Mercy Maricopa Demographic Data Element & Submittal File Notes

Transcription

1 Mercy Maricopa Demographic Data Element & Submittal File Notes This documents reflects the fields, conditions, values, and validations for demographics submitted 7/01/016 and later ( 8.1) File name: udemogxxxxxx.dayyyymmdd.nn (XXXXXX=Provider Site AHCCCS ID, yyyymmdd=date and nn=sequence Number) File name example: udemog13456.da For TEST files: add 'TEST' to the end of the file name. This will allow the file to be intercepted before processing. Files will be rejected that do not comply with the naming convention or have a duplicate name to a previously received file. Place a carriage-return (C) and line-feed (LF) after the last byte of every record The file is a pipe-delimited with "trimmed" data meaning spaces are not required between pipes for optional fields or to pad data to ensure fields align properly. Validation rules and error messages are identfied for each field/field grouping Header ecord Notes Pipe ( ) delimited file layout, 10 fields, 11 pipes All fields including those related to certification of the file are mandatory The submittal date field is used to evaluate date fields in the demographic detail for future dates Layout Example: H 37 DEMOG PAT DOE TOMYKNOWLEDGEINFOMATIONANDBELIEFTHEDATAINTHISFILEISACCUATECOMPLETEANDTUE PDOE@YOUDOMAIN.COM Detail ecord Notes Pipe ( ) delimited file layout, 88 fields, 89 pipes All s must be capitalized (UPPE CASE) efer to the 'Valid Values' tab and ADHS/DBHS v8 ( for a detailed listing of field values Values are required in most fields (refer to specific field rules). In cases where a value is not required, and a value is not supplied, the field value must be blank, i.e., no spaces are entered between the field delimiter pipes (ex: Value Value ). Change transaction (eason for Submission value 3): Mercy Maricopa does not accept a type 3 transaction. Correction transaction (eason for Submission value 9): Mercy Maricopa does not accept a type 3 transaction. Crisis transactions (eason for Submission value 5 & 6): Crisis transactions are obsolete beginning with 8.1 (July 016). Valid Mental Health and Physical Health Code values, allowable field usage, and corresponding validation rules all vary based on the demographic effective date in reference to 10/01/015. Mental Health code rules are identified by a red banner (Submitted Effective Date before 10/01/015) or a dark red banner (Submitted Effective Date 10/01/015 or later) and the Physical Health codes are idnetified by a teal banner (Submitted Effective Date before 10/01/015) or a dark teal banner (Submitted Effective Date 10/01/015 or later). Valid Mental Health and Physical Health Code values are defined as values that are acceptable and active as of the submitted effective date of the transaction. On 10/1/016, CMS issued an ICD change that included expiration of 4 MH ICD10 codes and the addition of 13 MH ICD10 codes. Usage of these codes is dependent upon the transaction effective date. Multi-axial Diagnosis Codes (DSM-IV): DSM-IV codes will not be accepted after 9/15/017 due to the -year historical limitation on demographic submissions. Each data field is evaluated. Multiple validation rules may be applied against a single data field to ensure data integrity. Validation rules fall into 1 of 3 levels: 0 (error encountered that prevents parsing or evaluating the transaction), 1 (error encountered that does not prevent parsing, but may adversely affect other field validations) & (error encountered but does not affect other field validations). 0: A critical error that prevents the transaction from parsing or will adversely affect field validation. The incorrect number of fields or invalid record length will result in this level of error. Additionally, a missing CISID or an invalid CISID length will result in a 0 error because Mercy Maricopa will not be able to link the transaction to the correct member episode. The transaction is rejected and no other validation rules applied. 1 As of 5/9/017

2 Mercy Maricopa Demographic Data Element & Submittal File Notes 1: A critical error that prevents accurate validation of other data fields. All 1 validation rules will be applied and must be satisfied before rules are applied. Generally, 1 rules are date relationship rules or field values necessary for other validation rules. ules are applied according to the order specified in the rule order column. If a 1 error is encountered, it will be logged and identified in the response file. : ules identified as a rule are not critical and have no affect on accurately processing additional rules. ules are applied according to the order specified in the rule order column. If a error is encountered, it will be logged and identified to the provider, and the next rule will be applied. All rules will be applied to a transaction if no 1 errors were not encountered. LAYOUT EXAMPLE: D A N N N N Y Y V 00 N X N X N X N 1 4 X X N F10.1 F95. F10.1 NONE NONE NONE NONE NONE NONE NONE NONE NONE NONE NONE NONE NONE W56.4XA NONE NONE NONE NONE NONE NONE NONE NONE NONE NONE NONE NONE NONE NONE G XX ABCDE NOTE: Field Numbers are for reference only and reflect the order in which fields must occur in the record. As of 5/9/017

3 Mercy Maricopa Demographics Data Elements - HEADE (Batch Submission only) Field Number Description / Comment Values Example Data Validation ule Message Must contain a value of 'H' Header ecord not identified 1 ecord Type Distinguishes header from detail records "H" H Must be first record in file Header record must be the first record in file Only one record in file can be identified as a header record ('H') Only one header record is allowed per batch submission BHA-ID Char Identifies BHA to which the file is sent (37 = ) Must contain a value of '37' Invalid BHA Value supplied for Mercy Maricopa 3 File Name/Contents Char 5 File contents / name DEMOG DEMOG Value must exist File Content value missing 4 Submittal ecord Count Numeric 8 Count of detail records submitted in the file (does not include the header record) Numeric Value 14 Must be Numeric Must match detail record count Non- value supplied Submitted record count does not match detail record count 5 Submittal Date Char 8 Date file was produced for submission Date in the Date must be less than or equal to process date (sysdate) Submittal date cannot be a future date 6 Submittal Time Char 6 Time file was produced for submission HHMMSS, using a 4-hour clock Value must exist Submittal Time is missing 7 Submitter Contact Name Char 60 Name of the person who certifies the file Must be a valid first and last name PAT DOE Value must exist Submitter Contact Name is missing TOMYKNOWLEDGEINFOMATIONANDBELIEF TOMYKNOWLEDGEINFOMATIONANDBELIEFT 8 File Certification Char 80 Attestation statement THEDATAINTHISFILEISACCUATECOMPLETEAN HEDATAINTHISFILEISACCUATECOMPLETEAND Value must exist File Content value missing DTUE TUE 9 Submitter Char 50 address of the person who certifies the file compliant with BBA specifications Must be a valid address PDOE@YOUDOMAIN.COM Value must exist Submitter is missing 10 Submitter Telephone Number Char 0 Telephone number of the person certifying the file Standard telephone number. Must be a valid phone number that can be used to reach the submitter Value must exist Submitter Tele Nbr is missing 3 As of 5/9/017

4 1 1 ecord-type Distinguishes header from detail records 1 4 Validation ule "D" "D" Must contain a value of 'D' F ecord type is invalid Message Code Cannot be a match to a previously submitted transaction that is still pending processing for the same EOC Provider. 0 Duplicate Submission - Previous Submission Pending for the same EOC Provider DG Cannot be a match to a previously accepted transaction for the same EOC Provider. 0 Duplicate Submission - Previous Submission Accepted for the same EOC Provider DG eason-for- Submission (Trans code) eason for submission () Type 3 Submission not allowed 0 Type 9 Submission not allowed 0 Valid values ('1' or '' or '4' or '9') Transaction Type 5 & 6 not allowed Cannot be submitted if current/existing EOC (type 1) is open with same submitting EOC Provider. Cannot be submitted if EOC does not exist or existing EOC is closed (for Type ) Cannot be submitted if EOC does not exist or existing EOC is closed (for Type 4) Type 3 demographics are currently not allowed for submission Type 9 demographics are currently not allowed for submission DG DG Invalid Transactions submitted DG Open EOC already exists for this EOC Provider DG Transaction must be submitted on open EOC - EOC does not exist or is closed Transaction must be submitted on open EOC - EOC does not exist or is closed DG DG & 4 4 & 5 Client-ID/AHCCCS- ID Char N/A Client-ID/AHCCCS-ID Ten (10) digit CIS number and/or Nine (9) digit AHCCCS ID (A or S ID) At least one ID field must be poplated. 1 Client-ID and AHCCCS-ID are missing DG Ten (10) digit 3 4 Client- ID 0 Member CIS ID CIS number 4 5 AHCCCS-ID Char 9 Member AHCCCS or NT AHCCCS ID Nine (9) digit AHCCCS or NT AHCCCS ID (A or S ID) S13131 Client-ID must be a valid 1 Client-ID must be a valid DG Must match DBHS Client ID (state roster) 1 Client-ID does not match roster DG Cannot be duplicated elsewhere in batch 0 Client ID duplicated in input file DG AHCCCS or NT AHCCCS ID must be valid if exists (Begin with 'A' or 'S' and length=9) 1 AHCCCS-ID is invalid DG Must match DBHS Client ID (state roster) 1 AHCCCS-ID does not match roster DG Cannot be duplicated elsewhere in batch 0 AHCCCS-ID duplicated in input file DG & 4 4 & 5 Client-ID/AHCCCS- ID Char N/A Client-ID/AHCCCS-ID Ten (10) digit CIS number and/or Nine (9) digit AHCCCS ID (A or S ID) If both Client-ID and AHCCCS-ID are populated, values must point to same client Client-ID and AHCCCS-ID do not point to same client DG As of 5/9/017

5 5 6 Date-of-Birth Date 8 Member date of birth Validation ule Message Code Must be a valid Gregorian Calendar Date 1 Date-of-Birth is missing or invalid DG DOB cannot be a future date DG Must match state roster for given ID in the Client-ID field or AHCCCS-ID field 1 Date-of-Birth does not match roster DG Must be a valid Gregorian Calendar Date 1 EOC-Start-Date is missing or invalid DG EOC-Start-Date Date EOC-Status Char Status of the episode of care 8 9 EOC-End-Date Date eferral-date Date 8 epresents the date the participant begins receiving services epresents the date the participant treatment ends The date when the provider or BHA received a referral for service. A referral includes an oral, written, faxed or electronic request for services made by the client or on the client's behalf Two () digit Must match EOC-Start-Date of accepted trans code 1 (EOC_Final) where submitted ECN_Update = EOC_Final.ECN 1 EOC-Start-Date cannot be a future date DG EOC-Start-Date does not match current EOC DG Value must exist and must be '00' EOC-Status code is Invalid DG Value must exist and be a Valid Value ('00' or '01' or '0' or '03' or '04' or '06' or '07' or '08' or '09' or '77'). Effective-Date will be used to determine valid values against Lookup table. X X An EOC End Date cannot be present for type 1 & transaction types 1 EOC-Status code is Invalid DG EOC End Date must be null for this submission reason DG Must be a valid Gregorian Calendar Date 1 Invalid EOC End Date DG Must be equal to or greater than EOC-Start-Date of accepted trans code 1 (EOC_Final) where submitted ECN_Update = EOC_Final.ECN 1 EOC End Date cannot be future date DG EOC-End-Date is before EOC-Start-Date of type 1 trans DG Must be a valid Gregorian Calendar Date 1 Invalid eferral Date DG eferral-date cannot be a future date DG Must be equal to or less than EOC-Start-Date of submitted value eferral-date cannot be after EOC Start Date DG O O eferral Date values is optional for type & 4 transactions. IF a value is submitted in this field, it Must be a valid Gregorian Calendar Date 1 Invalid eferral Date Format DG eferral-source Char 11 1 Assessment-Date Date 8 Identifies the principal source of referral for a member Date of the most recent complete assessment Two () digit O O Valid Value (see list). Effective-Date will be used to determine valid values against Lookup table. eferral-source invalid or missing DG If value submitted in this field for a trans code or 4, must be a valid value but does not need to match type 1. Submitted eferral-source must be a valid value DG Must be a valid Gregorian Calendar Date 1 Invalid Assessment Date DG Assessment-Date cannot be a future date DG Must be equal to or less than Effective Date Assessment-Date cannot be after the Effective- Date DG Must be within 365-days of Effective-Date Assessment-Date cannot be more than 365 day prior to Effective-Date if less than EOC Start-Date DG As of 5/9/017

6 1 4 Validation ule Must be less than or equal to EOC-End-Date Message Assessment-Date cannot be after the EOC-End- Date Code DG Must be a valid Gregorian Calendar Date 1 Invalid Effective Date DG Effective Date cannot be future date DG Must be greater than or equal to the EOC-Start-Date Effective-Date cannot be before EOC-Start-Date DG Must be less than or equal to EOC-End-Date Effective-Date cannot be after the EOC-End-Date DG Effective-Date Date 8 efers to the effective date of any addition or change to a field Must be less than or equal to Date-of-Death (QNXT) Effective-Date cannot be after the Date-of-Death DG Cannot be greater than 44-days from EOC-Start-Date Must be within 715 days of Submittal Date (Header) Effective-Date cannot be more than 44-days from EOC-Start-Date Effective date cannot be more than 715-days prior to the date of submission DG DG Cannot match the effective date of a previously accepted transaction within the same EOC 0 The submitted effective date matches a previously accepted effective date for this EOC DG Cannot be less than (Before) the latest effective date (MAX) of any accepted transaction within the EOC The submitted closure effective date is earlier than a previously accepted transaction DG OMB-American- Indian OMB (Office of Management and Budget) race category. Is member American Indian or Alaska native? N Must be either 'Y' or 'N' OMB-American-Indian must be a valid value DG OMB-Asian OMB race category. Is client Asian? OMB-Black OMB-Native- Hawaiian OMB race category. Is client Black or African American? OMB race category. Is client native Hawaiian or Pacific Islander? OMB-White OMB race category. Is client white? N Must be either 'Y' or 'N' OMB-Asian must be a valid value DG Y Must be either 'Y' or 'N' OMB-Black must be a valid value DG N Must be either 'Y' or 'N' OMB-Native-Hawaiian must be a valid value DG Y Must be either 'Y' or 'N' OMB-White must be a valid value DG thru thru 18 OMB ace Fields OMB (Office of Management and Budget) race category fields (5 fields) for each field At least one of the five OMB ace fields (American Indian, Asian, Black, Native Hawaiian or White) must be 'Y' At least one OMB ace must be 'Y' DG As of 5/9/017

7 OMB-Hispanic- Latino Treatment- Participation 0 1 Number-of-Arrest Char 1 OA-ADC-Parole 3 OA-ADJC-Parole OA-AOC-Adult- Probation OA-AOC-Juvenile- Probation OMB ethnicity category. Is client Hispanic or Latino? efers to the presence of a court order or conditions of parole/probation pertaining to the delivery of Behavioral Health services Number of times client has been arrested in past 30 days. Is the client, age 18 and older, involved with the Arizona Department of Corrections (ADC) or on parole? Is the client, age 0 thru 17, involved with the Arizona Department of Juvenile Corrections (ADJC)? Is the client, age 18 & older, on adult probation through the Administrative Office of the Courts (AOC)? Is the client, age 0 thru 17, on probation through the County Juvenile Probation Department.? Two () digit 1 4 Validation ule Message Code N Must be either 'Y' or 'N' OMB-Ethnicity must be a valid value DG V Valid Value ('V', or 'C', or 'N') Treatment Participation is invalid DG Must be a value between 00 and 31 (front zero fill if less than 10) Number of Arrests is invalid DG N X Y X Age 0 thru 17, valid value ('X') Age 18 and older, valid value ('Y' or 'N') Age 0 thru 17, valid value ('Y' or 'N') Age 18 and older, valid value ('X') Age 0 thru 17, valid value ('X') Age 18 and older, valid value ('Y' or 'N') Age 0 thru 17, valid value ('Y' or 'N') Age 18 and older, valid value ('X') Adult-Parole value must be 'X' for ages 0-17 DG Adult-Parole value must be 'Y' or 'N' for ages 18 and older Juvenile-Parole value must be 'Y' or 'N' for ages 0-17 Juvenile-Parole value must be 'X' for ages 18 and older DG DG DG Adult-Probation value must be 'X' for ages 0-17 DG Adult-Probation value must be 'Y' or 'N' for ages 18 and older Juvenile-Probation value must be 'Y' or 'N' for ages 0-17 Juvenile-Probation value must be 'X' for ages 18 and older DG DG DG OA-DES-SA Is the client involved with the Department of Economic Security (DES)/ ehabilitative Services Administration (SA)? N Must be either 'Y' or 'N' DES-SA value must be 'Y' or 'N' DG OA-School- Special-Ed 7 8 Education-Status Is the client receiving special education services through an Individualized Education Program (IEP) or accommodations through a 504 Accommodation Plan at his/her school? (Ages 3-1 only) Is the member currently attending a school or vocational progam? N Age 0 thru, valid value ('X') Age 3 thru 1, valid value ('Y' or 'N') Age and older, valid value ('X') School-Special-Ed value must be 'X' for ages or less School-Special-Ed value must be 'X' for ages or less School-Special-Ed value must be 'X' for ages or greater DG DG DG N Must be either 'Y' or 'N' Education-Status must be 'Y' or 'N' DG As of 5/9/017

8 Education-- Completed Employment- Status SP-Pregnancy Char Highest formal education (school level) completed. Two () digit Two () digit Char Client Employment status 4 Char 1 Female Only. Identifies clients who are pregnant or post-partum. X Validation ule Valid Value (see list). Effective-Date will be used to determine valid values against Lookup table. Valid Value (see list). Effective-Date will be used to determine valid values against Lookup table. Code 99 is only valid for ages 0 to 17. Based on gender from state roster If field value = 'F', valid values ('Y' or 'N') Based on gender from state roster If field value = 'M', valid values 'X' Message Code Education mising or an invalid value DG Employment Status must be a valid value for the submitted effective date. DG Employment Status code not valid for age. DG Pregnancy indicator must be 'Y' or 'N' for female gender DG Pregnancy indicator must be 'X' for male gender DG SP-Woman-DC Female Only. Identifies clients who have dependent child(ren). Includes children that have been removed and are in the custody of CPS. X Based on gender from state roster If field value = 'F', valid values ('Y' or 'N') Based on gender from state roster If field value = 'M', valid values 'X' Woman with dependent children indicator must be 'Y' or 'N' for female gender Woman with dependent children indicator must be 'X' for female gender DG DG Social-Supportand-ecovery How often did you/your child participate in any self help or recovery groups (such as Alcoholics Anonymous, Narcotics Anonymous, WAP/WELL, ecovery Center programming, etc.) in the past 30 days? 1 Valid Values are ('1' or '' or '3' or '4' or '5') Social-Support-and-ecovery must be a valid value DG Gender-Identity Char efers to how the client selfidentifies their gender. It is not necessarily based on the person s anatomy. Two () digit 03 Age 0 thru 17, valid value ('98') Age 18 and older, valid value ('01' or '0' or '03' or '04' or '05' or '06' or '97') Gender-Identity must be '98' for ages 0-17 DG Gender-Identity must be a valid value for ages 18 and older DG Sexual- Orientation Char Sexual Orientation Two () digit 04 Age 0 thru 17, valid value ('98') Age 18 and older, valid value ('01' or '0' or '03' or '04' or '05' or '06' or '97') Sexual-Orientation must be '98' for ages 0-17 DG Sexual-Orientation must be a valid value for ages 18 and older DG Military-Status Primary- Is member a current or former member of the U.S. Army, Army eserve/national Guard, U.S. Navy, Navy eserve, U.S. Marine Corps, Marine Corps eserve, U.S. Air Force O are they a military family The place where the client has spend most of his or her time wthin Two () digit F Age 17 and older, Valid Value (see list) other than 'X'. Effective-Date will be used to determine valid values. Ages 0 thru 16, valid value ('X' or 'E'). Effective-Date will be used to determine valid values.' Valid Values are ('01' or '0' or '03' or '04' or '05' or '06' or '07' or '08' or '09' or '1' or '16' or '19' or '' or '3'). Effective-Date will be used to determine valid values against Lookup table. Military-Status must be a valid value other than 'X' for ages 17 and older. Military-Status must be a valid value ('X' or 'E') for ages 0-16 DG DG Primary-esidence code is invalid DG As of 5/9/017

9 36 37 Primary- esidence Char spend most of his or her time wthin the past 30 days prior to intake or any change thereafter Validation ule Value '01', Age 15 and older Value '04' or '05', Age 18 and older Message Primary-esidence submitted value only valid for ages 15 and older Primary-esidence submitted value only valid for ages 18 and older Code DG DG Household-Size Char Number in household including client Two () digit 05 O O O IF Effective-Date field is before 01/05/015, field may be blank. If value submitted, value must be between 01 and 99 (front zero fill if less than 10). IF Effective-Date field is 01/05/015 or later, value required between 01 and 99 (front zero fill if less than 10). Household-Size must be for the submitted effective date Household-Size required for the submitted effective date and must be between 01 and 99 (front zero fill if less than 10) DG DG Household- Income Char 6 Gross Monthly Income of household of the client O O O IF value submitted, must be a value between thru (front zero fill if less than ). Value cannot have non- s such as a leading dash. IF Effective-Date field is before 01/05/015, field may be blank. If value submitted, value must be between thru (front zero fill if less than ) 1 Household-Income value must be DG Household-Income must be thru for the submitted effective date DG For Mental Health Field Evaluation with Effective Date BEFOE 10/1/ thru & 46 4 thru & 47 Principle- Diagnosis ICD-10-cd-1 ICD-10-cd- thru 5 ICD-10-cd-6 & 7 Char 8 Char 8 Char 8 Char 8 Mental Health disorder/condition which is the focus of clinical attention. Mental Health disorder/condition (old DSM-IV, Axis I-I) Mental Health disorder/condition (old DSM-IV, Axis I-II thru V) Mental Health disorder/condition (old DSM-IV, Axis II-I & II) - DSM-IV-T Code - DSM-IV-T Code - DSM-IV-T Code - DSM-IV-T Code IF Effective-Date field is 01/05/015 or later, value required between thru (front zero fill if less than ) Household-Income required for the submitted effective date and must be between thru for the submitted effective date DG Must contain a valid, active DSM-IV code Invalid DSM-IV code DG Must match a diagnosis value from one of the Mental Health-ICD-10 fields 1 thru 7 Principle Diagnosis must match one of the specified Mental Health codes in fields 1 thru 7 DG Must contain a valid, active DSM-IV code and cannot be blank DSM-IV Code not entered in order DG Codes must be entered in order for Mental Health-ICD-10 fields 1 thru 5 (e.g. cannot enter code in fields 1 and 3 and skip ) DSM-IV Code cannot be duplicated DG Value cannot be duplicated among the Mental Health-ICD-10 fields 1 thru 7, unless value = 'NONE' DSM-IV Code cannot be duplicated DG Must contain a valid, active DSM-IV code or a value of 'NONE' Invalid DSM-IV code for Axis_I- thru 5 DG If a value of 'NONE', all remaining fields must have a value of 'NONE' (ICD-10-cd- thru 5) Once a value of 'NONE' has been entered, all remaining fields must have a value of 'NONE' DG Must contain a valid, active DSM-IV code or a value of 'NONE' Invalid DSM-IV code DG If a value of 'NONE', all remaining fields must have a value of 'NONE' (ICD-10-cd-6 thru 7) Must contain a valid value ('0' or '1' or '' or '3' or '4' or '5' or '6' or '7' or '8') (90- days). Effective-Date will be used to determine valid values against Lookup table. Once a value of 'NONE' has been entered, all remaining fields must have a value of 'NONE' DG Invalid AXIS-IV Code DG As of 5/9/017

10 47 & & 49 Mental Health disorder/condition - Char 8 ICD-10-cd-8 & 9 (old DSM-IV, Axis IV-I & II) DSM-IV-T Code 1 4 Validation ule ICD-10-cd-8 value = '0', then ICD-10-cd-9 must = '0' Message Once a value of '0' has been entered, all remaining fields must have a value of '0' Code DG Codes must be entered in order (e.g. cannot enter code in fields 9 and skip 8) Axis-IV Code not entered in order DG Value cannot be duplicated among the Mental Health-ICD-10 fields 8 thru 9, unless value is '0' Axis-IV Code cannot be duplicated DG ICD-10-cd-10 Char 3 Mental Health disorder/condition (old DSM-IV, Axis V) Three (3) digit Must be a value between 000 and 100 (front zero fill if less than 100) AXIS V must be a value between 000 and 100 DG thru thru 55 ICD-10-cd-11 thru 15 Char 8 Mental Health disorder/condition "NONE" Must contain a value of 'NONE' For Mental Health Field Evaluation with Effective Date 10/1/015 and Later Principle- Diagnosis Char 8 Mental Health disorder/condition which is the focus of clinical attention. Valid ICD-10 value,'3-7 in 3.4 (total length = F43.3 Must contain a valid Mental Health ICD 10 value (Cannot be blank) Must match a diagnosis value from one of the Mental Health-ICD-10 fields 1 thru 15 ICD-10-cd-11 thru 15 must be a value of 'NONE' for effective dates prior to 10/1/015 Invalid or missing Mental Health ICD-10 code for Principle Diagnosis Principle Diagnosis must match one of the specified Mental Health-ICD-10 codes in fields 1 thru 15 DG DG DG ICD-10-cd-1 Char 8 Mental Health disorder/condition Valid ICD-10 value,'3-7 in 3.4 (total length = 8) F43.3 Must contain a valid Mental Health ICD 10 value (Cannot be blank) Invalid or missing Mental Health ICD-10 code DG thru thru 55 ICD-10-cd- thru 15 For Physical Health Field Evaluation with Effective Date BEFOE 10/1/ thru 56 thru Physical-Health- Must contain a valid Mental Health ICD 10 value or a value of 'NONE' Invalid or missing Mental Health ICD-10 code DG Valid ICD-10 value,'3-7 Once a value of 'NONE' has been entered, all If a value of 'NONE', all remaining fields must have a value of 'NONE' DG in remaining fields must have a value of 'NONE' Char 8 Mental Health disorder/condition NONE 3.4 Codes must be entered in order (e.g. cannot enter code in fields 1 and 3 and skip (total length = Mental Health ICD-10 code not entered in order DG ). 8) or "NONE" Value cannot be duplicated among the Mental Health-ICD-10 fields 1 thru 15, Duplicate Mental Health ICD-10 code encountered DG unless value = 'NONE' Physical Health disorder/condition -digit Must be a valid -digit Health Condition Code (efer to the valid values list for acceptable values). Effective-Date will be used to determine valid values against Lookup table. If '99' is used, Physical Health Condition-1 to 5 must also be '99'. Invalid Physical Health Code DG Once a value of '99' has been entered, all remaining fields must have a value of '99 DG As of 5/9/017

11 55 thru thru thru thru 70 Physical Health disorder/condition -digit ICD-10-cd-1 thru Char 8 (old multi-axial, Axis III code) 5 Physical-Health- ICD-10-cd-6 thru Validation ule If '00' is used for any Physical Health Condition field, all Physical Health Condition fields after must also be '00'. Codes must be entered in order (e.g. cannot enter code in fields 1 and 3 and skip ). Value cannot be duplicated among the Physical-Health-ICD-10 fields 1 thru 5, unless value is '00' or '99' Char 8 Physical Health disorder/condition NONE NONE Must contain a value of 'NONE' For Physical Health Field Evaluation with Effective Date 10/1/015 and Later Message Once a value of '00' has been entered, all remaining fields must have a value of '00' Code DG Physical Health Codes not entered in order DG Duplicate Physical Health Code encountered DG Physical-Health-ICD-10-cd-6 thru 15 must be a value of 'NONE' for effective dates prior to 10/1/015 DG thru thru 70 Physical-Health- ICD-10-cd-1 thru 15 Valid ICD-10 value,'3-7 Char 8 Physical Health disorder/condition in 3.4 NONE (total length = 8) Must contain a valid ICD 10 value (not Mental Health ) or a value of 'NONE' Invalid Physical-Health-ICD-10 code DG If a value of 'NONE', all remaining fields must have a value of 'NONE' Codes must be entered in order (e.g. cannot enter code in fields 1 and 3 and skip ). Value cannot be duplicated among the Physical-Health-ICD-10 fields 1 thru 15. Once a value of 'NONE' has been entered, all remaining fields must have a value of 'NONE' DG Physical-Health-ICD-10 codes not entered in order DG Duplicate Physical-Health-ICD-10 code encountered DG Behavior-Health- Category Date-of- Treatment-Plan Identifies the behavioral health category on the basis of age, diagnosis and, when applicable, functional status. Date 8 Date of Treatment Plan M Valid Value must exist 1 BHC Missing or invalid DG Ages 0 thru 17, valid value ('C' or 'Z') BHC must be 'C' or 'Z' for ages 0-17 DG Ages 18 and older, valid value ('M' or 'G' or 'S') BHC must be 'M' or 'G' or 'S' for ages 18 and older DG If Behavior-Health-Category = 'S', then one of the ICD10-cd fields 1 BHC value cannot be 'S' if not supported by a valid thru 15 must contain a Mental-Health code from Ad.DIAGCODE table where SMI DX code column SMIInd value is 'Y' DG If Behavior-Health-Category = 'G', then one of the ICD10-cd fields 1 thru 15 must contain a Mental-Health code from Ad.DIAGCODE table where column SAIInd value is 'Y' If Behavior-Health-Category = 'Z', then one of the ICD10-cd fields 1 thru 15 must contain a Mental-Health code from Ad.DIAGCODE table where column SEDInd value is 'Y' BHC value cannot be 'G' if not supported by a valid substance abuse DX code BHC value cannot be 'Z' if not supported by a valid SED DX code DG DG Must be a valid Gregorian Calendar Date 1 Treatment Plan Date is invalid DG Treatment Plan Date cannot be a future date DG Must be equal to or greater than EOC-Start-Date Treatment Plan Date must be equal to or greater than EOC-Start-Date DG Must be equal to or less than Effective-Date Date-of-Treatment-Plan Must be equal to or less than Effective-Date DG As of 5/9/017

12 1 4 Validation ule Must be equal to or less than EOC-End-Date Message Date-of-Treatment-Plan Must be equal to or less than EOC-End-Date Code DG Valid Value ('00' or '01' or '0' or '03' or '04' or '05' or '06' or 'XX'). Effective-Date will be used to determine valid values against Lookup table. CASII-Intensity-Lvl Valid Value ('00' or '01' or '0' or '03' or '04' or '05' or '06' or 'XX') DG CASII-Intensity- Lvl Char It describes an array of services and a level of service intensity rather than a specific treatment setting or program. It does not describe a recommended level of care CASII-Date Date 8 Last CASII Assessment Date Two () digit or blank XX For ages <6, valid value ('XX') For ages >=18, valid value ('XX') For >=6 to <18, valid value ('00' or '01' or '0' or '03' or '04' or '05' or '06' ). Valid Value (see list). Effective-Date will be used to determine valid values against Lookup table. CASII-Intensity-Lvl Based on calculated age (Effective-Date less Date-of-Birth) For ages <6, valid value ('XX') CASII-Intensity-Lvl Based on calculated age (Effective-Date less Date-of-Birth) For ages >=18, valid value ('XX') CASII-Intensity-Lvl Based on calculated age (Effective-Date less Date-of-Birth) For >=6 to <18, valid value ('00' or '01' or '0' or '03' or '04' or '05' or '06' ) DG DG DG Must be a valid Gregorian Calendar Date O Blank Invalid CASII Date DG CASII-Date cannot be a future date DG If value in field CASII-Intensity-Lvl = 'XX', then value must be blank CASII-Date If value in field CASII-Intensity-Lvl = 'XX', then value must be blank DG Must be equal to or greater than EOC-Start-Date CASII-Date Must be equal to or greater than EOC- Start-Date DG If value is less than EOC-Start-Date, value must be within 6-months of Effective- Date CASII-Date If value is less than EOC-Start-Date, value must be within 6-months of Effective-Date DG Must be equal to or less than Effective Date CASII-Date cannot be after the Effective-Date SA-Type-1 Char SA-Freq SA-oute-1 The primary psychoactive substance used. The frequency of use of the current primary substance use. Method through which primary abusive substance was consumed. Four (4) digit 001 Must be equal to or less than EOC-End-Date 4 Must be a valid value ('0001' or '001' or '030' or '0401' or '0501' or '0706' or '090' or '1001' or '101' or '1308' or '1605' or '1703' or '00') If value = '0001' (none), then Behavior-Health-Category cannot be 'G' Must be a valid value ('1' or '' or '3' or '4' or '5' or '6' or '7' or '8') If SA-Type-1 value = '0001' (none), then SA-Freq-1 must be '1' Must be a valid value ('1' or '' or '3' or '4' or '6') If SA-Type-1 value = '0001' (none), then SA-oute-1 must be '6' CASII-Date Must be equal to or less than EOC-End- Date SA-Type 1 Must be a valid value ('0001' or '001' or '030' or '0401' or '0501' or '0706' or '090' or '1001' or '101' or '1308' or '1605' or '1703' or '00') Substance Type must be entered if BHC value is 'G' SA-Freq-1 Must be a valid value ('1' or '' or '3' or '4' or '5' or '6' or '7' or '8') If SA-Type-1 value = '0001' (none), then SA-Freq-1 must be '1' SA-oute-1 Must be a valid value ('1' or '' or '3' or '4' or '6') If SA-Type-1 value = '0001' (none), then SA-oute- 1 must be '6' DG DG DG DG DG DG DG As of 5/9/017

13 77 78 SA-Age-First-Use- 1 Char The client's age at first use of the reported current primary substance use Two () digit Validation ule Must be a valid value '01' thru '99' or '00' (no use) If SA-Type-1 value = '0001', then value must be '00' Must be less than or equal to calculated age. Message SA-Age-1 Must be a valid value '01' thru '99' or '00' (no use) If SA-Type-1 value = '0001', then SA-Age-1 value must be '00' SA-Age-1 must be less than or equal to the calculated age (Effective-Date less Date-of-Birth). Code DG DG DG SA-Type- Char SA-Freq SA-oute SA-Age-First-Use- Char The secondary psychoactive substance used. Secondary substance abuse frequency. Method through which secondary abusive substance was consumed. The client's age at first use of the reported current secondary substance use Four (4) digit Two () digit Must be a valid value ('0001' or '001' or '030' or '0401' or '0501' or '0706' or '090' or '1001' or '101' or '1308' or '1605' or '1703' or '00') If SA-Type-1 value = '0001', then value must be '0001' Value cannot be duplicated among the SA-Type fields 1 thru 3. Must be a valid value ('1' or '' or '3' or '4' or '5' or '6' or '7' or '8') If SA-Type- value = '0001' (none), then SA-Freq-1 must be '1' Must be a valid value ('1' or '' or '3' or '4' or '6') If SA-Type- value = '0001' (none), then SA-oute-1 must be '6' Must be a valid value '01' thru '99' or '00' (no use) If SA-Type- value = '0001', then value must be '00' Must be less than or equal to calculated age. SA-Type Must be a valid value ('0001' or '001' or '030' or '0401' or '0501' or '0706' or '090' or '1001' or '101' or '1308' or '1605' or '1703' or '00') If SA-Type-1 value = '0001', then SA-Type- value must be '0001' SA-Type- Value cannot be duplicated among the SA-Type fields 1 thru 3. SA-Freq- Must be a valid value ('1' or '' or '3' or '4' or '5' or '6' or '7' or '8') If SA-Type- value = '0001' (none), then SA-Freq- must be '1' SA-oute- Must be a valid value ('1' or '' or '3' or '4' or '6') If SA-Type- value = '0001' (none), then SA-oute- must be '6' SA-Age- Must be a valid value '01' thru '99' or '00' (no use) If SA-Type- value = '0001', then SA-Age- value must be '00' SA-Age- Must be less than or equal to calculated age (Effective-Date less Date-of-Birth). DG DG DG DG DG DG DG DG DG DG SA-Type-3 Char SA-Freq-3 The tertiary psychoactive substance used. Tertiary substance abuse frequency. Four (4) digit Must be a valid value ('0001' or '001' or '030' or '0401' or '0501' or '0706' or '090' or '1001' or '101' or '1308' or '1605' or '1703' or '00'). Effective-Date will be used to determine valid values against Lookup table. If SA-Type- value = '0001', then value must be '0001' Value cannot be duplicated among the SA-Type fields 1 thru 3. Must be a valid value ('1' or '' or '3' or '4' or '5' or '6' or '7' or '8') If SA-Type-3 value = '0001' (none), then SA-Freq-1 must be '1' SA-Type 3 Must be a valid value ('0001' or '001' or '030' or '0401' or '0501' or '0706' or '090' or '1001' or '101' or '1308' or '1605' or '1703' or '00') If SA-Type-1 value = '0001', then SA-Type-3 value must be '0001' SA-Type-3 Value cannot be duplicated among the SA-Type fields 1 thru 3. SA-Freq-3 Must be a valid value ('1' or '' or '3' or '4' or '5' or '6' or '7' or '8') If SA-Type-3 value = '0001' (none), then SA-Freq-3 must be '1' DG DG DG DG DG As of 5/9/017

14 84 85 SA-oute SA-Age-First-Use- 3 Char Method through which tertiary abusive substance was consumed. The client's age at first use of the reported current tertiary substance use Two () digit Validation ule Must be a valid value ('1' or '' or '3' or '4' or '6') If SA-Type-3 value = '0001' (none), then SA-oute-1 must be '6' Must be a valid value '01' thru '99' or '00' (no use) If SA-Type-3 value = '0001', then value must be '00' Must be less than or equal to calculated age. Message SA-oute-3 Must be a valid value ('1' or '' or '3' or '4' or '6') If SA-Type-3 value = '0001' (none), then SA-oute- 3 must be '6' SA-Age-3 Must be a valid value '01' thru '99' or '00' (no use) If SA-Type-3 value = '0001', then SA-Age-3 value must be '00' SA-Age-3 Must be less than or equal to calculated age (Effective-Date less Date-of-Birth). Code DG DG DG DG DG Custom-1 (formerly Provider Patient Account ID) 5 Pass-thru field for provider usage. Can be utilized to identify a Provider's unique ID for member (if any). Any up to 3C87D78 15 charcters in O O O gth must be equal to or less than 15 s Value exceeds 15 s in length DG length ECN-Update 5 ECN Update is used to refer to a previously submitted and accepted demographic record The ECN will be provided to the contracted provider in the demographic response files. 15 Digit ECN number Digit ECN number must exist 1 ECN-Update is invalid DG Must match an existing ECN value of a previously accepted record (type 1) where submitted ECN_Update = EOCFinal.ECN and Submitted CISID (or AHCCCS ID) = EOCFinal.Client_ID (AHCCCS_ID) and Submitted EOC-Start-Date = EOCFinal.EOC- Start-Date AND EOC is OPEN ECN-Update does not point to a valid OPEN Initial EOC DG X Must be Blank ECN-Update not valid for trans code 1 or 5 DG Valid value must exist 1 EOC SiteID is missing or not a valid DG N/A Agency-Site- AHCCCS-ID Char 6 The six (6) AHCCCS ID of the agency site completing the assessment and is used when assigning the Primary Provider Service Agency (PPSA) value. s Must be a valid site AHCCCS ID (matches active site value in QNXT) 1 EOC SiteID does not match QNXT Site AHCCCS ID DG Must match AssignedAgencyID of most recent, 'Assigned' entry in AD.PPSAAssignment table WHEE Submitted AgencySiteAHCCCSID = PPSAAssignment.AssignedAgencyID and submitted ECN_Update = PPSAAssignment.ECN and submitted CISID = PPSAAssignment.CID ' cannot be used as a site ID EXCEPT for Mercy Maricopa administrative closure action(s) 1 Submitted EOC SiteID does not match assigned EOC SiteID for the EOC Provider EOC SiteID '999999' can only be used for administrative closures DG DG As of 5/9/017

15 Mercy Maricopa Demographic Data Element Valid Values eference efer to AHCCCS Guides-Manuals-Policies and select Behavioral Health Guides and Manuals for the latest Demographic & Outcome Data Set User Guide () inion and acceptable values 15 As of 5/9/017