DATA NAME |
TYPE |
SIZE |
REMARKS |
HEADER RECORD |
|||
| File Date | X | 8 | (ccyymmdd) REQUIRED |
| Health Plan Id Number | X | 6 | REQUIRED |
| Filler | X | 369 | |
DETAIL RECORD |
|||
| Transaction Type | X | 1 | A – Add |
| Activity Date | X | 8 | (ccyymmdd) |
| Member Last Name | X | 17 | REQUIRED |
| Member First Name | X | 12 | REQUIRED |
| Member Middle Initial | X | 1 | |
| Gender | X | 1 | M=Male, F=Female |
| Social Security No | X | 9 | |
| AHCCCS ID | X | 10 | REQUIRED |
| Date of Birth | X | 8 | (ccyymmdd) |
| Date of Death | X | 8 | (ccyymmdd) |
| Insured Relation to Client | X | 3 | Relationship to policy holder |
| Carrier Name | X | 36 | REQUIRED |
| Carrier Street 1 | X | 40 | |
| Carrier Street 2 | X | 40 | |
| Carrier City | X | 30 | |
| Carrier State | X | 2 | |
| Carrier ZIP | X | 9 | |
| Carrier Phone | X | 10 | |
| Policy Number | X | 20 | REQUIRED if no Insured SSN |
| Group Number | X | 20 | |
| Policy Begin Date | X | 8 | (ccyymmdd) |
| Policy End Date | X | 8 | (ccyymmdd) |
| Filler | X | 3 | |
| Insured Last Name | X | 17 | REQUIRED |
| Insured First Name | X | 12 | REQUIRED |
| Insured Middle Initial | X | 1 | |
| Insured SSN | X | 9 | REQUIRED if no Policy Number |
| Insured Employer | X | 40 | |
TRAILER RECORD |
|||
| Number of Records | X | 5 | REQUIRED |
| Filler | X | 378 | |