Information Flyer Template Free 6564 | Specifications Worksheet State 6

Partial file snippet.

Sheet 1: Contact_Request Info

	
	
	
	
	
	
	
	
	
	
	
	
		Specification Worksheet 
01/2016                                                         
		
	
		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
		

		

		

		

		

		

		

		

	



Sheet 2: Part D Variables

	
	
	
	
	
	
		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

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 studyproject information date insert today s projectstudy name study dua number data extract list all applicable select years x population claimsassessmentsevents qtrly segment for listed above national sample inpatient outpatient snf hospice home health carrier dmerc medicare medicaid linked enrollee analytic source mmleads medpar sslssnf mds assessment oasis irfpai swing bed part d event plan bridge file if requesting please fill out the variables tab in this document files includes drug characteristics are available as annual only pharmacy and formulary included with order states previously requested enrollment pde andor now able to obtain a cy containing encrypted id unencrypted crosswalk beginning ccw will be changing ncpdp enrollmentsummary master beneficiary summary ab chronic conditions cost use crosswalks identifier bene hic ssn buccaneer approved by cms receive names msis cd res addi...

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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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