Information Flyer Template Free 6563 | Specifications Worksheet State 24

Partial file snippet.

Sheet 1: Contact_Request Info

	
	
	
	
	
	
	
	
	
	
	
		Specification Worksheet 
11/2020                                                       
		
	
		State Programs
		
	
		ResDAC TA:
		

		
	
		Requester (Name/Org): 
		

		
	
		   STUDY / PROJECT INFORMATION 
		
	
		Date:
		

		
	
		Project/Study Name: 
		

		
	
		DUA: 
		

		
	
		State(s):
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		
	
		

		

		Select Files (X)
		

		

		

		

		Select Population (X)
		
	
		

		

		

		2009
		2010
		2011
		2012
		2013
		2014
		2015
		2016
		2017
		2018
		2019
		Qtrly* 2020
		State Segment 
		5% National Sample
	
	
		

		

		      Enrollment Data
		
	
		

		

		

		Master Beneficiary Summary File (A/B/C/D)
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		Master Beneficiary Summary File Chronic Conditions
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		Master Beneficiary Summary File Cost & Use
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		Master Beneficiary Summary File Other Conditions
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		Plan Characteristics
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		     Fee for Service Claims
		
	
		

		

		

		Inpatient
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		Outpatient
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		SNF
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		Hospice
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		Home Health
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		Carrier
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		DMERC
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		     *Quarterly data is available on a six month lag.  i.e. Q1 data is available in October of the same year.
     *2020 claims are not considered fully mature and will continue to be updated for 13 months.
		
	
		

		

		     Encounter Claims
		
	
		

		

		

		Inpatient
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		Outpatient
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		SNF
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		Home Health
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		Carrier
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		DMERC
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		     Part D Event
		
	
		

		

		

		Part D Event***
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		   Drug Characteristics
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		   Prescriber Characteristics
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		   Pharmacy Characteristics
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		   Plan Characteristics
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		   Formulary Characteristics
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		     ***If requesting Part D Event data, please fill out the Part D Variables tab in this document
		
	
		

		

		     ***Beginning with 2014 PDE data, the CCW Pharmacy ID has changed to the NCPDP ID, and States are now eligible to request the Prescriber Characteristics file
		
	
		

		

		     Assessments
		
	
		

		

		

		MDS Assessment
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		OASIS Assessment
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		IRF-PAI Assessment
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		Swing Bed Assessment
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		     Other Files
		
	
		

		

		

		MMLEADS - Medicare Medicaid Linked Enrollee Analytic Data Source 
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		MedPAR (ss/ls/snf)
		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		     Crosswalks (Available for State Segment Only)
		
	
		

		

		

		Identifier Crosswalk CCW BENE_ID to HIC 
		
	
		

		

		

		Identifier Crosswalk CCW BENE_ID to SSN
		
	
		

		

		

		Identifier Crosswalk CCW BENE_ID to NAME
		
	
		

		

		

		Identifier Crosswalk CCW BENE_ID to MSIS_ID / STATE_CD
		
	
		

		

		

		Identifier Crosswalk CCW BENE_ID to RES_ID
		
	
		

		

		

		Identifier Crosswalk CCW BENE_ID to MBI 
		
	
		

		

		     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 Account Number:
		

		

		

		

		

		

		

		

		

		

		

	
	
		Special Instructions:
		

		
	
		Ship Data To (X) :
		→
		

		Project Contact
		

		

		User
		

		Custodian
		
	
		OPERATING SYSTEM
		
	
		Windows 2000 or higher
		X
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		.
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	



Sheet 2: Part D Variables

	
	
	
	
	
	
		PDE Variable Justification
		
	
		Current Version:  3/2019
		
	
		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 submitting plan
		

		

		New variable for 2012 PDE extracts and forward. 
	
	
		Dispensing Variables
		
	
		

		Compound Code
		

		

		

	
	
		

		Dispense as Written/Product Selection Code
		

		

		

	
	
		

		Dispensing Status Code
		

		

		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
		

		

		

	
	
		

		RX / 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
		

		

		Field is optional for PDEs w/ Jan 2011 Service Dates going forward.
	
	
		

		Benefit Phase
		

		

		

	
	
		UM variables (2006-2009 only)
		
	
		

		Drug Tier
		

		

		Variable valid 2006-2009.  Starting in 2010, it is included in the formulary file.
	
	
		

		Prior Authorization
		

		

		Variable valid 2006-2009.  Starting in 2010, it is included in the formulary file.
	
	
		

		Quantity Limits
		

		

		Variable valid 2006-2009.  Starting in 2010, it is included in the formulary file.
	
	
		

		Maximum Step Number
		

		

		Variable valid 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  (2006-2013) / 
NCPDP ID  (2014 →)
		

		Not applicable
		Needed to link to CCW Pharmacy characteristics file.  Pharmacy linking variable switched from CCW Pharmacy ID to NCPDP ID in 2014.

	
	
		X      [Automatically included with PDE data]
		Prescriber ID (unencrypted)
		

		Not applicable
		Prescriber identification variable newly released for 2013 and available historically to 2006.  Delivered 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 available historically to 2006.  Delivered 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 of Record ID
		

		Not applicable
		Needed to link to the Plan characteristics file
	
	
		X      [Automatically included with PDE data]
		Plan Benefit Package of Record ID
		

		Not applicable
		Needed to link to the Plan characteristics file

The words contained in this file might help you see if this file matches what you are looking for:

...Sheet contact request info specification worksheet state programs resdac ta requester nameorg study project information date projectstudy name dua s select files x population qtrly segment national sample enrollment data master beneficiary summary file abcd chronic conditions cost amp use other plan characteristics fee for service claims inpatient outpatient snf hospice home health carrier dmerc quarterly is available on a six month lag ie q in october of the same year are not considered fully mature and will continue to be updated months encounter part d event drug prescriber pharmacy formulary if requesting please fill out variables tab this document beginning with pde ccw id has changed ncpdp states now eligible assessments mds assessment oasis irfpai swing bed mmleads medicare medicaid linked enrollee analytic source medpar sslssnf crosswalks only identifier crosswalk bene hic ssn msis cd res mbi additional comments rif delivered fixed column format sas users fts nonsas person who ...

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PDE Variable Justification
Current Version: 3/2019
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 submitting plan			New variable for 2012 PDE extracts and forward.
Dispensing Variables
	Compound Code
	Dispense as Written/Product Selection Code
	Dispensing Status Code			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
	RX / 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			Field is optional for PDEs w/ Jan 2011 Service Dates going forward.
	Benefit Phase
UM variables (2006-2009 only)
	Drug Tier			Variable valid 2006-2009. Starting in 2010, it is included in the formulary file.
	Prior Authorization			Variable valid 2006-2009. Starting in 2010, it is included in the formulary file.
	Quantity Limits			Variable valid 2006-2009. Starting in 2010, it is included in the formulary file.
	Maximum Step Number			Variable valid 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 (2006-2013) / NCPDP ID (2014 →)		Not applicable	Needed to link to CCW Pharmacy characteristics file. Pharmacy linking variable switched from CCW Pharmacy ID to NCPDP ID in 2014.
X [Automatically included with PDE data]	Prescriber ID (unencrypted)		Not applicable	Prescriber identification variable newly released for 2013 and available historically to 2006. Delivered 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 available historically to 2006. Delivered 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 of Record ID		Not applicable	Needed to link to the Plan characteristics file
X [Automatically included with PDE data]	Plan Benefit Package of Record ID		Not applicable	Needed to link to the Plan characteristics file

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