COVERAGE_4

Description:

The COVERAGE_4 table contains high-level information on both managed care and indemnity coverage records in your system. This table also contains information related to Health Insurance Marketplace and Medicare Advantage coverages.

Primary Key

Column Name	Ordinal Position
CVG_ID	1

Column Information

	Name	Type	Discontinued?
1	CVG_ID	NUMERIC	No
	The unique identifier for the coverage record
2	ALTR_ZIP	VARCHAR	No
	The alternate ZIP code to which claims submitted under this coverage can be sent.
3	ALTR_CVG_COUNTY_C_NAME	VARCHAR	No
	The alternate county to which claims submitted under this coverage can be sent. May contain organization-specific values: Yes
4	ALTR_CVG_COUNTRY_C_NAME	VARCHAR	No
	The alternate country to which claims submitted under this coverage can be sent. May contain organization-specific values: Yes
5	ALTR_CVG_HOUSE_NUM	VARCHAR	No
	The alternate house number to which claims submitted under this coverage can be sent.
6	ALTR_CVG_DISTRICT_C_NAME	VARCHAR	No
	The alternate district to which claims submitted under this coverage can be sent. May contain organization-specific values: Yes
7	ALTR_CVG_PHONE	VARCHAR	No
	The alternate phone number for claims submitted under this coverage.
8	ALTR_CVG_FAX	VARCHAR	No
	The alternate fax number for claims submitted under this coverage.
9	CVG_HEALTH_CENTER_C_NAME	VARCHAR	No
	The category number of the health center for this coverage. May contain organization-specific values: Yes
10	CVG_CREATOR_USER_ID	VARCHAR	No
	The unique ID of the user who created the coverage. This column is frequently used to link to the CLARITY_EMP table.
11	CVG_CREATOR_USER_ID_NAME	VARCHAR	No
	The name of the user record. This name may be hidden.
12	CVG_ISOLATED_YN	VARCHAR	No
	This flag is set if a coverage is isolated with regard to patient data restrictions. Coverages created from isolated patients or isolated guarantors are flagged as isolated coverages May contain organization-specific values: No Category Entries: No Yes Needs review
13	SELF_VERIF_DATE	DATETIME	No
	Stores the last self-verification date. Used by Welcome.
14	CONT_FROM_CVG_ID	NUMERIC	No
	Points to a coverage that is logically the same coverage. This coverage record is continuing from the specified coverage record.
15	HIX_POLICY_ID	VARCHAR	No
	The exchange policy identifier
16	MA_WORKFLOW_STAT_C_NAME	VARCHAR	No
	Keeps track of what state of the workflow the Medicare Advantage process is in. May contain organization-specific values: No Category Entries: Applied Eligibility Request Generated Eligibility Denied Eligibility Confirmed Eligibility Needs Review Segment Change Queued Segment Change Generated Segment Change Error Enrollment Queued Enrollment Generated Enrollment Error Enrollment Confirmed Enrollment Rejected Cancel Enrollment Initiated Cancel Enrollment Queued Cancel Enrollment Generated Cancel Enrollment Error Cancel Enrollment Confirmed Disenrollment Initiated Disenrollment Queued Disenrollment Generated Disenrollment Error Disenrollment Confirmed Cancel Disenrollment Initiated Cancel Disenrollment Queued Cancel Disenrollment Generated Cancel Disenrollment Error Cancel Disenrollment Confirmed
17	NUM_UNCVRD_MO	INTEGER	No
	The incremental number of uncovered months (NUNCMO). This is determined from the later of the prior part D date, last LIS date, or the member's Initial Enrollment Period (IEP) date. To get the total NUNCMO add this amount to the existing NUNCMO.
18	PPO_C_NAME	VARCHAR	No
	This value contains the premium payment option for a Medicare Advantage coverage. The premium payment option indicates whether the beneficiary has elected to withhold Part C and Part D premiums from their Social Security or Railroad Retirement Board (RRB) benefits, and if so, the type of withholding to use. After running deferred conversion 767822, this column will be obsolete. The premium payment option will be available in table MCARE_PREMIUM_PMT_OPT. May contain organization-specific values: No Category Entries: Social Security Benefits Railroad Retirement Board Benefits No Premium Direct Self-Pay
19	PART_D_OPT_OUT_YN	VARCHAR	No
	This flag indicates that the beneficiary does not want Automated Enrollment in a Part D Plan. It applies to Low Income Subsidy beneficiaries who are subject to Automated Enrollment-Facilitated Enrollment into Part D. May contain organization-specific values: No Category Entries: No Yes
20	MMP_OPT_OUT_YN	VARCHAR	No
	This flag indicates the beneficiary does not want passive enrollment into a Medicare and Medicaid Plan (MMP). The category values for this column were already listed for column: PART_D_OPT_OUT_YN
21	ESRD_OVRIDE_YN	VARCHAR	No
	This value indicates whether the End Stage Renal Disease (ESRD) override was used to enroll the beneficiary into a non-Prescription Drug Plan. The category values for this column were already listed for column: PART_D_OPT_OUT_YN
22	CR_CVG_FLG_C_NAME	VARCHAR	No
	This value indicates whether the beneficiary has creditable drug coverage in the period prior to enrollment in this Part D Prescription Plan. It is also used to reset the number of uncovered months to zero due to a new initial enrollment period (IEP) or laboratory information system (LIS) change and to remove resets that were set in error. May contain organization-specific values: No Category Entries: Beneficiary has creditable coverage Beneficiary does not have creditable coverage Accumulated NUNCMO is reset to zero as of the effective date on the transaction Previous reset is removed and total uncovered month accumulation is reinstated Uncovered months reset to zero due to a new IEP Uncovered months reset to zero due to a beneficiary Low Income Cumulative uncovered months reset to zero because beneficiary enrolled in Part D plan and dual eligible
23	EMPR_SUB_ENROLL_YN	VARCHAR	No
	This value indicates that the beneficiary is currently in a plan receiving an employer subsidy, but still wants to enroll in a Part D plan The category values for this column were already listed for column: PART_D_OPT_OUT_YN
24	ELECTION_TYP_C_NAME	VARCHAR	No
	This value tracks the election type associated with the enrollment. The election type is associated with a particular election period, and a particular type might be limited to a certain number of usages per member. This value is only applicable to Medicare Advantage coverages. May contain organization-specific values: No Category Entries: Annual Enrollment Period Medicare Advantage Disenrollment Period Initial Enrollment Period Second Initial Enrollment Period Initial Coverage Election Period 5 Star Quality Rating Special Election Period Other Special Election Period Open Enrollment Period for Institutionalized Individuals Dual/Low-Income Subsidy Special Enrollment Period Permanent Change in Residence Special Enrollment Period Employer Group Health Plan Special Enrollment Period Administrative Special Enrollment Period CMS/Case Worker Special Enrollment Period Open Enrollment Period Plan-Submitted Rollover SEP Low-Income Subsidy Special Enrollment Period Default Enrollment Mechanism Medicare Advantage Open Enrollment Period Open Enrollment for Newly Eligible Individuals Auto Enrollment, Facilitated Enrollment, Reassign Enrollment, or POS enrollment
25	ENROLL_SRC_C_NAME	VARCHAR	No
	This value indicates the source of enrollment, which is used only for Medicare Advantage coverages. May contain organization-specific values: Yes Category Entries: Auto enrolled by CMS Beneficiary Election Facilitated enrollment by CMS CMS Annual Rollover Plan initiated auto-enrollment Plan initiated facilitated-enrollment Point-of-sale submitted enrollment CMS or Plan reassignment State-submitted passive enrollment CMS-submitted passive enrollment MMP beneficiary election No enrollment source code Invalid submitted value Rollover by Plan Transaction
26	BEQ_RESP_F_NAM	VARCHAR	No
	This item stores the first name of the member as received from the CMS eligibility response file. The system checks for mismatches between this name and the first name stored in the member record (EPT).
27	BEQ_RESP_MID_INIT	VARCHAR	No
	This item stores the middle initial of the member as received from the CMS eligibility response file. The system checks for mismatches between this initial and the initial of the middle name stored in the member record (EPT).
28	BEQ_RESP_L_NAM	VARCHAR	No
	This item stores the last name of the member as received from the CMS eligibility response file. The system checks for mismatches between this name and the last name stored in the member record (EPT).
29	BEQ_RESP_GENDER_C_NAME	VARCHAR	No
	The gender category ID for the gender of the member as received from the CMS eligibility response file. The system checks for mismatches between this value and the sex stored in the member record (EPT). May contain organization-specific values: Yes Category Entries: Female Male Unknown Nonbinary X Other
30	BEQ_RESP_DOB_DT	DATETIME	No
	This item stores the date of birth of the member as received from the CMS eligibility response file. The system checks for mismatches between this date and the date of birth stored in the member record (EPT).
31	BEQ_RESP_DOD_DT	DATETIME	No
	This item stores the date of death of the member as received from the CMS eligibility response file. An error is flagged if this is populated, since a deceased member cannot receive benefits.
32	PART_A_STAT_C_NAME	VARCHAR	No
	This column stores the status category ID for the current Medicare Part A eligibility status of the coverage. May contain organization-specific values: No Category Entries: Eligible Not Eligible Applied Not Applied
33	PART_B_STAT_C_NAME	VARCHAR	No
	This column stores the status category ID for the current Medicare Part B eligibility status of the coverage. The category values for this column were already listed for column: PART_A_STAT_C_NAME
34	PART_D_STAT_C_NAME	VARCHAR	No
	This column stores the status category ID for the current Medicare Part D eligibility status of the coverage. The category values for this column were already listed for column: PART_A_STAT_C_NAME
35	PART_D_ELIG_STRT_DT	DATETIME	No
	This column identifies the date on which the beneficiary became eligible for Part D benefits.
36	PEND_PPO_EFF_DT	DATETIME	No
	This column holds a future expected date on which the Pending Premium Payment Option (CVG-18566) becomes the Premium Payment Option (CVG-18567).
37	PEND_PPO_C_NAME	VARCHAR	No
	This column tracks what the new value for Premium Payment Option (see PPO_C) is expected to become as of the effective date given in PEND_PPO_EFF_DT. May contain organization-specific values: No Category Entries: Social Security Benefits Railroad Retirement Board Benefits No Premium Direct Self-Pay
38	APCLM_CVG_VER_DATE	DATETIME	No
	Stores the date when the coverage was last verified. This data is only intended to be used when verification record (VRX) verification is used in an Accounts Payable (AP) Claims instance.
39	DIS_ELECTION_TYP_C_NAME	VARCHAR	No
	This value tracks the election type associated with the disenrollment. The election type is associated with a particular election period, and a particular type might be limited to a certain number of usages per member. This value is only applicable to Medicare Advantage coverages. The category values for this column were already listed for column: ELECTION_TYP_C_NAME
40	HIX_CSR_SRC_CVG_ID	NUMERIC	No
	This column is used to identify Cost Sharing Reduction (CSR) coverages and their corresponding source coverage (CVG) record. The value stored in this column is the ID of the source coverage of this CSR coverage. If the value is null, this coverage is not a CSR coverage.
41	ADDR_CHG_USER_ID	VARCHAR	No
	The user who initiated the linked address changes.
42	ADDR_CHG_USER_ID_NAME	VARCHAR	No
	The name of the user record. This name may be hidden.
43	ADDR_CHG_INSTANT_DTTM	DATETIME (Local)	No
	The instant that the linked address changes were initiated.
44	ADDR_CHG_SOURCE	VARCHAR	No
	The source record that initiated the linked address changes.
45	ENROLL_GEO_VERIF_FAIL_YN	VARCHAR	No
	Tracks coverages that have failed service/geographic area verification. The category values for this column were already listed for column: PART_D_OPT_OUT_YN
46	SUB_ADDR_IS_UNDELIV_YN	VARCHAR	No
	Indicates if subscriber home address is undeliverable. The category values for this column were already listed for column: PART_D_OPT_OUT_YN
47	MA_WORKFLOW_STAT_RSN_C_NAME	VARCHAR	No
	The reason for the Medicare status pertaining to a coverage. May contain organization-specific values: Yes Category Entries: Failure to pay premiums Relocation out of plan service area (no special provisions) Failure to convert to risk provisions Fraud Loss of Part B Entitlement Loss of Part A Entitlement (Plan-Specific) For cause Report of death Termination of contract (CMS-Initiated) Termination of contract/Plan Benefit Package (PBP)/Segment (Plan Withdrawal) Voluntary disenrollment through plan Voluntary disenrollment through district office Disenrollment because of enrollment in another plan Retroactive Terminated in error by CMS system End of State and County Code (SCC) conditional enrollment period Beneficiary does not meet age criterion (Plan-Specific) Rollover Terminated by Social Security Administration (SSA) district office Invalid enrollment with End Stage Renal Disease (ESRD) Cannot travel/poor health to HMO/Plan doctors Spouse is no longer member of HMO/Plan Couldn't use Medicare card to see other plan Unknowingly joined this HMO Difficulty reaching HMO/Plan doctor by phone Called HMO/Plan but could not get help with problem Dissatisfied with medical care/docs or hospital Told by plan doctors or staff to disenroll Prefers traditional Medicare Had other health insurance benefits available Found HMO/Plan to be too confusing Claims/bills were not paid Had little or no choice of specialist Treated discourteously by doctor/nurse/staff Doctor couldn't improve condition HMO/Plan medical group was located too far away Had limited or no choice of primary doctor Moved permanently out of area where plan provides services Doctor or plan instructed to disenroll Doctor didn't provide good quality care Used up the prescription allowance Plan cost too much Couldn't get care when it was needed Doctor isn't in the plan Unknowingly signed up for this plan Didn't like how the plan worked Rolled over enrollment removed/audited Part A or B start date change Beneficiary Medicaid period received Beneficiary hospice period received Invalid enrollment with hospice Beneficiary lives in USA fewer than 183 days a year Loss of Part D eligibility Part D disenrollment due to failure to pay IRMAA MMP (Medicare and Medicaid Plan) opt-out after enrolled Loss of demonstration eligibility Loss of employer group plan eligibility Confirmed incarceration Not lawfully present Disenrollment due to plan-submitted rollover Conversion Enrollment cancelled due to beneficiary merge Failure to pay premium Relocation out of plan service area Lost specific plan eligibility (Special Needs Plan (SNP) Only) Other (Not supplied by beneficiary) Report of death date change Report of death date change Beneficiary name required Incorrect birth date Invalid beneficiary ID Beneficiary ID not found No beneficiary match No Part A and Part B entitlement Pace under 55 Beneficiary not entitled for Part B Beneficiary not entitled for Part A Beneficiary is not age 65 Beneficiary is in hospice Beneficiary is deceased Incorrect effective date (Enroll) Duplicate Transaction Blocked Outside contract period Beneficiary is in ESRD Not enrolled (Disenroll) Incorrect effective date (Disenroll) Retroactive effective date Demonstration enrollment rejected Not enrolled Incorrect or missing application date Missing A/B entitlement date Invalid or missing election type Invalid effective date for election type Transaction received with later app date Invalid or missing PBP number Election limits exceeded Duplicate PBP number No Part A and no EGHP enrollment waiver Not AEP or OEPI Invalid segment number Invalid Premium Amount Invalid PPO Code Invalid NUNCMO Invalid CCF Employer subsidy status Subsidy set: No prior transaction Opt-Out flag not valid Invalid secondary insurer Transaction rejected, user not authorized for contract Contract not authorized for transaction code Invalid EGHP flag value Auto enroll or facilitated enroll rejected Reinsurance demonstration enrollment rejected Another transaction accepted Beneficiary is in Medicaid Beneficiary not eligible for Part D Rx BIN blank or not valid Rx ID blank or not valid Rx Group not valid Rx PCN not valid Re-Assignment enrollment rejected Invalid POS enroll source code Invalid birth date Invalid effective date Invalid application date Enroll/Disenroll cancellation Enrollment cancellation rejected Disenrollment cancellation rejected Was cancellation attempt MMP passive enrollment rejected Invalid MMP Opt-Out code MMP enrollment cancellation rejected Invalid Cancellation TC Archived beneficiary Invalid or missing MMP enrollment source code Confirmed incarceration (TRC) Not lawfully present period Plan rollover not in POVER file Plan rollover without ESC or ETC Plan rollover impacts dual enroll Incorrect ESC or ETC IEP/ICEP enroll available Invalid plan for DEM Beneficiary without MA enrollment or ICEP Enrollment Rejected, LIS SEP Invalid SEP reason code Not Entitled to Part A Not Entitled to Part B Not Entitled to Parts A and B Not Eligible for Part D Not Entitled for Part A, Not Eligible for Part D Not Entitled for Part B, Not Eligible for Part D Not Entitled for Parts A and B, Not Eligible for Part D Date of Death on CMS file Not Matched by CMS BEQ Not Processed by CMS BEQ Application Date Outside Election Period Unlawfully Present Residence is outside of service area Lack of information Unauthorized request Declined due to EGHP Incarceration ESRD Loss of Medicaid Eligibility Missing required info Coverage already termed
48	IN_NON_PREFERRED_AREA_YN	VARCHAR	No
	If 'Y' then subscriber address associated with coverage was either only in a geographic area marked as "non-preferred" on the employer group or coverage was not in any geographic area linked to the employer group and employer group not configured to restrict enrollment by residency. If 'N' or NULL, the subscriber address is in a geographic area linked to the employer group that is not marked as "non-preferred" or geographic area verification has not been run for this coverage. The category values for this column were already listed for column: PART_D_OPT_OUT_YN
49	GEO_TERM_TRACK_DATE	DATETIME	No
	The date that geographic area verification based termination tracking has started for a coverage. If not populated, coverage is not being tracked for termination.
50	HIX_RENEW_COVERAGE_ID	NUMERIC	No
	Stores the coverage ID that this coverage is renewing.
51	EFF_DT_CHNG_RSN_C_NAME	VARCHAR	No
	The effective date change reason at the coverage level. May contain organization-specific values: Yes No Entries Defined
52	HIX_RENEWAL_TYPE_C_NAME	VARCHAR	No
	The exchange renewal type for the coverage. May contain organization-specific values: No Category Entries: Passive Active
53	PAYMENT_TX_IDENT	VARCHAR	No
	The payment transaction ID for the coverage.
54	CARRIER_TO_BILL_BINDER_PMT_YN	VARCHAR	No
	Indicates whether the carrier (exchange) is responsible for collecting the binder payment for this coverage. 'Y' indicates that the carrier is responsible for collecting the binder payment. 'N' or NULL indicate that the carrier is not responsible. The category values for this column were already listed for column: PART_D_OPT_OUT_YN
55	HOUSEHOLD_IDENT	VARCHAR	No
	The household ID sent by the exchange for the coverage.
56	MA_COVERAGE_TYPE_C_NAME	VARCHAR	No
	Stores the types of Medicare covered by the managed Medicare coverage. May contain organization-specific values: No Category Entries: Parts A and B Parts A, B, and D Part B Parts B and D
57	PLAN_CHANGE_VERIF_PREV_CVG_ID	NUMERIC	No
	The unique ID for the original coverage in the plan change.
58	PLAN_CHANGE_VERIF_COMPLETE_YN	VARCHAR	No
	Indicates whether the plan change has completed execution for this coverage. 'Y' means the plan change has completed. 'N' means the plan change has not yet completed. NULL means this coverage is not the result of a plan change. The category values for this column were already listed for column: PART_D_OPT_OUT_YN
59	ENTRY_DATE	DATETIME	No
	The date the coverage was created.
60	EXISTING_NUNCMO	INTEGER	No
	The cumulative number of uncovered months (NUNCMO) as of the most recent prior Part D coverage. To get the total NUNCMO add the incremental NUNCMO to this amount.
61	NUNCMO_SET_BY_C_NAME	VARCHAR	No
	Captures how the NUNCMO was set May contain organization-specific values: Yes Category Entries: Eligibility Process Adjustment Reconsideration IEP Zero LIS Zero Plan Change
62	PRIOR_PART_D_DATE	DATETIME	No
	The end date of the Part D coverage prior to this enrollment.
63	MA_ENROLL_SEP_RSN_C_NAME	VARCHAR	No
	The special election period reason used for enrollment on this coverage. This is required if the Enrollment Election Type is Other Special Election Period. This column can be linked to ZC_MA_ENROLL_SEP_RSN for additional information about the categories. May contain organization-specific values: No Category Entries: System Generated Government Emergency or Disaster Government Emergency or Disaster - COVID 19 CMS Term of Contract Term/Contract Modified by Mutual Consent Accessible Format Receipt Delay Involuntary Loss of Creditable Coverage Disenroll Due to CMS Sanction Part D Disenroll for Other Creditable Coverage Involuntary Disenroll from Loss of Part B MA OEPI Disenroll from MA PACE Cost Plans Non-Renewals Drop Medigap in Trial Period Chronic Care C-SNP Institutional Individual Retro Entitlement Determination Beneficiaries Age 65 (SEP65) Part B GEP Enrollment Loss of SNP Cost Disenroll or Optional Supplemental Part D Lawfully Present Qualified / Lose SPAP Eligibility Plan in Receivership CMS ID Consistent Poor Performance MA Additional Part D IEP Part A or B SEP Enrollment for MA or MAPD Part A or B SEP Enrollment for Part D Misinform Creditable Status Provider Network Contract Violation Other Exceptional Circumstance Insulin SEP Plan List Correction SEP Marketing Misrepresentation SEP CMS - Exceptional Circumstance CMS - Invalid Enrollment CMS - Provider Network CMS - Contract Violation CMS - Excep Circ-Market Misrep CMS - GOVT Emergency or Disaster CMS - GOVT Emerg/Disaster COVID19
64	MA_DISENROLL_SEP_RSN_C_NAME	VARCHAR	No
	The special election period reason used for disenrollment on this coverage. This is required if the Disenrollment Election Type is Other Special Election Period. This column can be linked to ZC_MA_ENROLL_SEP_RSN for additional information about the categories. The category values for this column were already listed for column: MA_ENROLL_SEP_RSN_C_NAME
65	MA_APPLICATION_CONFIRM_NUM	VARCHAR	No
	The confirmation number associated with the Online Enrollment Center (OEC) enrollment application.
66	MA_PLAN_CHANGE_TYPE_C_NAME	VARCHAR	No
	The category ID for the type of plan change that led to the creation of this coverage. May contain organization-specific values: No Category Entries: Contract Change PBP Change Segment Change
67	MA_PLAN_CHANGE_COVERAGE_ID	NUMERIC	No
	The unique ID of the previous coverage that this coverage was created as a plan change from.
68	GEO_AREA_INVEST_START_DATE	DATETIME	No
	The date when the coverage begins geographic area investigation.
69	GEO_AREA_TEMP_ADDR_START_DATE	DATETIME	No
	The subscriber temporary address start date for this coverage.
70	REQ_TRM_DATE	DATETIME	No
	Stores the original termination date requested when the advanced logic is applied to the coverage's termination date.
71	TRM_NTC_DATE	DATETIME	No
	Stores the date that notice of termination was given to be used for advanced term date logic.
72	CVG_PHONE2	VARCHAR	No
	Payer phone number