| A | B | C | D | E | F | G | H | I | J | |
|---|---|---|---|---|---|---|---|---|---|---|
1 | COZEVA RAPS File Format | |||||||||
2 | Delimiter Type | Data file should preferably be in pipe (|) delimited text file (.txt) with header rows. | ||||||||
3 | Frequency | Share as needed | ||||||||
4 | File Header | Required. Field names and their order are provided below. | ||||||||
5 | File Name | <customer acronym>_<healthplan acronym if required>_RAPS_inbound_<weekly/monthly/quarterly>_100_<batch date YYYYMMDD>.txt | ||||||||
6 | File Dependencies | Member | ||||||||
7 | RAPS RECORD CCC - DETAIL LEVEL | |||||||||
8 | Order | PK | Req | Field | Max Length | Data Format | Value | Required Field Comments | CMS Description | |
9 | 1 | RECORD-ID | 3 | ENUM ('CCC') | Field-1:Detail-level information that identifies the beneficiary information. This field should always be populated with “CCC.” | |||||
10 | 2 | Y | Y | SEQ-NO | 7 | Should Start with '0000001' | SEQ-NO is similar to Line Number; which helps to reference the exact line in the file | Field-2:This field identifies the detail record submitted. The first detail record in a batch must begin with 0000001. All successive detail sequence numbers in the batch must be incremented by one. This is a numeric field. Limited to 1,000,000 per day. | ||
11 | 3 | SEQ-ERROR-CODE | 3 | Field-3:This field must be submitted with spaces. Upon return, this field is populated with an error code if RAPS finds an error in the sequence number, or will remain blank if no errors were detected in the sequence number. | ||||||
12 | 4 | Y | Y | PATIENT-CONTROL-NO | 40 | Either PATIENT-CONTROL-NO or HIC-NO should be matched with any of the member ID from Member File | Field-4:This optional field may be used by the MA organization to identify the claim submitted. The field allows up to 40 alphanumeric characters | |||
13 | 5 | Y | Y | HIC-NO | 25 | Either PATIENT-CONTROL-NO or HIC-NO should be matched with any of the member ID from Member File | Field-5:The Health Insurance Claim number for the beneficiary. This is a 25-digit alphanumeric field. Enter spaces, not zeros, in unused spaces. | |||
14 | 6 | HIC-ERROR-CODE | 3 | Field-6:This should be submitted with spaces. Upon return, this field is populated with an error code if RAPS finds an error in the HIC number, or remains blank if no errors were detected in the HIC number | ||||||
15 | 7 | Y | PATIENT-DOB | 8 | CCYYMMDD | Field-7:This optional field may be populated with the patient’s date of birth and is used to verify that the correct beneficiary identification was submitted. If the field is populated, it must be formatted as CCYYMMDD, and CMS edits this field against the information on file at the MBD. If no DOB is submitted, fill with spaces | ||||
16 | 8 | DOB-ERROR-CODE | 3 | Field-8:This field must be submitted with spaces. Upon return, this field is populated with an error code if RAPS finds an error with DOB, or remains blank if no errors were detected in the DOB. | ||||||
17 | 9 | Y | PROVIDER-TYPE-0 | 2 | ENUM (01, 02, 10, 20) | HOSPITAL IP PRINCIPAL = 01 HOSPITAL IP OTHER = 02 HOSPITAL OP = 10 PHYSICIAN = 20 | 0th Provider Type field should not be blank; It will help to determine the type of submitting provider | Field-9.0:This 2-digit alphanumeric field identifies the site of service provided (01,02,10,20). | The following 8 fields (9.0-9.7) may be repeated 10 times in the same “CCC” record with one diagnosis per cluster. Each diagnosis cluster must contain 32 characters or spaces. Plans must not skip clusters when submitting active diagnosis codes. If there are less than 10 diagnosis clusters the remaining clusters are space filled. If there are more than 10 diagnoses, a new “CCC” record must be established. | |
18 | 10 | Y | Y | FROM-DATE-0 | 8 | CCYYMMDD | 0th From-Date field should not be blank; It will be considered as service date of the corresponding diagnosis code | Field-9.1:For hospital inpatient this describes the admission date. For physician and hospital outpatient this describes the date of service. Must be formatted as CCYYMMDD. | ||
19 | 11 | Y | THRU-DATE-0 | 8 | CCYYMMDD | Field-9.2:For hospital inpatient this describes the discharge date. For physician and hospital outpatient this may be left blank and the system will fill with the “From Date.” Must be formatted as CCYYMMDD. | ||||
20 | 12 | Y | DELETE-IND-0 | 1 | ENUM ('D', space) | Field-9.3:This field allows the MA organization to delete a diagnosis, for correction purposes, that has been stored in the RAPS database. Enter a “D” or space | ||||
21 | 13 | Y | Y | DIAGNOSIS-CODE-0 | 7 | ICD10CM | ICD-9 or ICD-10 | 0th Diagnosis Code field should not be blank | CMS has two separate fields. Field 9.4=ICD9, 9.5=ICD10. Field-9.4: This field is populated with the three-to five-digit ICD-9-CM diagnosis code. The decimal is implied and should not be included (e.g., 42732). Fill with spaces when ICD-9-CM is not used. Left justify. Field-9.5: This field is populated with the three-to seven-digit ICD-10-CM diagnosis code. The decimal is implied and should not be included (e.g., 4273432). Fill with spaces when ICD-10-CM is not used. Left justify | |
22 | 14 | DIAG-CLSTR-ERROR-1-0 | 3 | Field-9.6:This field must be submitted with spaces. Upon return, this field is populated with one error code if RAPS finds an error in the diagnosis cluster, or remains blank if no errors were detected in the diagnosis cluster. | ||||||
23 | 15 | DIAG-CLSTR-ERROR-2-0 | 3 | Field-9.7:This field must be submitted with spaces. Upon return, this field is populated with one error code if RAPS finds an error in the diagnosis cluster, or remains blank if no errors were detected in the diagnosis cluster. | ||||||
24 | 16 | PROVIDER-TYPE-1 | 2 | ENUM (01, 02, 10, 20, Blank Space) | HOSPITAL IP PRINCIPAL = 01 HOSPITAL IP OTHER = 02 HOSPITAL OP = 10 PHYSICIAN = 20 Blank if no data | If DIAGNOSIS-CODE-1 is not blank; FROM-DATE-1 & PROVIDER-TYPE-1 should be also not blank | ||||
25 | 17 | FROM-DATE-1 | 8 | CCYYMMDD or Blank Space | ||||||
26 | 18 | THRU-DATE-1 | 8 | CCYYMMDD or Blank Space | ||||||
27 | 19 | DELETE-IND-1 | 1 | ENUM ('D', Blank space) | ||||||
28 | 20 | DIAGNOSIS-CODE-1 | 7 | ICD10CM or Blank Space | ICD-9 or ICD-10 | |||||
29 | 21 | DIAG-CLSTR-ERROR-1-1 | 3 | |||||||
30 | 22 | DIAG-CLSTR-ERROR-2-1 | 3 | |||||||
31 | 23 | PROVIDER-TYPE-2 | 2 | ENUM (01, 02, 10, 20, Blank Space) | HOSPITAL IP PRINCIPAL = 01 HOSPITAL IP OTHER = 02 HOSPITAL OP = 10 PHYSICIAN = 20 Blank if no data | If DIAGNOSIS-CODE-2 is not blank; FROM-DATE-2 & PROVIDER-TYPE-2 should be also not blank | ||||
32 | 24 | FROM-DATE-2 | 8 | CCYYMMDD or Blank Space | ||||||
33 | 25 | THRU-DATE-2 | 8 | CCYYMMDD or Blank Space | ||||||
34 | 26 | DELETE-IND-2 | 1 | ENUM ('D', Blank space) | ||||||
35 | 27 | DIAGNOSIS-CODE-2 | 7 | ICD10CM or Blank Space | ||||||
36 | 28 | DIAG-CLSTR-ERROR-1-2 | 3 | |||||||
37 | 29 | DIAG-CLSTR-ERROR-2-2 | 3 | |||||||
38 | 30 | PROVIDER-TYPE-3 | 2 | ENUM (01, 02, 10, 20, Blank Space) | HOSPITAL IP PRINCIPAL = 01 HOSPITAL IP OTHER = 02 HOSPITAL OP = 10 PHYSICIAN = 20 Blank if no data | If DIAGNOSIS-CODE-3 is not blank; FROM-DATE-3 & PROVIDER-TYPE-3 should be also not blank | ||||
39 | 31 | FROM-DATE-3 | 8 | CCYYMMDD or Blank Space | ||||||
40 | 32 | THRU-DATE-3 | 8 | CCYYMMDD or Blank Space | ||||||
41 | 33 | DELETE-IND-3 | 1 | ENUM ('D', Blank space) | ||||||
42 | 34 | DIAGNOSIS-CODE-3 | 7 | ICD10CM or Blank Space | ||||||
43 | 35 | DIAG-CLSTR-ERROR-1-3 | 3 | |||||||
44 | 36 | DIAG-CLSTR-ERROR-2-3 | 3 | |||||||
45 | 37 | PROVIDER-TYPE-4 | 2 | ENUM (01, 02, 10, 20, Blank Space) | HOSPITAL IP PRINCIPAL = 01 HOSPITAL IP OTHER = 02 HOSPITAL OP = 10 PHYSICIAN = 20 Blank if no data | If DIAGNOSIS-CODE-4 is not blank; FROM-DATE-4 & PROVIDER-TYPE-4 should be also not blank | ||||
46 | 38 | FROM-DATE-4 | 8 | CCYYMMDD or Blank Space | ||||||
47 | 39 | THRU-DATE-4 | 8 | CCYYMMDD or Blank Space | ||||||
48 | 40 | DELETE-IND-4 | 1 | ENUM ('D', Blank space) | ||||||
49 | 41 | DIAGNOSIS-CODE-4 | 7 | ICD10CM or Blank Space | ||||||
50 | 42 | DIAG-CLSTR-ERROR-1-4 | 3 | |||||||
51 | 43 | DIAG-CLSTR-ERROR-2-4 | 3 | |||||||
52 | 44 | PROVIDER-TYPE-5 | 2 | ENUM (01, 02, 10, 20, Blank Space) | HOSPITAL IP PRINCIPAL = 01 HOSPITAL IP OTHER = 02 HOSPITAL OP = 10 PHYSICIAN = 20 Blank if no data | If DIAGNOSIS-CODE-5 is not blank; FROM-DATE-5 & PROVIDER-TYPE-5 should be also not blank | ||||
53 | 45 | FROM-DATE-5 | 8 | CCYYMMDD or Blank Space | ||||||
54 | 46 | THRU-DATE-5 | 8 | CCYYMMDD or Blank Space | ||||||
55 | 47 | DELETE-IND-5 | 1 | ENUM ('D', Blank space) | ||||||
56 | 48 | DIAGNOSIS-CODE-5 | 7 | ICD10CM or Blank Space | ||||||
57 | 49 | DIAG-CLSTR-ERROR-1-5 | 3 | |||||||
58 | 50 | DIAG-CLSTR-ERROR-2-5 | 3 | |||||||
59 | 51 | PROVIDER-TYPE-6 | 2 | ENUM (01, 02, 10, 20, Blank Space) | HOSPITAL IP PRINCIPAL = 01 HOSPITAL IP OTHER = 02 HOSPITAL OP = 10 PHYSICIAN = 20 | If DIAGNOSIS-CODE-6 is not blank; FROM-DATE-6 & PROVIDER-TYPE-6 should be also not blank | ||||
60 | 52 | FROM-DATE-6 | 8 | CCYYMMDD or Blank Space | ||||||
61 | 53 | THRU-DATE-6 | 8 | CCYYMMDD or Blank Space | ||||||
62 | 54 | DELETE-IND-6 | 1 | ENUM ('D', Blank space) | ||||||
63 | 55 | DIAGNOSIS-CODE-6 | 7 | ICD10CM or Blank Space | ||||||
64 | 56 | DIAG-CLSTR-ERROR-1-6 | 3 | |||||||
65 | 57 | DIAG-CLSTR-ERROR-2-6 | 3 | |||||||
66 | 58 | PROVIDER-TYPE-7 | 2 | ENUM (01, 02, 10, 20, Blank Space) | HOSPITAL IP PRINCIPAL = 01 HOSPITAL IP OTHER = 02 HOSPITAL OP = 10 PHYSICIAN = 20 Blank if no data | If DIAGNOSIS-CODE-7 is not blank; FROM-DATE-7 & PROVIDER-TYPE-7 should be also not blank | ||||
67 | 59 | FROM-DATE-7 | 8 | CCYYMMDD or Blank Space | ||||||
68 | 60 | THRU-DATE-7 | 8 | CCYYMMDD or Blank Space | ||||||
69 | 61 | DELETE-IND-7 | 1 | ENUM ('D', Blank space) | ||||||
70 | 62 | DIAGNOSIS-CODE-7 | 7 | ICD10CM or Blank Space | ||||||
71 | 63 | DIAG-CLSTR-ERROR-1-7 | 3 | |||||||
72 | 64 | DIAG-CLSTR-ERROR-2-7 | 3 | |||||||
73 | 65 | PROVIDER-TYPE-8 | 2 | ENUM (01, 02, 10, 20, Blank Space) | HOSPITAL IP PRINCIPAL = 01 HOSPITAL IP OTHER = 02 HOSPITAL OP = 10 PHYSICIAN = 20 | If DIAGNOSIS-CODE-8 is not blank; FROM-DATE-8 & PROVIDER-TYPE-8 should be also not blank | ||||
74 | 66 | FROM-DATE-8 | 8 | CCYYMMDD or Blank Space | ||||||
75 | 67 | THRU-DATE-8 | 8 | CCYYMMDD or Blank Space | ||||||
76 | 68 | DELETE-IND-8 | 1 | ENUM ('D', Blank space) | ||||||
77 | 69 | DIAGNOSIS-CODE-8 | 7 | ICD10CM or Blank Space | ||||||
78 | 70 | DIAG-CLSTR-ERROR-1-8 | 3 | |||||||
79 | 71 | DIAG-CLSTR-ERROR-2-8 | 3 | |||||||
80 | 72 | PROVIDER-TYPE-9 | 2 | ENUM (01, 02, 10, 20, Blank Space) | HOSPITAL IP PRINCIPAL = 01 HOSPITAL IP OTHER = 02 HOSPITAL OP = 10 PHYSICIAN = 20 Blank if no data | If DIAGNOSIS-CODE-9 is not blank; FROM-DATE-9 & PROVIDER-TYPE-9 should be also not blank | ||||
81 | 73 | FROM-DATE-9 | 8 | CCYYMMDD or Blank Space | ||||||
82 | 74 | THRU-DATE-9 | 8 | CCYYMMDD or Blank Space | ||||||
83 | 75 | DELETE-IND-9 | 1 | ENUM ('D', Blank space) | ||||||
84 | 76 | DIAGNOSIS-CODE-9 | 7 | ICD10CM or Blank Space | ||||||
85 | 77 | DIAG-CLSTR-ERROR-1-9 | 3 | |||||||
86 | 78 | DIAG-CLSTR-ERROR-2-9 | 3 | |||||||
87 | 79 | CORRECTED-HIC-NO | 25 | |||||||
88 | 80 | FILLER | 75 | SPACES | Must be populated with 75 spaces. The “Filler” field allows for additional fields in the future. | |||||