NYSDOH Stop Loss File Specifications
File format should be submitted as tab-delimited text
First row must contain field names
Please include ALL columns in layout whether or not they are to be used
DO NOT submit IP, MH, or RHCF claims in the same file.
Field Name
Field Type
Field Length Field Description
ClmType
Date
Plan Name
Plan ID
Contact Name
Contact Phone
Email
Patient Name
CIN
TCN
Benefit Year
Ttl Stays
Text
Date
Text
Text
Text
Text
Text
Text
Text
Text
Text
Integer or Long
4
8
55
8
55
15
55
55
8
16
4
1
Value Indicating NYSDOH Stop Loss Form Rate Type Based on Admission Date (IP) or Rate
(MH, SNP, or RHCF). IMPORTANT: Please include only 1 benefit year per file for IP and SNP
claim types. For MH and RHCF claim types; benefit years may be mixed only if there are 20 or
fewer claims within the file.
Date of file submission
Plan Name
Plan Medicaid Identification Number (MMIS)
Plan Contact Name
Plan Contact Phone
Plan Contact E-mail
Enrollee Name
Enrollee Client Identification Number
Transaction Control Number (If submitting an adjustment)
Year (YYYY) of Claim based on Date of Admission
Count of Stay
Stop Loss Threshold
Amt Over Threshold
Plan Liability
Liability Type
Net Amt Due
HCO
HCO Stays
HCO Date From1
HCO Date To1
HCO Date From2
HCO Date To2
HCO Date From3
HCO Date To3
HCO Date From4
HCO Date To4
HCO Date From5
HCO Date To5
HCO Date From6
HCO Date To6
HCO Date From7
HCO Date To7
HCO Date From8
HCO Date To8
HCO Date From9
HCO Date To9
HCO Date From10
Double
Double
Double
Text
Double
Boolean or Integer
Integer
Date
Date
Date
Date
Date
Date
Date
Date
Date
Date
Date
Date
Date
Date
Date
Date
Date
Date
Date
15
15
15
40
15
1
1
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
Stop Loss Dollar/Day Threshold
Dollar/Day Amount Over Threshold
Dollar Amount of Plan Liability
Specify Any Applicable Dollar Liability Type e.g. Copay, Third Party Payment
Net Dollar Amount Due
True if Claim includes stays to be reviewed as High Cost Outlier
Count of HCO Stay
Date Span Admit Date 1
Date Span Discharge Date 1
Date Span Admit Date 2
Date Span Discharge Date 2
Date Span Admit Date 3
Date Span Discharge Date 3
Date Span Admit Date 4
Date Span Discharge Date 4
Date Span Admit Date 5
Date Span Discharge Date 5
Date Span Admit Date 6
Date Span Discharge Date 6
Date Span Admit Date 7
Date Span Discharge Date 7
Date Span Admit Date 8
Date Span Discharge Date 8
Date Span Admit Date 9
Date Span Discharge Date 9
Date Span Admit Date 10
11/15/2012
Values
Required
IP08: (1/1/08 - 12/31/08)
Rate: 2296/2299, IP09:
(1/1/09 - 12/31/09) Rate:
2296/2299, IP10: (1/1/10 12/31/10),Rate: 2296/2299,
IP11: (1/1/11 - 12/31/11),
IP12: (1/1/12 - 12/31/12),
Rate: 2296/2299, MH Rate:
2295, SNP Rate: 2296,
RHCF Rate: 2297
m/d/yyyy
Yes
Yes
Yes
Yes
Yes
(999)999-9999
Yes
Yes
Last, First
Yes
Yes
Yes, if applicable
i.e. 2008, 2009, 2010,2011
Yes
1 Yes
$50,000, $100,000,
$250,000, $300,000, 30, 60
1 = True, 0 = False
m/d/yyyy
m/d/yyyy
m/d/yyyy
m/d/yyyy
m/d/yyyy
m/d/yyyy
m/d/yyyy
m/d/yyyy
m/d/yyyy
m/d/yyyy
m/d/yyyy
m/d/yyyy
m/d/yyyy
m/d/yyyy
m/d/yyyy
m/d/yyyy
m/d/yyyy
m/d/yyyy
m/d/yyyy
Yes
Yes
Yes, if applicable
Yes, if applicable
Yes
Yes
1 Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Required Claim Type
All
All
All
All
All
All
All
All
All
All
All
All
All
All
All
All
All
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
1
NYSDOH Stop Loss File Specifications
Field Name
HCO Date To10
HCO Date From11
HCO Date To11
Hospital Name
Out Of State
Out of State Address
MMIS ID
Field Type
Field Length
Date
8
Date
8
Date
8
Text
55
Boolean or Integer
1
Text
55
Text
8
Field Description
Date Span Discharge Date 10
Date Span Admit Date 11
Date Span Discharge Date 11
Hospital Name
True if Out of State Hospital
Out of State Address for Hospital Facility
Hospital Medcaid MMIS ID #
NPI
Admit Date
Discharge Date
LOS
Acute Care Days
ALC Days
DOB
Age
Sex
Birth Wgt
Text
Date
Date
Long
Long
Long
Date
Long
Text
Long
National Provider Identification Number
Admission Date
Discharge Date
Length of Stay (Number of Days in Stay)
Total Number of Acute Care Days
Total Number of Alternate Level of Care Days
Date of Birth
Age at Time of Discharge
Sex (Gender)
Birth Weight (Must be included for newborns up to 28 days old)
Disposition
Text
Admitting Dx
Ttl Hospital Charges
Plan Per Diem Rate
RHCF Per Diem Rate
Text
Double
Double
Double
Principal DX
POAP
Text
Boolean or Integer
6 Principal Diagnosis
1 True if Present on Admission: Principle Diagnosis
Other DX1
POA1
Text
Boolean or Integer
6 Other Diagnosis 1
1 True if Present on Admission: Diagnosis 1
Other DX2
POA2
Text
Boolean or Integer
6 Other Diagnosis 2
1 True if Present on Admission: Diagnosis 2
Other DX3
POA3
Text
Boolean or Integer
6 Other Diagnosis 3
1 True if Present on Admission: Diagnosis 3
Other DX4
POA4
Text
Boolean or Integer
6 Other Diagnosis 4
1 True if Present on Admission: Diagnosis 4
Other DX5
POA5
Text
Boolean or Integer
6 Other Diagnosis 5
1 True if Present on Admission: Diagnosis 5
Other DX6
POA6
Text
Boolean or Integer
6 Other Diagnosis 6
1 True if Present on Admission: Diagnosis 6
Other DX7
POA7
Text
Boolean or Integer
6 Other Diagnosis 7
1 True if Present on Admission: Diagnosis 7
Other DX8
Text
6 Other Diagnosis 8
11/15/2012
10
8
8
4
4
4
8
3
1
4
2 Disposition (Status)
6
15
15
15
Admitting Diagnosis
Total Hospital Charges
Plan Per Diem Rate
RHCF Per Diem Rate
Values
m/d/yyyy
m/d/yyyy
m/d/yyyy
1 = True, 0 = False
m/d/yyyy
m/d/yyyy
m/d/yyyy
Required
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes
Yes
Yes, if applicable
Yes
Yes, if MMIS ID is
Unavailable
Yes
Yes
Yes
Yes
Yes, if applicable
Yes
Yes
Yes
Yes, if applicable
M, F
In grams
01, 02, 03, 04, 05, 06, 07, 08,
09, 10, 13, 20, 21, 30, 40, 41,
42, 43, 50, 51, 61, 62, 63, 64,
65, 66, 70
Yes
ICD9 Diagnosis Code : NO
DECIMAL
Yes
Yes
Yes, if applicable
Yes, if applicable
ICD9 Diagnosis Code : NO
DECIMAL
Yes, if applicable
1 = True, 0 = False
Yes, if applicable
ICD9 Diagnosis Code : NO
DECIMAL
Yes, if applicable
1 = True, 0 = False
Yes, if applicable
ICD9 Diagnosis Code : NO
DECIMAL
Yes, if applicable
1 = True, 0 = False
Yes, if applicable
ICD9 Diagnosis Code : NO
DECIMAL
Yes, if applicable
1 = True, 0 = False
Yes, if applicable
ICD9 Diagnosis Code : NO
DECIMAL
Yes, if applicable
1 = True, 0 = False
Yes, if applicable
ICD9 Diagnosis Code : NO
DECIMAL
Yes, if applicable
1 = True, 0 = False
Yes, if applicable
ICD9 Diagnosis Code : NO
DECIMAL
Yes, if applicable
1 = True, 0 = False
Yes, if applicable
ICD9 Diagnosis Code : NO
DECIMAL
Yes, if applicable
1 = True, 0 = False
Yes, if applicable
ICD9 Diagnosis Code : NO
DECIMAL
Yes, if applicable
Required Claim Type
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
All
All
All
All
All
All
All
All
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP, MH
All
All
All
IP08, IP09, IP10, IP11, IP12, SNP
All
All
All
MH, RHCF
RHCF
IP08, IP09, IP10, IP11, IP12, SNP, MH
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP, MH
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP, MH
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP, MH
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP, MH
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP, MH
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP, MH
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP, MH
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
2
NYSDOH Stop Loss File Specifications
Field Name
POA8
Field Type
Field Length Field Description
Boolean or Integer
1 True if Present on Admission: Diagnosis 8
Other DX9
POA9
Text
Boolean or Integer
6 Other Diagnosis 9
1 True if Present on Admission: Diagnosis 9
Other DX10
POA10
Text
Boolean or Integer
6 Other Diagnosis 10
1 True if Present on Admission: Diagnosis 10
Other DX11
POA11
Text
Boolean or Integer
6 Other Diagnosis 11
1 True if Present on Admission: Diagnosis 11
Other DX12
POA12
Text
Boolean or Integer
6 Other Diagnosis 12
1 True if Present on Admission: Diagnosis 12
Other DX13
POA13
Text
Boolean or Integer
6 Other Diagnosis 13
1 True if Present on Admission: Diagnosis 13
Other DX14
POA14
Text
Boolean or Integer
6 Other Diagnosis 14
1 True if Present on Admission: Diagnosis 14
Other DX15
POA15
Text
Boolean or Integer
6 Other Diagnosis 15
1 True if Present on Admission: Diagnosis 15
Other DX16
POA16
Text
Boolean or Integer
6 Other Diagnosis 16
1 True if Present on Admission: Diagnosis 16
Other DX17
POA17
Text
Boolean or Integer
6 Other Diagnosis 17
1 True if Present on Admission: Diagnosis 17
Other DX18
POA18
Text
Boolean or Integer
6 Other Diagnosis 18
1 True if Present on Admission: Diagnosis 18
Other DX19
POA19
Text
Boolean or Integer
6 Other Diagnosis 19
1 True if Present on Admission: Diagnosis 19
Other DX20
POA20
Text
Boolean or Integer
6 Other Diagnosis 20
1 True if Present on Admission: Diagnosis 20
Other DX21
POA21
Text
Boolean or Integer
6 Other Diagnosis 21
1 True if Present on Admission: Diagnosis 21
Other DX22
POA22
Text
Boolean or Integer
6 Other Diagnosis 22
1 True if Present on Admission: Diagnosis 22
Other DX23
POA23
Text
Boolean or Integer
6 Other Diagnosis 23
1 True if Present on Admission: Diagnosis 23
Other DX24
POA24
Permanent
Temporary
Text
Boolean or Integer
Boolean or Integer
Boolean or Integer
6
1
1
1
Principal Proc
Text
6 Principal Procedure
11/15/2012
Other Diagnosis 24
True if Present on Admission: Diagnosis 24
True if Patient's placement status in a Residential Health Care Facility is permanent
True if Patient's placement status in a Residential Health Care Facility is temporary
Values
1 = True, 0 = False
ICD9 Diagnosis Code : NO
DECIMAL
1 = True, 0 = False
ICD9 Diagnosis Code : NO
DECIMAL
1 = True, 0 = False
ICD9 Diagnosis Code : NO
DECIMAL
1 = True, 0 = False
ICD9 Diagnosis Code : NO
DECIMAL
1 = True, 0 = False
ICD9 Diagnosis Code : NO
DECIMAL
1 = True, 0 = False
ICD9 Diagnosis Code : NO
DECIMAL
1 = True, 0 = False
ICD9 Diagnosis Code : NO
DECIMAL
1 = True, 0 = False
ICD9 Diagnosis Code : NO
DECIMAL
1 = True, 0 = False
ICD9 Diagnosis Code : NO
DECIMAL
1 = True, 0 = False
ICD9 Diagnosis Code : NO
DECIMAL
1 = True, 0 = False
ICD9 Diagnosis Code : NO
DECIMAL
1 = True, 0 = False
ICD9 Diagnosis Code : NO
DECIMAL
1 = True, 0 = False
ICD9 Diagnosis Code : NO
DECIMAL
1 = True, 0 = False
ICD9 Diagnosis Code : NO
DECIMAL
1 = True, 0 = False
ICD9 Diagnosis Code : NO
DECIMAL
1 = True, 0 = False
ICD9 Diagnosis Code : NO
DECIMAL
1 = True, 0 = False
1 = True, 0 = False
1 = True, 0 = False
ICD9 Procedure Code : NO
DECIMAL
Required
Required Claim Type
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
RHCF
RHCF
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP, MH
3
NYSDOH Stop Loss File Specifications
Field Name
Field Type
Field Length Field Description
Other Proc1
Text
6 Other Procedure 1
Other Proc2
Text
6 Other Procedure 2
Other Proc3
Text
6 Other Procedure 3
Other Proc4
Text
6 Other Procedure 4
Other Proc5
Text
6 Other Procedure 5
Other Proc6
Text
6 Other Procedure 6
Other Proc7
Text
6 Other Procedure 7
Other Proc8
Text
6 Other Procedure 8
Other Proc9
Text
6 Other Procedure 9
Other Proc10
Text
6 Other Procedure 10
Other Proc11
Text
6 Other Procedure 11
Other Proc12
Text
6 Other Procedure 12
Other Proc13
Text
6 Other Procedure 13
Other Proc14
Text
6 Other Procedure 14
Other Proc15
Text
6 Other Procedure 15
Other Proc16
Text
6 Other Procedure 16
Other Proc17
Text
6 Other Procedure 17
Other Proc18
Text
6 Other Procedure 18
Other Proc19
Text
6 Other Procedure 19
Other Proc20
Text
6 Other Procedure 20
Other Proc21
Text
6 Other Procedure 21
Other Proc22
Text
6 Other Procedure 22
Other Proc23
Text
6 Other Procedure 23
Other Proc24
APRDRG
SevLevel
SIW
Low
High
Upstate ALOS
Text
Text
Text
Double
Long
Long
Long
6
6
1
8
3
3
3
11/15/2012
Other Procedure 24
AP - DRG (claims 1/1/08 - 11/30/09) or APR - DRG (12/1/09 - ) dependent upon the Benefit Year
Severity Level
Service Intensity Weight as indicated by APR - DRG
Low Trim Point as indicated by AP - DRG
High Trim Point as indicated by AP - DRG
Upstate Average Length of Stay as indicated by AP - DRG
Values
ICD9 Procedure Code : NO
DECIMAL
ICD9 Procedure Code : NO
DECIMAL
ICD9 Procedure Code : NO
DECIMAL
ICD9 Procedure Code : NO
DECIMAL
ICD9 Procedure Code : NO
DECIMAL
ICD9 Procedure Code : NO
DECIMAL
ICD9 Procedure Code : NO
DECIMAL
ICD9 Procedure Code : NO
DECIMAL
ICD9 Procedure Code : NO
DECIMAL
ICD9 Procedure Code : NO
DECIMAL
ICD9 Procedure Code : NO
DECIMAL
ICD9 Procedure Code : NO
DECIMAL
ICD9 Procedure Code : NO
DECIMAL
ICD9 Procedure Code : NO
DECIMAL
ICD9 Procedure Code : NO
DECIMAL
ICD9 Procedure Code : NO
DECIMAL
ICD9 Procedure Code : NO
DECIMAL
ICD9 Procedure Code : NO
DECIMAL
ICD9 Procedure Code : NO
DECIMAL
ICD9 Procedure Code : NO
DECIMAL
ICD9 Procedure Code : NO
DECIMAL
ICD9 Procedure Code : NO
DECIMAL
ICD9 Procedure Code : NO
DECIMAL
ICD9 Procedure Code : NO
DECIMAL
1, 2, 3, 4
Required
Required Claim Type
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP, MH
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP, MH
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP, MH
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP, MH
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP, MH
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP, MH
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable
Yes
Yes, if applicable
Yes
Yes, if applicable
Yes, if applicable
Yes, if applicable
IP08, IP09, IP10, IP11, IP12, SNP
All
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09
IP08, IP09
IP08, IP09
4
NYSDOH Stop Loss File Specifications
Field Name
Downstate ALOS
ALOS
Field Type
Long
Long
APR ExcInc
Amt Paid
Text
Double
Detox Code
Blank2
Inlier
Long Stay
Short Stay
Transfer
Exempt Unit
Text
Exempt Desc
Top 20 DRG
HCO
DRG
Per Diem
Other
Other Desc
Respite Days
Reservation Days
Reserve Date From
Reserve DateTo
Occupy Rate
Reserve Per Diem
adjust
adjustnbr
resubmit
resubmitnbr
Text
Boolean or Integer
Boolean or Integer
Boolean or Integer
Boolean or Integer
Boolean or Integer
Text
Long
Long
Date (m/d/yy)
Date (m/d/yy)
Percent
Double
Boolean or Integer
Long
Boolean or Integer
Long
Boolean or Integer
Boolean or Integer
Boolean or Integer
Boolean or Integer
Boolean or Integer
11/15/2012
Field Length Field Description
3 Downstate Average Length of Stay as indicated by AP - DRG
3 Average Length of Stay (12/1/09 - )
Applies to APR rates used on inpatient stays after 7/1/08 and before 1/1/2010: based on whether
7 the plan has a contracted rate: Exclude if Yes, Include if No
15 Amount Paid by Plan
4 Rate Code for IP Chemical Dependency Detox
Null
1 True if stay is calculated as an Inlier
1 True if stay is calculated as a Long Stay
1 True if stay is calculated as a Short Stay
1 True if stay is calculated as a Transfer
1 True if stay is calculated as an Exempt Unit
55
1
1
1
1
1
55
4
4
8
8
5
15
1
3
1
3
Exempt Unit Description
True if stay is calculated as a Top 20 DRG
True if stay is calculated as a High Cost Outlier
True if stay is calculated as DRG
True if stay is calculated as Per Diem
True if stay is calculated as Other
Other Description
Total Number of Respite Days Authorized
Total Number of Reservation Days Authorized
First Date of Bed Reservation Day
Last Date of Bed Reservation Day
RHCF Occupancy Rate on Date of First Bed Reservation Day
Per Diem Rate Paid to RHCF for Bed Reservation Days
True if =Claim Adjustment
Number of claim adjustments
True if =Claim Resubmission
Number of claim resubmissions
Values
Required
Required Claim Type
Yes, if applicable IP08, IP09
Yes, if applicable IP09, IP10, IP11
"Exclude", "Include" (Always
"Include" after 1/1/10)
Yes
Yes
4800,4801,4802,4803, 4804
For future use
1 = True, 0 = False
1 = True, 0 = False
1 = True, 0 = False
1 = True, 0 = False
1 = True, 0 = False
Other Exempt, Drug Exempt,
Epilepsy Exempt, Aids
Exempt, Alcohol Exempt,
Medical Rehab, Specialty
Hospital, Chemical
Dependency Rehab, Critical
Access, Psychiatric Exempt,
Detox, Medically Managed
Detox
1 = True, 0 = False
1 = True, 0 = False
1 = True, 0 = False
1 = True, 0 = False
1 = True, 0 = False
1 = True, 0 = False
1 = True, 0 = False
IP08, IP09, IP10, IP11, IP12, SNP
All
Yes, if applicable IP08, IP09, IP10, IP11, IP12, SNP
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09
IP08, IP09
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP, MH
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
Yes, if applicable
IP08, IP09, IP10, IP11, IP12, SNP, MH
IP08, IP09
IP08, IP09, IP10, IP11, IP12, SNP
MH
MH
IP08, IP09, IP10, IP11, IP12, SNP
IP08, IP09, IP10, IP11, IP12, SNP
RHCF
RHCF
RHCF
RHCF
RHCF
RHCF
All
All
All
All
5