DATA NAME

PICTURE

ACTUAL POSITIONS

REMARKS

FROM

TO

RECORD TYPE

X(02)

1

2

‘01'=DETAIL, ‘XX'=TRAILER

PROCESS DATE

X(08)

3

10

CCYYMMDD

HEALTH PLAN ID

X(06)

11

16

CONTRACT TYPE

X(01)

17

17

See Contract Types Table

AHCCCS ID

X(09)

18

26

CASE ID

X(09)

27

35

PRIMARY AHCCCS ID

X(09)

36

44

ALTERNATE ID

X(15)

45

59

MEDICARE CLAIM ID

X(12)

60

71

PROCESS SEQUENCE

X(02)

72

73

‘01', ‘02', ‘03', ETC.

ACTION TYPE

X(01)

74

74

A=ADD, C=CHANGE, or D=DELETE/DISENROLL

GSA CODE

X(02)

75

76

02=YUMA , 04=LA PAZ/MOHAVE, 06=COCONINO/YAV, 08=GILA/PINAL, 10=PIMA, 12=MARICOPA, 14=GRAHAM/GREEN, 16=APACHE/NAVAJO, 18=COCHISE/SANTA, 98=ALL

GSA DESCRIPTION

X(15)

77

91

COUNTY CODE

X(02)

92

93

01=APACHE, 03=COCHISE, 05=COCONINO, 07=GILA, 09=GRAHAM, 11=GREENLEE, 13=MARICOPA, 15=MOHAVE, 17=NAVAJO, 19=PIMA, 21=PINAL, 23=SANTA CRUZ, 25=YAVAPAI, 27=YUMA, 29= LA PAZ

COUNTY NAME

X(15)

94

108

MEDICARE COVERAGE ‘A'

X(01)

109

109

‘Y' or ‘N'

MEDICARE COVERAGE ‘B'

X(01)

110

110

‘Y' or ‘N'

ACTION CODE

X(02)

111

126

MAY OCCUR UP TO 8 TIMES (SEE ATTACHED AC TABLE)

RECIPIENT LAST NAME

X(23)

127

149

RECIPIENT FIRST NAME

X(10)

150

159

RECIPIENT M. INITIAL

X(01)

160

160

RECIPIENT GENDER

X(01)

161

161

‘M' or ‘F'

DATE OF BIRTH

X(08)

162

169

CCYYMMDD

DATE OF DEATH

X(08)

170

177

CCYYMMDD

MAIL STREET ADDRESS 1

X(25)

178

202

MAIL STREET ADDRESS 2

X(25)

203

227

MAIL CITY

X(20)

228

247

MAIL STATE

X(02)

248

249

MAIL ZIP CODE 5

X(05)

250

254

MAIL ZIP CODE 4

X(04)

255

258

FILLER 1

X(05)

259

263

RESIDENCE ST. ADD. 1

X(25)

264

288

RESIDENCE ST. ADD. 2

X(25)

289

313

RESIDENCE CITY

X(20)

314

333

RESIDENCE STATE

X(02)

334

335

RESIDENCE ZIP CODE 5

X(05)

336

340

RESIDENCE ZIP CODE 4

X(04)

341

344

FILLER 2

X(04)

345

348

TELEPHONE NUMBER

X(10)

349

358

ELIGIBILITY BEGIN DATE

X(08)

359

366

CCYYMMDD (MN/MI and ELIC ONLY)

ELIGIBILITY END DATE

X(08)

367

374

CCYYMMDD (MN/MI and ELIC ONLY)

PPC/ENROLL BEGIN DATE

X(08)

375

382

CCYYMMDD

PPC/ENROLL END DATE

X(08)

383

390

CCYYMMDD

ENROLLMENT RATE CODE

X(04)

391

394

FILLER 3

X(10)

395

404

RISK GROUP

X(04)

405

408

TACI=TANF M&F<1, FMAL=TANF ‘F' 14 - 44, ADLT=TANF M & F 45+, SSIW=SSI W/MEDICARE, SFPS=SOBRA FPS, ALTC=TANF (LTC)

RISK GROUP QUALIFIER

X(02)

409

410

AF=AFDC(NON-SOBRA), EL=ELIC, KC=KIDSCARE, MN=MEDICALLY NEEDY, QB=QMB ONLY BLIND, SD=SSI DISABLED, SO=SOBRA WOMAN

FILLER 4

X(08)

411

418

VOUCHER NUMBER

X(09)

419

427

CAPITATION AMOUNT

N(7.2)

428

436

NUMBER DAYS COVERED

X(03)

437

439

PAYMENT FROM DATE

X(08)

440

447

CCYYMMDD

PAYMENT THRU DATE

X(08)

448

455

CCYYMMDD

PREGNANCY INDICATOR

X(01)

456

456

‘Y' or BLANK

LTC TRANSITION IND.

X(01)

457

457

‘T' or BLANK

FACILITY ID

X(06)

458

463

ALTCS from LEDS

FACILITY NAME

X(25)

464

488

ALTCS from LEDS

SHARE OF COST DATE

X(06)

489

524

MMCCYY - OCCURS 6 TIMES (ALTCS ONLY)

SHARE OF COST AMOUNT

N(6.2)

525

572

OCCURS 6 TIMES (ALTCS ONLY)

PRIOR PLAN INDICATOR

X(01)

573

573

‘Y' or BLANK

PRIOR PLAN NAME

X(25)

574

598

MENTAL HEALTH CAT.

X(01)

599

599

C=CHILDRENS SVCS, I=NON-SMI 18-20 & 65+, S=SMI, H=GMH AL/SUBS. SVCS, K=KC CHILDREN 18 - 19, Z=SED CHILDREN

FILLER 5

X(02)

600

601

MENTAL HLTH BEGIN DT

X(08)

602

609

CCYYMMDD

MENTAL HEALTH END DT

X(08)

610

617

CCYYMMDD

FILLER 6

X(83)

618

700

THE LAST RECORD OF EACH DISK FILE HAS THE FOLLOWING SPECIFICATIONS:

RECORD TYPE

X(02)

1

2

‘XX'

PROCESS DATE

X(08)

3

10

CCYYMMDD

HEALTH PLAN ID

X(06)

11

16

NUMBER OF RECIPIENTS

X(08)

17

24

TOTAL CAP AMOUNT

N(9.2)

25

35

FILLER

X(665)

36

700