200x Filetype XLS File size 0.07 MB Source: resdac.umn.edu
Sheet 1: Contact_Request Info
Specification Worksheet 01/2016 |
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State Programs | ||||||||||||||
ResDAC TA: | ||||||||||||||
REQUESTER (Name/Org): | ||||||||||||||
STUDY/PROJECT INFORMATION | ||||||||||||||
Date: | Insert today's date | |||||||||||||
Project/Study Name: | Insert Study Name: | |||||||||||||
DUA: | Insert DUA number: | |||||||||||||
Data Extract Specification: | List all applicable state(s): | |||||||||||||
Select Years (X) | Select Population | |||||||||||||
CLAIMS/ASSESSMENTS/EVENTS | 2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 | Qtrly 2015 |
State Segment (for state[s] listed above) |
5% National Sample (X) | ||||
Inpatient | ||||||||||||||
Outpatient | ||||||||||||||
SNF | ||||||||||||||
Hospice | ||||||||||||||
Home Health | ||||||||||||||
Carrier | ||||||||||||||
DMERC | ||||||||||||||
Medicare Medicaid Linked Enrollee Analytic Data Source (MMLEADS) | ||||||||||||||
MedPAR (ss/ls/snf) | ||||||||||||||
MDS Assessment | ||||||||||||||
OASIS Assessment | ||||||||||||||
IRF-PAI Assessment | ||||||||||||||
Swing Bed Assessment | ||||||||||||||
Part D Event* | ||||||||||||||
Part D Plan Bridge File** | ||||||||||||||
*If requesting Part D Event, please fill out the Part D Variables tab in this document | ||||||||||||||
*Part D Event files (includes Part D Drug Characteristics) are available as annual files only. | ||||||||||||||
*Pharmacy, Plan and Formulary Characteristics are included with Part D Event order. | ||||||||||||||
**States with previously requested Part D Enrollment, PDE and/or Plan Characteristics files are now able to obtain a CY2013 Plan Bridge File containing | ||||||||||||||
CY2006-2012 encrypted Plan ID's to unencrypted Plan ID's crosswalk. | ||||||||||||||
Beginning with 2014 PDE data, the CCW Pharmacy ID will be changing to the NCPDP ID | ||||||||||||||
Select Years (X) | Select Population | |||||||||||||
ENROLLMENT/SUMMARY FILES | 2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 | 2015 |
State Segment (for state[s] listed above) | 5% National Sample (X) | ||||
Master Beneficiary Summary File (A/B) | ||||||||||||||
Master Beneficiary Summary File (D) | ||||||||||||||
Part D Plan Bridge File* | ||||||||||||||
Master Beneficiary Summary File Chronic Conditions | ||||||||||||||
Master Beneficiary Summary File Cost and Use | ||||||||||||||
*States with previously requested Part D Enrollment, PDE and/or Plan Characteristics files are now able to obtain a CY2013 Plan Bridge File containing | ||||||||||||||
CY2006-2012 encrypted Plan ID's to unencrypted Plan ID's crosswalk. | ||||||||||||||
CROSSWALKS | ||||||||||||||
Identifier Crosswalk CCW BENE ID to HIC | ||||||||||||||
Identifier Crosswalk CCW BENE ID to SSN | ||||||||||||||
Identifier Crosswalk Buccaneer BENE ID to NAME (if approved by CMS to receive Names) | ||||||||||||||
Identifier Crosswalk CCW BENE_ID to MSIS_ID / STATE_CD | ||||||||||||||
Identifier Crosswalk CCW BENE_ID to RES_ID | ||||||||||||||
ADDITIONAL COMMENTS | ||||||||||||||
RIF data files will be delivered in a fixed column format with SAS programs (for SAS users) and FTS files (for non-SAS users). | ||||||||||||||
REQUESTER INFORMATION | ||||||||||||||
(1) Project Contact (person who will be responsible for operational and acquisition questions about the data) | ||||||||||||||
Name: | ||||||||||||||
Organization: | ||||||||||||||
Address: | ||||||||||||||
City: | State: | Zip Code: | ||||||||||||
Telephone: | Email: | |||||||||||||
(2) User (person who signed DUA #16) | ||||||||||||||
Name: | ||||||||||||||
Organization: | ||||||||||||||
Address: | ||||||||||||||
City: | State: | Zip Code: | ||||||||||||
Telephone: | Email: | |||||||||||||
(3) Custodian (person who signed DUA #17) | ||||||||||||||
Name: | ||||||||||||||
Organization: | ||||||||||||||
Address: | ||||||||||||||
City: | State: | Zip Code: | ||||||||||||
Telephone: | Email: | |||||||||||||
DELIVERY OPTIONS - Shipment via Courier Service | ||||||||||||||
Courier Service: | ||||||||||||||
Courier Service Account Number: | ||||||||||||||
Special Instructions if applicable: | ||||||||||||||
Ship Data To (X) : | Project Contact | User | Custodian | |||||||||||
OPERATING SYSTEM | ||||||||||||||
Windows (Windows 2000 or higher) | X |
PDE Variable Justification | ||||
Current Version: V3.0 - 12/2015 | ||||
This justification worksheet only needs to be completed if requesting Part D Event (PDE) data | ||||
'X' to request | PDE Variable | Reason for Requesting PDE Element (In a few sentences, provide detailed justification for each element.) |
Risk of not receiving element (high, medium, low) If risk is high or medium, please provide explanation. |
CCW / ResDAC Notes |
General Variables | ||||
X [Automatically included with PDE data] |
Encrypted Part D Event ID | Unique key for each Part D event | Not applicable | Needed to link to the Drug characteristics file |
X [Automatically included with PDE data] |
Encrypted CCW Beneficiary ID | Need for linking | Not applicable | Needed for linking to other files |
Phase 1 and Demographic Variables | ||||
Patient Date of Birth (DOB) | Not edited - Recommend using Beneficiary Summary file | |||
Patient Gender | Not edited - Recommend using Beneficiary Summary file | |||
RX Service Date | ||||
Quantity Dispensed | ||||
Product/Service Identifier | ||||
Days Supply | ||||
Patient Pay Amount | ||||
Gross Drug Cost (sum of Ingredient Cost Paid, Dispensing Fee Paid, Total Amount Attributed to Sales Tax) | ||||
Patient Residence Code | New variable for 2013 PDE extracts and forward. | |||
Submission Clarification Code | New variable for 2013 PDE extracts and forward. | |||
Drug Coverage Status Code | ||||
The Brand-Generic Code reported by the submitting plan | New variable for 2012 PDE extracts and forward. | |||
Dispensing Variables | ||||
Compound Code | ||||
Dispense as Written/Product Selection Code | ||||
Dispensing Status | This field will be blank starting with January 2011 service dates. | |||
Fill Number | Limitations: Fill Number is not edited across pharmacies. For example, Fill Number resets to 0 if a new pharmacy fills the prescription or if a "new" prescription for the same drug is filled more than once. This variable is supplied by the pharmacy. | |||
Adjustment/Deletion Code | ||||
Non-Standard Format Code | ||||
RX Pricing Exception Code | ||||
Prescription/Service Reference Number | ||||
Pharmacy Service Type Code | New variable for 2013 PDE extracts and forward. | |||
Prescription Origin Code | A code indicating the origin of the prescription. | |||
Payment Variables | ||||
Gross Drug Cost Below Out of-Pocket Threshold (GDCB) | ||||
Gross Drug Cost Above Out-of-Pocket Threshold (GDCA) | ||||
Other True Out-of-Pocket (TrOOP) Amount | ||||
Low-Income Cost-Sharing Subsidy Amount (LICS) | ||||
Patient Liability Reduction due to Other Payer Amount (PLRO) | ||||
Covered D Plan Paid Amount (CPP) | ||||
Non-covered Plan Paid Amount (NPP) | ||||
Gap Discount Amount reported by the Submitting Plan | New variable for 2012 PDE extracts and forward. | |||
Paid Date | ||||
Catastrophic Coverage Code | This field is optional for PDEs with January 2011 Service Dates going forward. | |||
Benefit Phase | ||||
UM variables (2006-2009 only) | ||||
Drug Tier | This variable is valid from 2006-2009. Starting in 2010, it is included in the formulary file. | |||
Prior Authorization | This variable is valid from 2006-2009. Starting in 2010, it is included in the formulary file. | |||
Quantity Limits | This variable is valid from 2006-2009. Starting in 2010, it is included in the formulary file. | |||
Maximum Step Number | This variable is valid from 2006-2009. Starting in 2010, it is included in the formulary file. | |||
Identification / Characteristics Linkage Variables | ||||
X [Automatically included with PDE data] |
CCW Pharmacy ID / NCPDP ID | Not applicable | Needed to link to the CCW Pharmacy characteristics file. The Pharmacy linking variable switched from CCW Pharmacy ID to NCPDP ID in 2014. |
|
X [Automatically included with PDE data] |
Prescriber ID | Not applicable | Prescriber identification variable newly released for 2013 and are available historically to 2006. Delivered together with Prescriber ID Qualifier Code. | |
X [Automatically included with PDE data] |
Prescriber ID Qualifier Code | Not applicable | Prescriber identification variable newly released for 2013 and are available historically to 2006. Delivered together with Prescriber ID. | |
X [Automatically included with PDE data] |
Formulary ID | Not applicable | ID assigned to each newly created formulary. Needed to link to the Formulary file | |
X [Automatically included with PDE data] |
CCW Formulary RX ID | Not applicable | A CCW identifier for a drug product found in a Part D prescription drug plan formulary. Needed to link to the Formulary file | |
X [Automatically included with PDE data] |
Plan Contract ID | Not applicable | Needed to link to the Plan characteristics file | |
X [Automatically included with PDE data] |
Plan Benefit Package ID | Not applicable | Needed to link to the Plan characteristics file |
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