANTS record segment, and the PRIMARY-ELIGIBILITY-GROUP-IND data element on each of these segments would be set to '1' (YES).\|
01/07/2022	3.0.0	ELG086	ADD	Data Dictionary	N/A	\|DE NO\| DATA ELEMENT NAME\| DEFINITION\| NECESSITY \|CODING REQUIREMENT\| \|ELG086\|PRIMARY-ELIGIBILITY-GROUP-IND\| Not Applicable \|Not Applicable \|Should a situation arise where a Medicaid/CHIP enrollee has been assigned both a primary and one or more secondary eligibility groups, there would be two or more ELIGIBILITY-DETERMINANTS record segments with overlapping effective time spans - one segment containing the primary eligibility group and the other(s) for the secondary eligibility group(s). To differentiate the primary eligibility group from the secondary group(s), only one segment should be assigned as the primary group using PRIMARY-ELIGIBILITY-GROUP-IND = 1; the others should be assigned PRIMARY-ELIGIBILITY-GROUP-IND = 0.\|