EDGE Server Schemas

Centers for Medicare & Medicaid Services
EDGE Server Production and Test Schema

Data Dictionary
Version 10.0
March 2016
EDGE Server Production and Test Schema Data Dictionary March Release
Document Version History
Version
Date
Author/Owner
Description of Change
1.0
10/19/2014
Accenture / CCIIO
Initial Version
2.0
1/27/2015
Accenture / CCIIO
Added new tables: RISKSCORE, STNG_RADV_POPULATION,

STNG_REINSURANCE and modified table MDCL_CLM_DGNS_CD_ASCTN.
3.0
2/15/2015
Accenture/CCIIO
Added new tables: SUBPLCY, SUB_PLCY_CLM_ASSOC, EDGE_EVENT_LOG,

MEDICAL_CLAIM_SRVC_MDFR_ASCTN.
Number
Added a new column: MEDICAL_SRVC_LINE_NUM in table

EDGE_ERROR_LOG.
4.0
3/10/2015
Accenture/CCIIO
Added group tag to the tables to group them logically. Changed

EDGE_ERROR_LOG category to Staging Table.
5.0
4/17/2015
Accenture/CCIIO
Added a new column: CLAIM_TYPE in table STNG_REINSURANCE.
6.0
5/26/2015
Accenture/CCIIO
Added a new table: SUP_CLM_DGNS_CD_ASCTN.
7.0
10/23/2015
Accenture/CCIIO
Changed the data type from BIT(1) to VARCHAR(1) in the column RA_FLAG
of table MEDICAL_CLAIM.
Deleted the columns: RA_FLAG and RA_REASON_CODE in table
SUPPLEMENTAL_CLAIM.
8.0
1/29/2016
Accenture/CCIIO
Added new tables: MMBR_INSRNC_PLCY_CVRG_CRSS_YR_HSTY,

STNG_MMBR_INSRNC_PLCY_CVRG_CRSS_YR,
STNG_MMBR_INSRNC_PLCY_CVRG_PROFILE_ASCTN,
STNG_INSRD_MMBR_CC_ASSOC, STNG_INSRD_MMBR_DGNS_ASSOC,
STNG_INSRD_MMBR_HCC_ASSOC,
STNG_INSRD_MMBR_HCC_GROUP_ASSOC;
Added new columns: CLAIM_FROM_DATE in table STNG_REINSURANCE,
HCC_UNIQUE_COUNT in table RISCKSCORE, V3_INDICATOR in table

RISKSCORE, SEVERITY_INTER_GRP in table RISKSCORE;
Removed constraints from these staging tables: SUB_PLCY to

MMBR_INSRNC_PLCY_CVRG, SUB_PLCY to
MMBR_INSRNC_PLCY_CVRG_PROFILE_ASCTN, RISKSCORE to
MMBR_INSRNC_PLCY_CVRG, and SUB_PLCY_CLM_ASSOC to SUB_PLCY.
9.0
2/26/2016
Accenture/CCIIO
Added new columns: MEDICAL_CLAIM_FAMILY_ID in table

SUPPLEMENTAL_CLAIM; INSRNC_PLAN_ID_REP in table
STNG_MMBR_INSRNC_PLCY_CVRG_CRSS_YR.
10.0
3/17/2016
Accenture/CCIIO
Added new columns: INSRNC_PLAN_ID_REP, PLCY_RATG_AREA_CD,

INSRD_MMBR_ID,MMBR_MNTHS, UTILIZER_IND,
CROSS_YEAR_CLAIM_UID, GNDR_CD, ARF_AGE, LAST_AGE,
INFANT_HCC_SEVERITY, INFANT_HCC_MATURITY,
RCVD_INSRD_MMBR_ID, CVRG_EFCTV_STRT_DT, CVRG_EFCTV_END_DT,
MTL_LVL, EXCHANGE_TYPE, MARKET_TYPE in table RISKSCORE.
Added new tables: STNG_INSRD_MMBR_DGNS_UTI_ASSOC,
STNG_INSRD_MMBR_DROP_HCC_ASSOC, RISKSCORE_REMOTE.
Changed a table name: changed the name of table
STNG_INSRD_MMBR_DGNS_ASSOC to
STNG_INSRD_MMBR_DGNS_ASSOC_ACCEP.
Contents
1.
INTRODUCTION ..................................................................................................................................................1
2.
DATABASECHANGELOG ......................................................................................................................................2
3.
DATABASECHANGELOGLOCK .............................................................................................................................3
4.
EDGE_ERROR_LOG .............................................................................................................................................4
5.
EDGE_EVENT_LOG..............................................................................................................................................6
6.
INSRD_MMBR .....................................................................................................................................................7
7.
MDCL_CLM_DGNS_CD_ASCTN ..........................................................................................................................8
8.
MEDICAL_CLAIM.................................................................................................................................................9
9.
MEDICAL_CLAIM_SRVC_LINE .......................................................................................................................... 11
10.
MEDICAL_CLAIM_SRVC_MDFR_ASCTN....................................................................................................... 13
11.
MMBR_INSRNC_PLCY_CVRG ....................................................................................................................... 14
12.
MMBR_INSRNC_PLCY_CVRG_CRSS_YR_HSTY............................................................................................. 16
13.
MMBR_INSRNC_PLCY_CVRG_PROFILE_ASCTN........................................................................................... 18
14.
PHARMACY_CLAIM ...................................................................................................................................... 19
15.
PRM_STBLZN_SUBMSN_STUS ..................................................................................................................... 21
16.
RECORD_LEVEL_HIER .................................................................................................................................. 22
17.
RISKSCORE ................................................................................................................................................... 23
18.
RISKSCORE_REMOTE ................................................................................................................................... 25
19.
STNG_ENRLMT_SUBMSN ............................................................................................................................ 27
20.
STNG_INSRD_MMBR_CC_ASSOC ................................................................................................................ 29
21.
STNG_INSRD_MMBR_DGNS_ASSOC_ACCEP .............................................................................................. 30
22.
STNG_INSRD_MMBR_DGNS_UTI_ASSOC ................................................................................................... 31
23.
STNG_INSRD_MMBR_DROP_HCC_ASSOC .................................................................................................. 32
24.
STNG_INSRD_MMBR_HCC_ASSOC.............................................................................................................. 33
25.
STNG_INSRD_MMBR_HCC_GROUP_ASSOC................................................................................................ 34
26.
STNG_MDCL_SUBMSN ................................................................................................................................ 35
27.
STNG_MMBR_INSRNC_PLCY_CVRG_CRSS_YR ............................................................................................ 37
28.
STNG_MMBR_INSRNC_PLCY_CVRG_PROFILE_ASCTN ................................................................................ 39
29.
STNG_PHRMCY_SUBMSN............................................................................................................................ 40
30.
STNG_RADV_POPULATION.......................................................................................................................... 42
ii
31.
STNG_REINSURANCE ................................................................................................................................... 43
32.
STNG_SPLMNTL_SUBMSN........................................................................................................................... 44
33.
SUB_PLCY..................................................................................................................................................... 46
34.
SUPPLEMENTAL_CLAIM............................................................................................................................... 47
35.
SUB_PLCY_CLM_ASSOC ............................................................................................................................... 49
36.
SUB_CLM_DGNS_CD_ASCTN....................................................................................................................... 50
iii
1. INTRODUCTION
This data dictionary documents the External Data Gathering Environment (EDGE) Server Production
and Test schemas. Two (2) schemas are utilized by the EDGE server application. The production and
test schemas are identical data models. The test schema can be used to test and validate inbound
eXtensible Markup Language (XML) files. Summary reports generated from the test schema are not
sent to the Centers for Medicare & Medicaid Services (CMS). Both detailed and error reports are
available to the issuer to facilitate remediation of inbound XML issues that may be encountered.
The EDGE Server Production schema is used by the issuer to process production files. Summary
reports generated from the production schema are sent to CMS. Both detailed and error reports are
available to the issuer to review.
2. DATABASECHANGELOG
Table Name: DATABASECHANGELOG
Group: Tracking Error Liquibase Table
Category: DB change log System Table (for system internal use only)
Table Definition: This is a system level table to track database changes. Should not be modified.
Column Name
Data Type
Null Option Type
Column Definition
ID
VARCHAR(255)
Not Null
Unique Liquibase ID.
AUTHOR
VARCHAR(255)
Not Null
EDGE server system.
FILENAME
VARCHAR(255)
Not Null
XML file name in Liquibase.
DATEEXECUTED
DATETIME
Not Null
Liquibase execution date.
ORDEREXECUTED
DATETIME
Not Null
UID that Liquibase is executed.
EXECTYPE
VARCHAR(10)
Not Null
Execution type.
MD5SUM
VARCHAR(35)
Null
Checksum value of the changeset.
DESCRIPTION
VARCHAR(255)
Null
Description.
COMMENTS
VARCHAR(255)
Null
Comments.
TAG
VARCHAR(255)
Null
Specify the tag name when launching

Liquibase.
LIQUIBASE
VARCHAR(20)
Null
Liquibase version.
3. DATABASECHANGELOGLOCK
Table Name: DATABASECHANGELOGLOCK
Category: DB change lock System Table (for system internal use only)
Table Definition: This is a system level table to track database changes. Should not be modified.
Column Name
Data Type
Null Option Type
Column Definition
ID
INT(11)
Not Null
Unique ID.
LOCKED
BIT(1)
Not Null
Number of records locked when launching

Liquibase.
LOCKGRANTED
DATETIME
Null
Date that lock is granted.
LOCKEDBY
VARCHAR(255)
Null
User that locked records when launching

Liquibase.
4. EDGE_ERROR_LOG
Table Name : EDGE_ERROR_LOG
Group: Staging & Reporting Table
Category: Staging Table
Table Definition: The table logs business validation errors, inline validation errors into this table, and it will be used for generating
the outbound reports.
Column Name
Data Type
Null Option Type
Column Definition
UID
INT(10)
Not Null
Unique database row identifier.
RECORDID
BIGINT(19)
Not Null
Unique identifier for each record in the received file.
RECORDLEVEL
VARCHAR(45)
Not Null
The record level is used to record the different levels in

the file. For instance, issuer level, plan level, enrollee
level, enrollment period level, claim detail level and claim
service line level, etc.
ELEMENTNAME
VARCHAR(100)
Null
The element name represents the XML tag name of the

inbound file. The name of the element that has the error.
ELEMENTVALUE
VARCHAR(100)
Null
The value of the element as it was received on

submission.
ERRORSPECIFICTYPE
VARCHAR(200)
Null
Text description of error specific type that relates to

ERRORTYPENO.
ERRORCODE
VARCHAR(45)
Null
The code associated with the error.

Internal unique Error Code number.
ERRORDETAIL
VARCHAR(500)
Null
A system generated Error Message for exceptions.
ERRORMESSAGE
VARCHAR(500)
Null
A pre-defined Error Message that corresponds to the

Error Code.
JOBID
BIGINT(19)
Not Null
Reference to the job that inserted this record.
Null
Type of record submitted. Valid values are:
M Medical Claim
P Pharmacy Claim
E Enrollment
S Supplemental Diagnosis
SUBMISSIONTYPE
VARCHAR(80)
ERROR_TYPE
VARCHAR(50)
Null
ERRORLEVELNO
BIGINT(19)
Null
ERRORTYPENO
BIGINT(19)
Null
Description of the error type associated with

ERRORTYPENO. Valid values are:
1 For required/situational
2 For face validity
3 Reference
4 Logical
5 Business
6 System
The Error Code consists of three (3) digits. The first digit
represents the Error Level.
Error type number. Valid values are:
1 For required/situational
2 For face validity
3 Reference
4 Logical
5 Business
6 System
Table Name : EDGE_ERROR_LOG (Cont.)
Category: Staging Table
Table Definition: The table logs business validation errors, inline validation errors into this table, and it will be used for generating
the outbound reports.
Column Name
Data Type
Null Option Type
Column Definition
STATUS_TYPE
CHAR(1)
Null
Describes the status type of the processed

data element in a received inbound file.
Valid values are:
A Accept
R Reject
I Informational (Accepted
with warning message)
CLAIM_IDENTIFIER
VARCHAR(80)
Null
The unique identifier for a claim.
MEDICAL_SRVC_LINE_NUM
VARCHAR(20)
Null
Medical service line number.
5. EDGE_EVENT_LOG
Table Name : EDGE_EVENT_LOG
Category: Transaction table
Table Definition: The table logs each event that happens on edge application into this table.
Column Name
Data Type
Null Option Type
Column Definition
UID
BIGINT(19)
NOT NULL
Unique identifier (Primary Key) of the

database row.
JOB_ID
BIGINT(19)
NULL
Reference to the job that inserted the

record.
JOB_TYPE
VARCHAR(25)
NULL
Defines the type of job the EDGE server

processed.
JOB_COND
VARCHAR(100)
NULL
Condition of the job processed. Valid

values:
Pre
Post
EVENT_ID
VARCHAR(100)
NULL
Short description of the job processed.
EVENT_VAL
VARCHAR(100)
NULL
Deprecated.
EVENT_MSG
VARCHAR(1000)
NULL
Full Description of the job processed.

Provides a status on the job run, identified
by the Job ID. Valid values are:
0 The job ran but there are

data issues, blank reports are
generated
1 The job ran successfully

and generated reports
EVENT_RESULT
VARCHAR(10)
NULL
EVENT_ORDER
INT(10)
NULL
CREATN_DT
DATETIME
NULL
CREATD_BY
VARCHAR(50)
NULL
Deprecated.
LAST_MDFYD_DT
DATETIME
NULL
Deprecated.
MDFYD_BY
VARCHAR(50)
NULL
Deprecated.
Order in which the event occurred in the

job process.
This date is used to indicate when the job
is created.
6. INSRD_MMBR
Table Name : INSRD_MMBR
Group: Member Table
Category: Ingested Data Table
Table Definition: This table has the ingested enrollee/member information.
Column Name
Data Type
Null Option Type
Column Definition
INSRD_MMBR_ID
INT(10)
Not Null
RCVD_SUBMSN_ID
BIGINT(19)
Not Null
Reference to the job that inserted this

record.
DOB
DATE
Not Null
Date of birth of the enrollee.
CREATN_DT
DATETIME
Null
Creation date of the row in the database.
INACTIVATION_DT
DATETIME
Null
Date enrollee was inactivated (null if

enrollee is active).
LAST_CNFRMED_DT
DATETIME
Null
Date the enrollee data on this row was last

updated.
CREATD_BY
VARCHAR(255)
Null
Deprecated.
LAST_MDFYD_DT
DATETIME
Null
The last date and time the enrollee

information was updated.
MDFYD_BY
VARCHAR(255)
Null
Deprecated.
ISSR_ORG_ID
VARCHAR(5)
Not Null
GNDR_CD
VARCHAR(1)
Not Null
INSRD_MMBR_STUS_CD
BIT(1)
Not Null
RCVD_INSRD_MMBR_ID
VARCHAR(80)
Not Null
Unique identifier of enrollee. This

represents a MASKED identifier; not a
medical record number or cardholder ID.
RCRD_IDNTFR
BIGINT(19)
Not Null
Record identifier for this enrollee from the

inbound XML file.
Unique Health Insurance Oversight

System (HIOS) Issuer ID.
Enrollee gender. Valid values are:
F Female
M Male
U Unknown (accepted only

for newborns)
Enrollee status. Valid values are:
0 inactive
1 active
7. MDCL_CLM_DGNS_CD_ASCTN
Table Name: MDCL_CLM_DGNS_CD_ASCTN
Group: Claim Table
Table Definition: This table has the ingested Diagnosis Codes from the medical claims.
Column Name
Data Type
Null Option Type
Column Definition
UID
BIGINT(19)
Not Null

database row.
MEDICAL_CLAIM_UID_FK
BIGINT(19)
Null
The unique identifier of the medical claim

in the medical claim table that this
Diagnosis Code is associated. This is a
foreign key reference to
MEDICAL_CLAIM.UID.
CREATN_DT
DATETIME
Null
This date is used to indicate when the

record is created.
CREATD_BY
VARCHAR(255)
Null
Deprecated.
LAST_MDFYD_DT
DATETIME
Null
The date and time the record is modified.
MDFYD_BY
VARCHAR(255)
Null
Deprecated.
ACTV_IND
VARCHAR(1)
Null
Deprecated.
Null
Code value for the Diagnosis Code as

determined by classification of
International Classification of Diseases.
Refer to DGNS_CD_TYPE for valid
values.
Null
Indicates if the Diagnosis Code is

International Classification of Diseases, 9th
Revision (ICD 9) or International
Classification of Diseases, 10th Revision
(ICD 10). Refer to DGNS_CD_QLFYR for
valid values.
DGNS_CD
DGNS_QLFYR_CD
CHAR(30)
CHAR(2)
8. MEDICAL_CLAIM
Table Name: MEDICAL_CLAIM
Group: Claim Table
Category: Ingest Data Table
Table Definition: This table has the ingested data for medical claims.
Column Name
Data Type
Null Option Type
Column Definition
UID
BIGINT(19)
Not Null
BENEFIT_YEAR
VARCHAR(4)
Not Null
STATEMENT_COVERS_TO_DATE
DATE
Null

The benefit year based for this claim, based on the statement
date. (1) Use Statement Covers To Date if it is not empty, (2)
Use Statement Covers From Date if Statement Covers To
Date is empty and the form type is I, (3) Use Year 9999 if
both dates are empty. This column is not used for RA/RI
processing.
Medical claim end date.
STATEMENT_COVERS_FROM_DATE
DATE
Null
Medical claim start date.
ADMISSION_DATE
DATE
Null
Deprecated.
DISCHARGE_DATE
DATE
Null
Deprecated.
ORIGINAL_CLAIM_ID
VARCHAR(50)
Null
The claim identifier of the medical claim that is to be voided or

replaced.
CLAIM_ALLOWED_TOTAL_AMOUNT
DECIMAL(18,2)
Null
The total amount that is allowed on the medical claim.
CLAIM_PAID_TOTAL_AMOUNT
DECIMAL(18,2)
Null
The total amount paid to the issuer for this claim.
CLAIM_STATUS_UPDATE_DATE
DATE
Null
The date the medical claim status was changed, from active to
inactive.
RECEIVED_INSURED_MEMBER_ID
VARCHAR(80)
Null
Unique identifier of enrollee. This represents a MASKED

identifier; not a medical record number or cardholder ID.
BILLING_PROVIDER_ID
CHAR(15)
Null
The Billing Provider's Identification (NPI or unique issuer

assigned Provider ID).
MEDICAL_CLAIM_ID
VARCHAR(50)
Null
The claim identifier of the medical claim.
INACTIVATION_DT
DATETIME
Null
Date the medical claim was inactivated (voided).
CREATION_DATE
DATETIME
Null
System date when the claim was first inserted into the
database.
CREATD_BY
VARCHAR(255)
Null
Deprecated.
LAST_MODIFIED_DATE
DATETIME
Null
System date when the claim was modified in the database.
MODIFIED_BY
VARCHAR(255)
Null
Deprecated.
INSURANCE_PLAN_ID
VARCHAR(16)
Null
Unique identifier for insurance plan offered by issuer that the

enrollee is covered under. The Plan ID includes the CSR
variant.
ISSR_ORG_ID
VARCHAR(5)
Not Null
Unique HIOS Issuer ID.
TRANSACTION_TYPE
CHAR(2)
Not Null
The type of the transaction. Valid values are:
O Original
R Replace
V Void
CLAIM_STATUS
VARCHAR(30)
Null
Claim status. Valid values are:
0 inactive
1 active
CLAIM_FILTERING_STATUS
CHAR(1)
Null
Deprecated.
Table Name: MEDICAL_CLAIM (Cont.)
Group: Claim Table
Table Definition: This table has the ingested data for medical claims.
Column Name
Data Type
Null Option Type
Column Definition
CLAIM_FORM_TYPE
CHAR(1)
Null
Describes claim form type as professional or

institutional. Valid values are:
P Professional
I Institutional
CLAIM_BILL_TYPE
CHAR(3)
Null
The code indicating a specific type of bill as

reported on institutional claims only. Refer to the
CLAIM_BILL_TYPE table for valid values.
DISCHARGE_STATUS
CHAR(2)
Null
The facility discharge status of the enrollee. Refer

to the DSCHRG_STUS_TYPE table for valid
values.
CLAIM_TYPE
CHAR(2)
Null
The type of claim. Valid values are:
M Medical Claim
P Pharmacy Claim
E Enrollment
CLAIM_PROCESSED_DATETIME
DATETIME
Null
The date and time when the claim was

adjudicated and resulted in a paid amount or
reported encounter.
DERIVED_SERVICE_CLAIM_IND
CHAR(1)
Null
Indicator used to distinguish between fee-forservice claims and claims covered under
capitation.
BILLING_PROVIDER_QLFYR_CODE
CHAR(2)
Null
Identifies the type of Provider ID being submitted

in the Billing Provider ID field. Valid values are:
XX Billing Provider ID is an NPI

provider
99 Can be a 15-digit long identifier
JOB_ID
BIGINT(19)
Null
DERIVED_BENEFIT_MONTH
VARCHAR(2)
Null
Deprecated.
RECORD_ID
BIGINT(19)
Null
Unique identifier for claim in medical claim file.
SERVICE_PAID_DATE
DATE
Null
The date a check or electronic funds transfer was

issued for paid claims. For encounters, the date
paid means the date of claim adjudication.
LAST_CONFIRMED_DATE
DATETIME
Null
Date the claim was last updated.
RA_FLAG
VARCHAR(1)
Null
Flag indicating that a claim was 1 or was not 0

selected for Risk Adjustment (RA).
CLAIM_FAMILY_ID
BIGINT(19)
Not Null
Unique identifier for a group of claims that belong

to the same claim family.
RA_REASON_CODE
VARCHAR(3)
Null
Reason Code indicating why a claim was not

selected.
RI_FLAG
VARCHAR(1)
Null
Reinsurance (RI) claim selection flag to indicate if

claim qualifies for RI.
RA_USED
VARCHAR(1)
Null
Flag used to help calculate multiple fields in RA

Payment Hierarchal Condition Category Enrollee
Report (RAPHCCER).
10
9. MEDICAL_CLAIM_SRVC_LINE
Table Name: MEDICAL_CLAIM_SRVC_LINE
Group: Claim Table
Table Definition: This table has the ingested data for medical claim service lines.
Column Name
Data Type
Null Option Type
Column Definition
MEDICAL_SRVC_LINE_NUM
INT(10)
Not Null
Unique number generated to represent service(s)

submitted on the claim.
SRVC_FROM_DT
DATE
Null
Represents the first date of service on a submitted

claim for a specific claim line.
Also represents the Service Date on an
institutional claim.
SRVC_TO_DT
DATE
Null
Represents the last Date of Service on a

submitted claim for a specific claim line.
ALOWD_AMT
DECIMAL(18,2)
Null
Total amount allowed by plan.
PLCY_PD_AMT
DECIMAL(18,2)
Null
Total amount paid, or derived, by plan.
MEDICAL_CLAIM_UID_FK
BIGINT(19)
Not Null
Reference to the medical claim this service line is

associated with. This is a foreign key reference to
MEDICAL_CLAIM.UID.
UID
BIGINT(19)
Not Null
RNDRNG_PRVDR_ID
CHAR(15)
Null
The Rendering Provider's identification number.
CREATN_DT
DATETIME
Null
System date when this service line was first

created in the database.
CREATD_BY
VARCHAR(255)
Null
Deprecated.
LAST_MDFYD_DT
DATETIME
Null
System date when this service line was modified in

the database.
MDFYD_BY
VARCHAR(255)
Null
Deprecated.
SRVC_PLACE_CD
CHAR(2)
Null
A code that identifies where the service was

rendered. Refer to SRVC_PLC_TYPE for valid
values.
REV_CD
CHAR(4)
Null
Describes the revenue center in which the service

was provided. Refer to REV_CD_TYPE table for
valid values.
SRVC_CD
CHAR(48)
Null
A code that identifies the source of the procedure

code (CPT or HCPCS). Refer to SRVC_CD_TYPE
table for valid values.
CLAIM_FLTRING_STUS_CD
CHAR(1)
Null
Deprecated.
Null
A procedure code that identifies the service

rendered: Valid values are:
01 Dental Service Codes
03 Healthcare Common Procedure

Coding System (HCPCS) or Current
Procedural Terminology (CPT)
SRVC_TYPE_CD
11
CHAR(2)
Table Name: MEDICAL_CLAIM_SRVC_LINE (Cont.)
Group: Claim Table
Table Definition: This table has the ingested data for medical claim service lines.
Column Name
DRVD_SRVC_CLM_CD
Data Type
CHAR(1)
Null Option Type
Column Definition
Null
Indicator used to distinguish between fee-forservice claims and claims covered under
capitation. Valid values are:
Y Derived (capitated Service)
N Actual (Fee-For-Service)
RNDRNG_PRVDR_QLFYR_CD
CHAR(2)
Null
Identifies the type of Provider ID being submitted

in the Rendering Provider ID field. Valid values
are:
XX Billing Provider ID is an NPI

provider
99 Can be a 15-digit long identifier
RECORD_ID
BIGINT(19)
Null
Unique identifier for each record in medical claim

file.
JOB_ID
BIGINT(19)
Null
12
10.
MEDICAL_CLAIM_SRVC_MDFR_ASCTN
Table Name: MEDICAL_CLAIM_SRVC_MDFR_ASCTN

Group: Claim Table
Table Definition: This table has the ingested service modifier codes from the medical claim service lines.
Column Name
Data Type
Null Option Type
Column Definition
SRVC_MDFR_CD
CHAR(2)
Not Null
The Service Modifier Code from the medical claim

service line. Refer to SRVC_CD_MDFR_TYPE for
valid values.
MEDICAL_CLAIM_SRVC_LINE_UID_FK
BIGINT(19)
Not Null
The unique identifier of the medical claim service

line this Service Modifier Code is linked. This is a
foreign key reference to
MEDICAL_CLAIM_SRVC_LINE.UID.
13
11.
MMBR_INSRNC_PLCY_CVRG
Table Name : MMBR_INSRNC_PLCY_CVRG

Group: Member Table
Table Definition: This table has the ingested enrollee policy/enrollment period information.
Column Name
Data Type
Null Option Type
Column Definition
MMBR_INSRNC_PLCY_CVRG_ID
BIGINT(19)
Not Null
RCVD_SUBMSN_ID
BIGINT(19)
Not Null
INSRNC_PLAN_ID
VARCHAR(16)
Not Null
Unique identifier for insurance plan offered by issuer that

the enrollee is covered under. The Plan ID will correspond
to the HIOS Standard Component ID. The Plan ID includes
the Cost-Sharing Reduction (CSR) variant.
CVRG_EFCTV_STRT_DT
DATE
Null
The date when the enrollment coverage for the enrollee

became effective for the associated plan.
CVRG_EFCTV_END_DT
DATE
Null
The date when the enrollment coverage for the enrollee is

no longer effective for the associated plan.
INSRNC_PLAN_PRM_AMT
DECIMAL(18,2)
Null
The Premium Amount is the monthly total rated premium

charged by the issuer for a subscriber, including the
Advance Premium Tax Credit (APTC) amount. The
Premium Amount may include more than the amount
charged directly to a subscriber. The Premium Amount
does not represent an amount paid by a subscriber.
CREATN_DT
DATETIME
Null
Date and time when this row was created in the database.
INACTIVATION_DT
DATETIME
Null
Date and time when this policy was inactivated, null if

policy is active.
LAST_CNFRMED_DT
DATETIME
Null
Date and time the policy data on this row was last updated.
It is the generation date and time from inbound XML file.
LAST_MDFYD_DT
DATETIME
Null
Date and time when this row was modified in the database.
MDFYD_BY
VARCHAR(255)
Null
Deprecated.
ISSR_ORG_ID
VARCHAR(5)
Not Null
ENRLMT_MNT_TYPE_CD
VARCHAR(6)
Not Null
Identifies the type of activity associated with the creation of

an enrollment period.
Valid values are:
021028 Initial issuance of the policy
001 Modification of existing policy
021EC Addition of member to an existing

policy
021041 Renewal of an existing policy for the

next year
PLCY_RATG_AREA_CD
VARCHAR(15)
Not Null
Rating Area used for the enrollee in the plan. If enrollee is

not rated, use the subscriber Rating Area.
INSRD_MMBR_STUS_CD
CHAR(2)
Not Null
0 inactive
1 active
CREATD_BY
VARCHAR(255)
Null
Deprecated.
14
Table Name : MMBR_INSRNC_PLCY_CVRG (Cont.)
Group: Member Table
Table Definition: This table has the ingested enrollee policy/enrollment period information.
Column Name
Data Type
Null Option Type
Column Definition
INSRD_MMBR_ID
INT(10)
Not Null
Foreign key to the enrollee table to identify the associated

member.
Indicates when the enrollee linked to this enrollment
period record is also the subscriber. A subscriber is
defined as the primary insured party. Valid values are:
S Subscriber
Null or Blank Non-subscriber

This ID represents a Unique Enrollee ID who is identified
as the primary insured party. This represents a MASKED
identifier, not a medical record number or cardholder ID.
If SBSCBR_IND is Null or Blank, this field must be
populated.
SBSCBR_IND
CHAR(1)
Null
SBSCBR_ID
CHAR(80)
Null
RCRD_IDNTFR
BIGINT(19)
Not Null
Unique identifier for each record in enrollment file.
RI_FLAG
VARCHAR(1)
Null
RI claim selection flag to indicate if claim qualifies for RI.
15
12.
MMBR_INSRNC_PLCY_CVRG_CRSS_YR_HSTY
Table Name : MMBR_INSRNC_PLCY_CVRG_CRSS_YR_HSTY

Group: Member Table
Category: Association Table
Table Definition: This table hosts the system generated cross-year enrollment periods for each RA run.
Column Name
Data Type
Null Option Type
Column Definition
UID
BIGINT(19)
Not Null
The UID.
BIGINT(19)
Not Null
MEDICAL_CLAIM_UID
BIGINT(19)
Null
The medical claim UID.
RCVD_SUBMSN_ID
BIGINT(19)
Not Null
INSRNC_PLAN_ID
VARCHAR(16)
Not Null

the CSR variant.
CVRG_EFCTV_STRT_DT
DATE
Null

CVRG_EFCTV_END_DT
DATE
Null

INSRNC_PLAN_PRM_AMT
DECIMAL(18,2)
Null

charged by the issuer for a subscriber, including the APTC
amount. The Premium Amount may include more than the
amount charged directly to a subscriber. The Premium
Amount does not represent an amount paid by a
subscriber.
CREATN_DT
DATETIME
Null
INACTIVATION_DT
DATETIME
Null

policy is active.
LAST_CNFRMED_DT
DATETIME
Null
LAST_MDFYD_DT
DATETIME
Null
MDFYD_BY
VARCHAR(255)
Null
Deprecated.
ISSR_ORG_ID
VARCHAR(5)
Not Null
ENRLMT_MNT_TYPE_CD
VARCHAR(6)
Not Null

Valid values are:

policy

next year
PLCY_RATG_AREA_CD
VARCHAR(15)
Not Null

16
Table Name : MMBR_INSRNC_PLCY_CVRG_CRSS_YR_HSTY (Cont.)
Group: Member Table
Table Definition: This table hosts the system generated cross-year enrollment periods for each RA run.
Column Name
Data Type
Null Option Type
Column Definition
INSRD_MMBR_STUS_CD
CHAR(2)
Not Null
0 inactive
1 active
CREATD_BY
VARCHAR(255)
Null
Deprecated.
INSRD_MMBR_ID
INT(10)
Not Null

member.
S Subscriber

populated.
SBSCBR_IND
CHAR(1)
Null
SBSCBR_ID
CHAR(80)
Null
RCRD_IDNTFR
BIGINT(19)
Not Null
RI_FLAG
VARCHAR(1)
Null
17
13.
MMBR_INSRNC_PLCY_CVRG_PROFILE_ASCTN
Table Name : MMBR_INSRNC_PLCY_CVRG_PROFILE_ASCTN

Group: Member Table
Table Definition: This table stores mapping between policy ID and insured member policy coverage ID.
Column Name
Data Type
Null Option Type
Column Definition
MMBR_INSRNC_PLCY_CVRG_ID_PK_FK
BIGINT(19)
NOT NULL
Primary key for the Member Insurance Policy ID.
POLICY_ID
BIGINT(19)
NOT NULL
Generated Policy ID for the Member Insurance Policy

Coverage ID.
18
14.
PHARMACY_CLAIM
Table Name : PHARMACY_CLAIM

Group: Claim Table
Table Definition: This table has the ingested pharmacy claim data.
Column Name
Data Type
Null Option Type
Column Definition
ID
INT(10)
Not Null
JOBID
BIGINT(19)
Not Null
Reference to the job that inserted the record.
VARCHAR(80)
Null
Unique identifier of enrollee. This represents a

MASKED identifier; not a medical record number or
cardholder ID.
CLAIM_IDENTIFIER
VARCHAR(50)
Null
Unique number generated by issuer adjudication

system to uniquely identify the transaction.
CLAIM_PROCESSED_DATETIME
DATETIME
Null
The date and time when the claim was adjudicated

and resulted in a paid amount or reported
encounter.
PRESCRIPTION_FILL_DATE
DATE
Not Null
Indicates the date that the prescription was

dispensed by the dispensing pharmacy.
ISSUER_CLAIM_PAID_DATE
DATE
Null

issued by the insurance company/issuer to the
vendor for paid claims. For encounters, the date
paid means the date of claim adjudication.
PRESCRIPTION_FILL_NUMBER
INT(10)
Null
Code identifying whether the prescription is an

original (01) or refill (02-99).
PRESCRIPTION_SERVICE_REFEREN
CE_NUMBER
VARCHAR(255)
Null
Unique number assigned by the pharmacy to the

dispensed prescription.
NATIONAL_DRUG_CODE
VARCHAR(255)
Null
Unique ID of the product or service dispensed

[National Drug Code (NDC) code].
DISPENSING_PROVIDER
_IDENTIFIER
VARCHAR(255)
Null
The Dispensing Provider's identification number

(NPI or unique Issuer assigned Provider ID).
DISPENSING_PROVIDER_ID_QUALIFI
ER
VARCHAR(255)
Null
Identifies the type of dispensing provider ID being

submitted in the Dispensing Provider ID field.
DISPENSING_STATUS_CODE
VARCHAR(1)
Null
Indicates if the prescription was a partial or the

completion of a partial fill. Valid values are:
Null, Empty Complete fill
P Partial fill
C Completion of a previous partial fill
POLICY_PAID_AMOUNT
DECIMAL(18,2)
Null
The total cost of the product/service paid by the

plan.
DERIVED_SERVICE_CLAIM_INDICAT
OR
VARCHAR(1)
Null
Indicator used to distinguish between fee-for-service

claims and claims covered under capitation. Valid
values are:
Y Capitated
N Fee-for-Service
INSURANCE_PLAN_IDENTIFIER
VARCHAR(80)
Null
Unique insurance plan identifier covering this claim.
19
Table Name : PHARMACY_CLAIM (Cont.)
Group: Claim Table
Table Definition: This table has the ingested pharmacy claim data.
Column Name
Data Type
Null Option Type
Column Definition
ISSUER_IDENTIFIER
VARCHAR(80)
Null
VOID_REPLACE_CODE
VARCHAR(1)
Null
Identifies if a previously accepted claim is

to be voided or replaced. Valid values are:
V Void
R Replace
Null, Empty Original
ALLOWED_TOTAL_COST_AMOUNT
DECIMAL(18,2)
Null
Represents the sum of allowed charges for

ingredient cost, dispensing fee, and sales
tax.
CREATION_DATE
DATETIME
Null
Date when this row/claim was created in

the database.
LAST_MODIFIED_DATE
DATETIME
Null
Date when this row/claim was modified in

the database.
CREATED_BY
VARCHAR(255)
Null
User ID that created this row/claim in the

database.
MODIFIED_BY
VARCHAR(255)
Null
User ID that modified this row/claim in the

database.
LAST_CONFIRMED_DATE
DATETIME
Null
Date when this claim was last updated by

an inbound XML file.
INACTIVATION_DATE
DATETIME
Null
Date when this claim was inactivated, null

if claim active.
CLAIM_TRANSACTION_TYPE
VARCHAR(1)
Not Null
Indicates claim type. Valid values are:
V Void
R Replace
O Original
BENEFIT_YEAR
VARCHAR(4)
Not Null
Benefit year of the pharmacy claim.
RI_FLAG
VARCHAR(1)
Null
RI claim selection flag to indicate if claim

qualifies for RI.
20
15.
PRM_STBLZN_SUBMSN_STUS
Table Name : PRM_STBLZN_SUBMSN_STUD

Group: Member Table
Category: Transitional Table
Table Definition: This table has meta information about the file ingest processes run by the system.
Column Name
Data Type
Null Option Type
Column Definition
RCVD_SUBMSN_ID
BIGINT(19)
Not Null
The unique Job ID for the batch job.
RCVD_SUBMSN_DT_TIME
DATETIME
Null
Date and time of the inbound XML file

submission.
ISSR_PROCD_RUN_DT
DATETIME
Null
Date and time when the inbound XML file

was generated.
CREATN_DT
DATETIME
Null
Creation date of this row in the database.
FIL_ID
VARCHAR(12)
Null
Unique file identifier from the inbound XML

file.
SBMTTING_ORG_ID
VARCHAR(5)
Null
ZN_CD
VARCHAR(1)
Null
Indicator to denote which environment the

inbound XML file is intended. Valid values
are:
T Test
P Production
SUBMSN_STUS_CD
VARCHAR(1)
Null
Deprecated.
SUBMSN_TYPE_CD
VARCHAR(1)
Null
Submission type code. Valid values are:
M Medical Claim
P Pharmacy Claim
E Enrollment
EXCTN_STUS_CD
VARCHAR(2)
Null
Deprecated.
PRCSG_STUS_CD
VARCHAR(2)
Null
Status of the job. Valid values are:
01 In Progress
02 Failed
03 Completed successfully
FIL_STUS_CD
VARCHAR(2)
Null
Status of the inbound file. Valid values are:
04 Header validation failed
05 File accepted
06 File rejected
FIL_NM
VARCHAR(34)
Null
Inbound XML file name.
GENERIC_INFO
BLOB
Null
Deprecated.
VERSION
VARCHAR(25)
Null
EDGE server version information.
INBOUND_FILE_HASH
VARCHAR(100)
Null
MD5 hash of the inbound XML file.
DETAIL_REPORT_HASH
VARCHAR(100)
Null
MD5 hash of the detail error report.
JOB_END_DT
DATETIME
Null
Date and time when file processing

completed.
RA_PROCESSED
BIT(1)
TRUE
Flag to indicate if record was included for

risk assurance.
21
16.
RECORD_LEVEL_HIER
Table Name : RECORD_LEVEL_HIER

Category: Transitional Table (internal application table)
Table Definition: The table is used to verify record level hierarchy reference codes, and used as the basis for file ingestion error
reports.
Column Name
Data Type
Null Option Type
Column Definition
UID
INT(10)
Not Null
JOBID
BIGINT(19)
Not Null
Reference to the job that inserted the

record.
RECORDID
BIGINT(19)
Not Null
Unique identifier for each record in the

received file.
PARENT_RECORDID
BIGINT(19)
Null
Parent record identifier, internally used by

the application for report generation.
RECORDLEVEL
VARCHAR(45)
Not Null
The record level is used to record the

different levels in the file. For instance,
issuer level, plan level, enrollee level,
enrollment period level, claim detail level,
and claim service line level, etc.
CURRENT_ELEMENTID
VARCHAR(100)
Null
Current Element ID Value, internally used

by the application for report generation.
Null
Describes the type of inbound XML file

submitted. Valid values are:
M Medical Claim
P Pharmacy Claim
E Enrollment
Not Null
Describes the status type of the processed

data element in a received inbound file.
Valid values are:
A Accept
R Reject
I Informational (Accepted with

warning message)
SUBMISSIONTYPE
STATUS_TYPE
VARCHAR(80)
CHAR(2)
CLAIM_FORM_TYPE
CHAR(1)
Null
Indicator for claim form type. Only used for

medical claims.
Valid values are:
I Institutional
P Professional
CLAIM_REFDATE
VARCHAR(80)
Null
Internally used for reporting. Claim

reference date to reference current and
previous claims.
22
17.
RISKSCORE
Table Name : RISKSCORE

Group: Member Table
Category: Risk Score Report Table
Table Definition: This table stores data from risk score report.
Column Name
Data Type
Null Option
Type
Column Definition
BIGINT(19)
Not Null
Member Enrollee Policy Coverage ID (Primary Key).
JOB_ID
BIGINT(19)
Not Null
Job ID of the process run (Primary Key).
MODEL_SCORE
DECIMAL(33,15)
Not Null
Model score.
CSR_SCORE
DECIMAL(33,15)
Not Null
CSR factor quantity.
DEMOGRAPHIC_SCORE
DECIMAL(33,15)
Not Null
Demographic factor quantity.
RA_SCORE
DECIMAL(33,15)
Not Null
Risk assurance quantity.
CC_FLAG
VARCHAR(1)
Not Null
Conditional category code flag.
MODEL_TYPE
VARCHAR(20)
Not Null
Age model type valid values are:
Adult
Child
Infant
MAX_PERIOD_DATE
DATETIME
Not Null
Enrollment End Date.
RA_CLAIM_COUNT
INT(10)
Not Null
Risk assurance claim counts.
TOTAL_PLAN_PAID
VARCHAR(33)
Not Null
Total number of paid plans.
DX_TO_CC_UNIQUE_COUNT
INT(10)
Not Null
Unique Diagnosis Code to Condition Code (CC) code

count.
DX_TO_CC_COUNT
INT(10)
Not Null
Total Diagnosis Code to CC code count.
DX_UNIQUE_COUNT
INT(10)
Not Null
Unique Diagnosis Code count.
DX_COUNT
INT(10)
Not Null
Diagnosis Code count.
CC_UNIQUE_COUNT
INT(10)
Not Null
Unique CC code count.
HCC_UNIQUE_COUNT
INT(10)
Not Null
V3_INDICATOR
VARCHAR(10)
Not Null
SEVERITY_INTER_GRP
VARCHAR(10)
Not Null
INSRNC_PLAN_ID_REP
VARCHAR(14)
Not Null
Unique insurance plan identifier with 14 digits.
PLCY_RATG_AREA_CD
VARCHAR(15)
Not Null
Rating Area code.
INSRD_MMBR_ID
INT(10)
Not Null

member.
MMBR_MNTHS
DECIMAL(33,15)
Null
The number of enrollment months for the current period.
UTILIZER_IND
VARCHAR(1)
Null
An indicator that indicates whether the enrollee is a

utilizer.
CROSS_YEAR_CLAIM_UID
BIGINT(19)
Null
Null
F Female
M Male
U Unknown (accepted only for newborns)
GNDR_CD
23
VARCHAR(1)
Holds the unique number of Hierarchal Condition

Category (HCC) codes.
'Y' or 'N' depending if there is a severity interaction
indicator.
The severity level interaction level either 'M' for medium
or 'H' for high or blank for no severity interaction.
Table Name : RISKSCORE (Cont.)
Group: Member Table
Table Definition: This table stores data from risk score report.
Column Name
Data Type
Null Option
Type
Column Definition
ARF_AGE
INT(10)
Null
The allowable rating factor (ARF) age of the enrollee.
LAST_AGE
INT(10)
Null
The age of the enrollee in the last day of enrollment.
INFANT_HCC_SEVERITY
VARCHAR(3)
Null
HCC severity code for infants.
INFANT_HCC_MATURITY
VARCHAR(3)
Null
Maturity code for infants.
RCVD_INSRD_MMBR_ID
VARCHAR(80)
Not Null

CVRG_EFCTV_STRT_DT
DATE
Not Null

CVRG_EFCTV_END_DT
DATE
Not Null

MTL_LVL
VARCHAR(2)
Not Null
Metal Level Code.
EXCHANGE_TYPE
VARCHAR(25)
Not Null
MARKET_TYPE
VARCHAR(20)
Not Null
24
Exchange Type. Values are:
On the exchange
Off the exchange

Market type describes where the plan is offered for
purchase. Valid values are:
'1' Individual
'2' Small group
18.
RISKSCORE_REMOTE
Table Name : RISKSCORE_REMOTE

Group: Member Table
Table Definition: This table stores data from risk score report. It is prepared for RADV 15.0.
Column Name
Data Type
Null Option
Type
Column Definition
BIGINT(19)
Not Null
Member Enrollee Policy Coverage ID (Primary Key).
JOB_ID
BIGINT(19)
Not Null
Job ID of the process run (Primary Key).
MODEL_SCORE
DECIMAL(33,15)
Not Null
Model score.
CSR_SCORE
DECIMAL(33,15)
Not Null
CSR factor quantity.
DEMOGRAPHIC_SCORE
DECIMAL(33,15)
Not Null
Demographic factor quantity.
RA_SCORE
DECIMAL(33,15)
Not Null
Risk assurance quantity.
CC_FLAG
VARCHAR(1)
Not Null
Conditional category code flag.
MODEL_TYPE
VARCHAR(20)
Not Null
Age model type valid values are:
Adult
Child
Infant
MAX_PERIOD_DATE
DATETIME
Not Null
Enrollment End Date.
RA_CLAIM_COUNT
INT(10)
Not Null
Risk assurance claim counts.
TOTAL_PLAN_PAID
VARCHAR(33)
Not Null
Total number of paid plans.
INT(10)
Not Null
Unique Diagnosis Code to CC code count.
DX_TO_CC_COUNT
INT(10)
Not Null
Total Diagnosis Code to CC code count.
DX_UNIQUE_COUNT
INT(10)
Not Null
Unique Diagnosis Code count.
DX_COUNT
INT(10)
Not Null
CC_UNIQUE_COUNT
INT(10)
Not Null
HCC_UNIQUE_COUNT
INT(10)
Not Null
Holds the unique number of HCC codes.
V3_INDICATOR
VARCHAR(10)
Not Null
SEVERITY_INTER_GRP
VARCHAR(10)
Not Null
INSRNC_PLAN_ID_REP
VARCHAR(14)
Not Null
PLCY_RATG_AREA_CD
VARCHAR(15)
Not Null
Rating Area code.
INSRD_MMBR_ID
INT(10)
Not Null

member.
MMBR_MNTHS
DECIMAL(33,15)
Null
The number of enrollment months for the current period.
UTILIZER_IND
VARCHAR(1)
Null
An indicator that indicates whether the enrollee is a

utilizer.
CROSS_YEAR_CLAIM_UID
BIGINT(19)
Null
GNDR_CD
VARCHAR(1)
Null
F Female
M Male
U Unknown (accepted only for newborns)
ARF_AGE
INT(10)
Null
The ARF age of the enrollee.
25
'Y' or 'N' depending if there is a severity interaction

indicator.
The severity level interaction level either 'M' for medium
or 'H' for high or blank for no severity interaction.
Table Name : RISKSCORE_REMOTE (Cont.)
Group: Member Table
Table Definition: This table stores data from risk score report. It is prepared for RADV 15.0.
Column Name
Data Type
Null Option
Type
Column Definition
LAST_AGE
INT(10)
Null
The age of the enrollee in the last day of enrollment.
INFANT_HCC_SEVERITY
VARCHAR(3)
Null
HCC severity code for infants.
INFANT_HCC_MATURITY
VARCHAR(3)
Null
Maturity code for infants.
RCVD_INSRD_MMBR_ID
VARCHAR(80)
Not Null

CVRG_EFCTV_STRT_DT
DATE
Not Null

CVRG_EFCTV_END_DT
DATE
Not Null

MTL_LVL
VARCHAR(2)
Not Null
Metal Level Code.
EXCHANGE_TYPE
VARCHAR(25)
Not Null
MARKET_TYPE
VARCHAR(20)
Not Null
26
Exchange Type. Values are:
On the exchange
Off the exchange

Market type describes where the plan is offered for
purchase. Valid values are:
'1' Individual
'2' Small group
19.
STNG_ENRLMT_SUBMSN
Table Name : STNG_ENRLMT_SUBMSN

Category: Transitional Data Table (for application internal use only)
Table Definition: This is a table used by the application to internally stage the enrollment submission files. It should not be
modified.
Column Name
Data Type
Null Option Type
Column Definition
RCVD_SUBMSN_ID
BIGINT(19)
Not Null
UID
BIGINT(19)
Not Null
Unique row identifier.
FILEIDENTIFIER
VARCHAR(80)
Not Null
Unique identifier for each inbound XML enrollment file.
EXECUTIONZONECODE
VARCHAR(80)
Not Null
Indicator to denote the environment the file is submitted. Valid

values are:
T Test
P Production
GENERATIONDATETIME
VARCHAR(80)
Not Null
The date indicating when the issuer generated the file.
SUBMISSIONTYPECODE
VARCHAR(80)
Not Null
Type of the inbound XML file. Valid values are:
M Medical Claim
P Pharmacy Claim
E Enrollment
INSUREDMEMBERTOTALQUA
NTITY
VARCHAR(80)
Not Null
Total count of enrollee records included in the submitted

enrollment file.
INSUREDMEMBERPROFILETO
TALQUANTITY
VARCHAR(80)
Not Null
Total count of enrollment period records for all enrollees

submitted in the enrollment file.
ISSUERRECORDIDENTIFIER
VARCHAR(80)
Null
Unique identifier for each record in the enrollment file.
ISSUERIDENTIFIER
VARCHAR(80)
Null
ISSUERINSUREDMEMBERTOT
ALQUANTITY
VARCHAR(80)
Null
Total count of enrollee records included in the submitted

enrollment file for the issuer.
ISSUERINSUREDMEMBERPR
OFILETOTALQUANTITY
VARCHAR(80)
Null
Total count of enrollment period records for all enrollees

submitted by the Issuer in the enrollment file.
ENROLLEEREOCRDIDENTIFIE
R
VARCHAR(80)
Null
INSUREDMEMBERIDENTIFIER
VARCHAR(80)
Null
Unique identifier for the enrollee. This represents a MASKED

Issuers should use the same Unique Enrollee ID if the enrollee
switches plans within the issuer.
INSUREDMEMBERBIRTHDATE
VARCHAR(80)
Null
Date of birth of enrollee.
VARCHAR(80)
Null
Gender of enrollee.
VARCHAR(80)
Null
SUBSCRIBERINDICATOR
VARCHAR(80)
Null
Indicates when the enrollee linked to this enrollment period

record is also the subscriber. A subscriber is defined as the
primary insured party.
SUBSCRIBERIDENTIFIER
VARCHAR(80)
Null
The identifier of the subscriber on the policy.
INSURANCEPLANIDENTIFIER
VARCHAR(80)
Null
Unique identifier for insurance plan offered by issuer that the

enrollee is covered under. The Plan ID will correspond to the
HIOS Standard Component ID. The Plan ID includes the CSR
variant.
COVERAGESTARTDATE
VARCHAR(80)
Null

INSUREDMEMBERGENDERCO
DE
ENROLLMENTPERIODRECOR
DIDENTIFIER
27
Table Name : STNG_ENRLMT_SUBMSN (Cont.)
Table Definition: This is a table used by the application to internally stage the enrollment submission files. It should not be
modified.
Column Name
Data Type
Null
Option
Type
Column Definition
COVERAGEENDDATE
VARCHAR(80)
Null
The date when the enrollment coverage for the

enrollee is no longer effective for the associated plan.
INSURANCEPLANPREMIUMAMOUNT
VARCHAR(80)
Null
The Premium Amount is the monthly total rated

premium charged by the issuer for a subscriber,
including the APTC amount. The Premium Amount
may include more than the amount charged directly to
a subscriber. The Premium Amount does not represent
an amount paid by a subscriber.
RATEAREAIDENTIFIER
VARCHAR(80)
Null
Rating Area used for the enrollee in the plan.

If enrollee is not rated, use the subscriber Rating Area.
PRCSG_STUS
CHAR(1)
Null
Status of the processing row.
VALIDATIONFLAG
CHAR(1)
Not Null
Flag indicating the validation status of the claim.
INTERFACECONTROLRELEASENUMBER
VARCHAR(80)
Null
Denotes the version number of the Interface Control

Document (ICD) that the file corresponds to as
identified on page 1 of this document. A file must have
the latest version number to be accepted. The last two
(2) digits of the version, however, reflect a cosmetic
change to the ICD and are not validated.
ENROLLMENTMAINTENANCETYPECODE
VARCHAR(80)
Null
Identifies the type of activity associated with the

creation of an enrollment period.
VALIDATIONDATE
VARCHAR(80)
Null
Date this enrollee was last validated.
POLICYID
VARCHAR(80)
Null
Policy ID.
POLICYSTARTDATE
VARCHAR(80)
Null
Policy start date.
POLICYENDDATE
VARCHAR(80)
Null
Policy end date.
28
20.
STNG_INSRD_MMBR_CC_ASSOC
Table Name : STNG_INSRD_MMBR_CC_ASSOC

Table Definition: This is an association table between INSRD_MMBR_ID and associated Conditional Category calculated in Risk
Score calculation. It is used for application to internally stage the data. It should not be modified.
Column Name
Data Type
Null Option Type
Column Definition
UID
INT(10)
Not Null
INSRD_MMBR
INT(10)
Not Null
Foreign key to the enrollee table to identify

the associated member.
CC
VARCHAR(30)
Not Null
The associated CC code per unique

identifier of enrollee.
29
21.
STNG_INSRD_MMBR_DGNS_ASSOC_ACCEP
Table Name : STNG_INSRD_MMBR_DGNS_ASSOC_ACCEP

Table Definition: This is an association table between INSRD_MMBR_ID and associated Diagnosis Codes that have been mapped
to CC codes on RA eligible claims. It is used for application to internally stage the data. It should not be modified.
Column Name
Data Type
Null Option Type
Column Definition
UID
INT(10)
Not Null
INSRD_MMBR
INT(10)
Not Null

DGNS
VARCHAR(30)
Not Null
The associated Diagnosis Code per

unique identifier of enrollee.
MEDICAL_CLAIM_UID
VARCHAR(50)
Not Null
The unique medical Claim ID the

Diagnosis Code came from.
30
22.
STNG_INSRD_MMBR_DGNS_UTI_ASSOC
Table Name : STNG_INSRD_MMBR_DGNS_UTI_ASSOC

Table Definition: This is an association table between INSRD_MMBR_ID and associated Diagnosis Codes on RA eligible claims. It
is used for application to internally stage the data. It should not be modified.
Column Name
Data Type
Null Option Type
Column Definition
UID
INT(10)
Not Null
INSRD_MMBR
INT(10)
Not Null

DGNS
VARCHAR(30)
Not Null
The associated Diagnosis Code per

unique identifier of enrollee.
MEDICAL_CLAIM_UID
VARCHAR(50)
Not Null
The unique medical Claim ID the

Diagnosis Code came from.
31
23.
STNG_INSRD_MMBR_DROP_HCC_ASSOC
Table Name : STNG_INSRD_MMBR_DROP_HCC_ASSOC

Table Definition: This is an association table between INSRD_MMBR_ID and associated HCC Codes that were dropped during Risk
Score. It is used for application to internally stage the data. It should not be modified.
Column Name
Data Type
Null Option Type
Column Definition
UID
INT(10)
Not Null
INSRD_MMBR_ID
INT(10)
Not Null

DROPPED_HCC_CD
VARCHAR(30)
Not Null
The dropped HCC code per unique

32
24.
STNG_INSRD_MMBR_HCC_ASSOC
Table Name : STNG_INSRD_MMBR_HCC_ASSOC

Table Definition: This is an association table between INSRD_MMBR_ID and associated HCC Codes calculated in Risk Score
calculation. It is used for application to internally stage the data. It should not be modified.
Column Name
Data Type
Null Option Type
Column Definition
UID
INT(10)
Not Null
INSRD_MMBR
INT(10)
Not Null

HCC
VARCHAR(30)
Not Null
The associated HCC code per unique

33
25.
STNG_INSRD_MMBR_HCC_GROUP_ASSOC
Table Name : STNG_INSRD_MMBR_HCC_GROUP_ASSOC

Table Definition: This is an association table between INSRD_MMBR_ID and associated HCC Group Codes. It is used for
application to internally stage the data. It should not be modified.
Column Name
Data Type
Null Option Type
Column Definition
UID
INT(10)
Not Null
INSRD_MMBR
INT(10)
Not Null

HCC_GROUP
VARCHAR(45)
Not Null
The associated HCC Group Code.
34
26.
STNG_MDCL_SUBMSN
Table Name : STNG_MDCL_SUBMSN

Table Definition: This is a table used for application to internally stage the medical submission data. It should not be modified.
Column Name
Data Type
Null
Option
Type
Column Definition
RCVD_SUBMSN_ID
BIGINT(19)
Not Null
UID
BIGINT(19)
Not Null
FILEIDENTIFIER
VARCHAR(80)
Not Null
Unique identifier for each inbound medical file.
EXECUTIONZONECODE
VARCHAR(80)
Not Null
Indicator to denote for which environment the file is

intended. Valid values are:
T Test
P Production
GENERATIONDATETIME
VARCHAR(80)
Not Null
The date indicating when the issuer generated the file.
SUBMISSIONTYPECODE
VARCHAR(80)
Not Null
Type of the inbound XML file. Valid values are:
M Medical Claim
P Pharmacy Claim
E Enrollment
CLAIMDETAILTOTALQUANTITY
VARCHAR(80)
Not Null
Total count of claims in the file.
CLAIMSERVICELINETOTALQUANTITY
VARCHAR(80)
Not Null
Total count of claim lines in the file.
INSURANCEPLANPAIDONFILETOTALAMOUNT
VARCHAR(80)
Not Null
Total amount paid for all claims on the file.
VARCHAR(80)
Null
Unique identifier for each record in the medical claim

file.
ISSUERIDENTIFIER
VARCHAR(80)
Null
ISSUERCLAIMDETAILTOTALQUANTITY
VARCHAR(80)
Null
Total count of claims on the file for the issuer.
ISSUERCLAIMSERVICELINETOTALQUANTITY
VARCHAR(80)
Null
Total count of claim lines for all claims for the issuer.
ISSUERPLANPAIDTOTALAMOUNT
VARCHAR(80)
Null
Total amount paid by issuer for claims on this file.
PLANRECORDIDENTIFIER
VARCHAR(80)
Null
Unique identifier for each record in the medical claim

file.
VARCHAR(80)
Null
Unique identifier for insurance plan offered by issuer

that the enrollee is covered under. The Plan ID
includes the CSR variant.
INSURANCEPLANCLAIMDETAILTOTALQUANTI
TY
VARCHAR(80)
Null
Total count of claims for this plan.
INSURANCEPLANCLAIMSERVICELINETOTALQ
UANTITY
VARCHAR(80)
Null
Total count of claim lines for all claims for the plan.
INSURANCEPLANPAIDTOTALAMOUNT
VARCHAR(80)
Null
Total amount paid for all claims by the plan.
MEDICALHEADERRECORDIDENTIFIER
VARCHAR(80)
Null
Unique identifier for each record in medical claim file.
Null
Unique identifier for the enrollee. This represents a

cardholder ID. Issuers should use the same Unique
Enrollee ID if the enrollee switches plans within the
issuer.
35
VARCHAR(80)
Table Name : STNG_MDCL_SUBMSN (Cont.)
Table Definition: This is a table used for application to internally stage the medical submission data. It should not be modified.
Column Name
Data Type
Null
Option
Type
Column Definition
FORMTYPECODE
VARCHAR(80)
Null
Describes claim form type as professional or

institutional.
CLAIMDIDENTIFIER
VARCHAR(80)
Null
Unique number generated by the issuer adjudication

system to uniquely identify the transaction. The issuer
adjudicated Claim ID may be de-identified by the
issuer.
ORIGINALCLAIMIDENTIFIER
VARCHAR(80)
Null
The Claim ID submitted on a previous claim file that

the issuer intends to void or replace.
CLAIMPROCESSEDDATETIME
VARCHAR(80)
Null
The date and time when the claim was adjudicated and
resulted in a paid amount or reported encounter.
BILLTYPECODE
VARCHAR(80)
Null
The code indicating a specific type of bill as reported

on institutional claims only.
VOIDREPLACECODE
VARCHAR(80)
Null
Identifies if a previously accepted claim is to be voided

or replaced.
DIAGNOSISTYPECODE
VARCHAR(80)
Null
Indicates if the Diagnosis Code ICD-9ICD-10.
DIAGNOSISCODE
BLOB
Null
Code value for the Diagnosis Code as determined by

classification of International Classification of
Diseases. Saved as a Blob in database.
ADMISSIONDATE
VARCHAR(80)
Null
Date of admission for inpatient.
DISCHARGEDATE
VARCHAR(80)
Null
Date of discharge for inpatient.
DISCHARGESTATUSCODE
VARCHAR(80)
Null
The facility discharge status of the enrollee.
STATEMENTCOVERFROMDATE
VARCHAR(80)
Null
Earliest Date of Service on the submitted claim (for

inpatient claims this would be the admission date).
STATEMENTCOVERTODATE
VARCHAR(80)
Null
Latest Date of Service on the submitted claim (for

inpatient claims this would be the discharge date).
BILLINGPROVIDERIDQUALIFIER
VARCHAR(2)
Null
Identifies the type of Provider ID being submitted in the

Billing Provider ID field.
BILLINGPROVIDERIDENTIFIER
VARCHAR(80)
Null
The Billing Provider's Identification (NPI or unique

issuer assigned provider ID).
ALLOWEDTOTALAMOUNT
VARCHAR(80)
Null
Total amount allowed for this claim.
POLICYPAIDTOTALAMOUNT
VARCHAR(80)
Null
Total paid amount for this claim.
SERVICELINES
BLOB
Null
A database Blob object of the service lines on the

claim.
SERVICELINECOUNT
INT(10)
Not Null
Number of service lines on the claim.
PRCSG_STUS
CHAR(1)
Null
Status of the processing row.
VALIDATIONFLAG
INT(10)
Not Null
Flag indicating the validation status of the claim/service

lines.
SERVICEPAIDDATE
VARCHAR(80)
Not Null

issued for paid claims. For encounters, the date paid
means the date of claim adjudication.
DERIVEDSERVICECLAIMINDICATOR
CHAR(1)
Not Null
Indicator used to distinguish between fee-for-service

claims and claims covered under capitation.
36
27.
STNG_MMBR_INSRNC_PLCY_CVRG_CRSS_YR
Table Name : STNG_MMBR_INSRNC_PLCY_CVRG_CRSS_YR

Category: Transitional Data Table (for application internal use)
Table Definition: This is a table used by the application to internally stage the cross-year enrollment submission files. It should not
be modified.
Column Name
Data Type
Null Option Type
Column Definition
BIGINT(19)
Not Null
MEDICAL_CLAIM_UID
BIGINT(19)
Null
RCVD_SUBMSN_ID
BIGINT(19)
Not Null
INSRNC_PLAN_ID
VARCHAR(16)
Not Null

the CSR variant.
CVRG_EFCTV_STRT_DT
DATE
Null

CVRG_EFCTV_END_DT
DATE
Null

INSRNC_PLAN_PRM_AMT
DECIMAL(18,2)
Null

charged by the issuer for a subscriber, including the APTC
amount. The Premium Amount may include more than the
amount charged directly to a subscriber. The Premium
Amount does not represent an amount paid by a
subscriber.
CREATN_DT
DATETIME
Null
INACTIVATION_DT
DATETIME
Null

policy is active.
LAST_CNFRMED_DT
DATETIME
Null
LAST_MDFYD_DT
DATETIME
Null
MDFYD_BY
VARCHAR(255)
Null
Deprecated.
ISSR_ORG_ID
VARCHAR(5)
Not Null
ENRLMT_MNT_TYPE_CD
VARCHAR(6)
Not Null

Valid values are:

policy

next year
PLCY_RATG_AREA_CD
VARCHAR(15)
Not Null

37
Table Name : STNG_MMBR_INSRNC_PLCY_CVRG_CRSS_YR (Cont.)
Category: Transitional Data Table (for application internal use)
Table Definition: This is a table used by the application to internally stage the cross-year enrollment submission files. It should not
be modified.
Column Name
Data Type
Null Option Type
Column Definition
INSRD_MMBR_STUS_CD
CHAR(2)
Not Null
0 inactive
1 active
CREATD_BY
VARCHAR(255)
Null
Deprecated.
INSRD_MMBR_ID
INT(10)
Not Null

member.
Null

S Subscriber
SBSCBR_IND
CHAR(1)
SBSCBR_ID
CHAR(80)
Null

populated.
RCRD_IDNTFR
BIGINT(19)
Not Null
RI_FLAG
VARCHAR(1)
Null
INSRNC_PLAN_ID_REP
VARCHAR(14)
Not Null
38
28.
STNG_MMBR_INSRNC_PLCY_CVRG_PROFILE_ASCTN
Table Name : STNG_MMBR_INSRNC_PLCY_CVRG_PROFILE_ASCTN

Table Definition: This is a table used by the application to internally stage the policy ID and insured member policy coverage ID for
cross-year enrollment submission files. It should not be modified.
Column Name
Data Type
Null Option Type
Column Definition
MMBR_INSRNC_PLCY_CVRG_ID_PK_FK
BIGINT(19)
NOT NULL
Primary key for the Member Insurance Policy ID.
POLICY_ID
BIGINT(19)
NOT NULL
Generated Policy ID for the Member Insurance Policy

Coverage ID.
39
29.
STNG_PHRMCY_SUBMSN
Table Name : STNG_PHRMCY_SUBMSN

Table Definition: This is a table used by the application to internally stage the pharmacy submission data. It should not be
modified.
Column Name
Data Type
Null
Option
Type
Column Definition
RCVD_SUBMSN_ID
BIGINT(19)
Not Null
Reference to the job that is inserted into

the record.
UID
BIGINT(19)
Not Null
FILEIDENTIFIER
VARCHAR(80)
Not Null
Unique identifier for each inbound

pharmacy file.
EXECUTIONZONECODE
VARCHAR(80)
Not Null
Indicators to denote which environment the

file is intended. Valid values are:
T Test
P Production
VARCHAR(80)
Null
Denotes the version number of the ICD

that the file corresponds to as identified on
page 1 of this document. A file must have
the latest version number to be accepted.
The last two (2) digits of the version,
however, reflect a cosmetic change to the
ICD and are not validated.
GENERATIONDATETIME
VARCHAR(80)
Not Null
The date and time that the claim

submission was generated.
SUBMISSIONTYPECODE
VARCHAR(80)
Not Null
Type of the inbound file. Valid values are:
M Medical Claim
P Pharmacy Claim
E Enrollment
CLAIMDETAILTOTALQUANTITY
VARCHAR(80)
Not Null
The total number of claim details that exist

for a given claim.
INSURANCEPLANPAIDONFILETOTALAMOUNT
VARCHAR(80)
Not Null
Total amount paid for all claims on this file.
VARCHAR(80)
Null
The record identifier of the issuer.
ISSUERIDENTIFIER
VARCHAR(80)
Null
ISSUERCLAIMDETAILTOTALQUANTITY
VARCHAR(80)
Null
The total number of claim details for a

given issuer.
ISSUERPLANPAIDTOTALAMOUNT
VARCHAR(80)
Null
The total amount that was paid to a given

issuer and insurance plan.
VARCHAR(80)
Null
The record identifier for the insurance plan.
VARCHAR(80)
Null
The identifier for the insurance plan.
INSURANCEPLANCLAIMDETAILTOTALQUANTITY
VARCHAR(80)
Null

given insurance plan.
POLICYPAIDTOTALAMOUNT
VARCHAR(80)
Null
The total amount was paid to a given

policy.
PHARMACYDETAILRECORDIDENTIFIER
VARCHAR(80)
Null
The record identifier for the pharmacy

detail record.
VARCHAR(80)
Null
The identifier for a given insured member.
40
Table Name : STNG_PHRMCY_SUBMSN (Cont.)
Table Definition: This is a table used by the application to internally stage the pharmacy submission data. It should not be
modified.
Column Name
Data Type
Null
Option
Type
Column Definition
CLAIMIDENTIFIER
VARCHAR(80)
Null
The identifier for a given claim.
CLAIMPROCESSEDDATETIME
VARCHAR(80)
Null
The date and time that the claim was being

processed.
PRESCRIPTIONFILLDATE
VARCHAR(80)
Null
The date the prescription was filled.
ISSUERCLAIMPAIDDATE
VARCHAR(80)
Null
The date the issuer claim was paid.
INSUREDMEMBERCLAIMPAIDDATE
VARCHAR(80)
Null
The date the insurance member claim was

paid.
PRESCRIPTIONSERVICEREFERENCENUMBER
VARCHAR(80)
Null
Unique number assigned by the pharmacy

to the dispensed prescription.
NATIONALDRUGCODE
VARCHAR(80)
Null
Unique ID of the product or service

dispensed (NDC code).
DISPENSINGPROVIDERIDQUALIFIER
VARCHAR(80)
Null
Identifies the qualifier of the Dispensing

Provider Identifier being submitted in the
Dispensing Provider ID field.
DISPENSINGPROVIDERIDENTIFIER
VARCHAR(80)
Null
Identifies the type of Dispensing Provider

ID being submitted in the Dispensing
Provider ID field.
PRESCRIPTIONFILLNUMBER
VARCHAR(80)
Null
Code identifying whether the prescription

is an original or refill.
DISPENSINGSTATUSCODE
VARCHAR(80)
Null
Indicates if the prescription was a partial fill

(P) or the completion of a partial fill (C).
VOIDREPLACECODE
VARCHAR(80)
Null
Identifies if a claim is to be voided or

replaced.
ALLOWEDTOTALCOSTAMOUNT
VARCHAR(80)
Null
Represents the sum of allowed charges for

ingredient cost, dispensing fee and sales
tax.
POLICYPAIDAMOUNT
VARCHAR(80)
Null
The total cost of the product/service paid

by the plan for a given policy.
DERIVEDSERVICECLAIMINDICATOR
VARCHAR(80)
Null
Indicator used to distinguish between feefor-service claims and claims covered

under capitation.
PRCSG_STUS
CHAR(1)
Null
The processing status.
VALIDATIONFLAG
BIGINT(19)
Null
The flag for the validation, either valid or

invalid.
41
30.
STNG_RADV_POPULATION
Table Name : STNG_RADV_POPULATION

Category: RADV Population Report Table
Table Definition: This table stores data on processing RADV population report.
Column Name
Data Type
Null Option Type
Column Definition
INSRD_MMBR_ID
INT(10)
Not Null
Insured Member ID (Primary Key).
RISK_SCORE_AVG
DECIMAL(65,30)
Not Null
Risk score average.
MODEL_TYPE
VARCHAR(20)
Not Null
Model type.
CC_FLAG
VARCHAR(1)
Not Null
Condition category flag.
STRATUM
VARCHAR(45)
Null
Statistical categories e.g. 1, 2, 9, 10.
MAX_PERIOD_DATE
VARCHAR(45)
Not Null
Enrollment period end date.
RA_CLAIM_COUNT
INT(10)
Not Null
Number of risk assurance claim counts.
TOTAL_PLAN_PAID
VARCHAR(45)
Not Null
Total plans that were paid.
INT(10)
Not Null
Unique Diagnosis Code to CC code.
DX_TO_CC_COUNT
INT(10)
Not Null
Total Diagnosis Code to CC code.
DX_UNIQUE_COUNT
INT(10)
Not Null
Diagnosis Code to CC code count.
DX_COUNT
INT(10)
Not Null
CC_UNIQUE_COUNT
INT(10)
Not Null
TOTAL_PREMIUM_AMT
VARCHAR(100)
Null
Total plan premium amount paid.
42
31.
STNG_REINSURANCE
Table Name : STNG_RADV_POPULATION

Category: Staging Table for Reinsurance
Table Definition: This table has temporary Reinsurance data.
Column Name
Data Type
Null Option Type
Column Definition
UID
INT(10)
Not Null
Unique ID.
INSRD_MMBR_ID
VARCHAR(80)
Null
Insured Member ID.
MEMBER_MONTHS
VARCHAR(80)
Null
Member months.
CSR_MOOP_ADJ
VARCHAR(80)
Null
CSR factor MOOP adjustment factor.
COINSURANCE_ADJ_TOTAL_RI_PAY
MENT
VARCHAR(80)
Null
Coinsurance adjustment total risk RI

payment.
INSRNC_PLAN_ID
VARCHAR(16)
Not Null
Insurance Plan ID.
CLAIM_ID
VARCHAR(50)
Null
Claim ID.
CLAIM_PAID_AMOUNT
VARCHAR(80)
Null
Claim paid amount.
CLAIM_ALLOWED_AMOUNT
VARCHAR(80)
Null
Claim allowed amount.
PERIOD_START_DATE
DATETIME
Null
Enrollment period start date.
PERIOD_END_DATE
DATETIME
Null
Enrollment period end date.
SUB_POLICY_ID
BIGINT(19)
Null
Sub policy ID.
CLAIM_TYPE
VARCHAR(1)
Null
Signifies the claim type of the claim, e.g.

M, P
CLAIM_FROM_DATE
DATETIME
Null
Claim from date.
43
32.
STNG_SPLMNTL_SUBMSN
Table Name : STNG_SPLMNTL_SUBMSN

Table Definition: This is a table used by the application to internally stage the supplemental submission data. It should not be
modified.
Column Name
Data Type
Null
Option
Type
Column Definition
RCVD_SUBMSN_ID
BIGINT(19)
Not Null
Reference to the job that is inserted into

the record.
UID
BIGINT(19)
Not Null
FILEIDENTIFIER
VARCHAR(80)
Not Null
Unique identifier for each inbound

supplemental file.
EXECUTIONZONECODE
VARCHAR(80)
Not Null
Indicators to denote which environment the

file is intended. Valid values are:
T Test
P Production
VARCHAR(80)
Null
Denotes the version number of the ICD

that the file corresponds to as identified on
page 1 of this document. A file must have
the latest version number to be accepted.
The last two (2) digits of the version,
however, reflect a cosmetic change to the
ICD and are not validated.
GENERATIONDATETIME
VARCHAR(80)
Not Null
The date and time that the claim

submission was generated.
SUBMISSIONTYPECODE
VARCHAR(80)
Not Null
Type of the inbound file. Valid values are:
M Medical Claim
P Pharmacy Claim
E Enrollment
FILEDETAILTOTALQUANTITY
VARCHAR(80)
Not Null
Total amount paid for all claims on this file.
VARCHAR(80)
Null
The record identifier of the issuer.
ISSUERIDENTIFIER
VARCHAR(80)
Null
ISSUERFILEDETAILTOTALQUANTITY
VARCHAR(80)
Null

given issuer.
VARCHAR(80)
Null
The record identifier for the insurance plan.
VARCHAR(80)
Null
The identifier for the insurance plan.
INSURANCEPLANFILEDETAILTOTALQUANTITY
VARCHAR(80)
Null

given insurance plan.
DETAILRECORDIDENTIFIER
VARCHAR(80)
Null
The record identifier for the supplemental

detail record.
VARCHAR(80)
Null
The identifier for a given insured member.
VARCHAR(80)
Null
The ID associated with the supplemental

claim.
VARCHAR(80)
Null
The Claim ID submitted on a previous

claim file that the issuer intends to void or
replace.
SUPPLEMENTALDIAGNOSISDETAILRECORDIDENTI
FIER
ORIGINALCLAIMIDENTIFIER
44
Table Name : STNG_SPLMNTL_SUBMSN (Cont.)
Table Definition: This is a table used by the application to internally stage the supplemental submission data. It should not be
modified.
Column Name
Data Type
Null
Option
Type
Column Definition
DETAILRECORDPROCESSEDDATETIME
VARCHAR(80)
Null
The date and time when the supplemental

diagnosis detail record was created by the
issuer.
ADDDELETEVOIDCODE
VARCHAR(80)
Null
Identifies if a previously accepted claim is

to be void or deleted.
ORIGINALSUPPLEMENTALDETAILID
VARCHAR(80)
Null
The Claim ID submitted on a previous

claim file that the issuer intends to void.
SERVICEFROMDATE
VARCHAR(80)
Null
Indicates the first day the service occurred

that supports the submission of a
supplemental diagnosis.
SERVICETODATE
VARCHAR(80)
Null
Indicates the last day the service occurred

that supports the submission of a
supplemental diagnosis.
DIAGNOSISTYPECODE
VARCHAR(80)
Null
Indicates if the Diagnosis Code is ICD-9 or

International.
SOURCECODE
VARCHAR(80)
Null
Identifies the source of the supplemental

diagnosis. Valid values are:
MR Medical record
EDI Electronic data

interchange
PRCSG_STUS
CHAR(1)
Null
The processing status.
VALIDATIONFLAG
INT(10)
Null
SUPPLEMENTALDIAGNOSISCODE
VARCHAR(80)
Null
The flag for the validation, either valid or

invalid.
Saved as a Blob in database.
45
33.
SUB_PLCY
Table Name : SUB_PLCY

Group: Member Table
Category: Sub Policy Table for Risk Score and Reinsurance
Table Definition: This table has the sub policy information.
Column Name
Data Type
Null Option Type
Column Definition
UID
BIGINT(19)
NOT NULL
Unique ID.
MMBR_INSRNC_PLCY_CVRG_ID_FK
BIGINT(19)
NOT NULL
Coverage ID of member insurance policy.
SUB_PLCY_STRT_DT
DATETIME
NOT NULL
Sub policy start date.
SUB_PLCY_END_DT
DATETIME
NOT NULL
Sub policy end date.
SUB_PLCY_ID
BIGINT(19)
NOT NULL
Sub policy ID.
POLICY_ID_FK
BIGINT(19)
NOT NULL
Policy ID Foreign key.
46
34.
SUPPLEMENTAL_CLAIM
Table Name: SUPPLEMENTAL_CLAIM

Group: Claim Table
Table Definition: This table stores the information related to supplemental claims.
Column Name
Data Type
Null Option Type
Column Definition
UID
INT(10)
NOT NULL
Unique identifier of the database row.
BENEFIT_YEAR
VARCHAR(4)
NOT NULL
The benefit year based for this claim, based on the

Statement Covers To Date.
SUPPLEMENTAL_DETAIL_ID
VARCHAR(50)
NULL
The ID associated with the supplemental claim.
JOB_ID
BIGINT(19)
NOT NULL
DETAIL_RECORD_PROCESSED_DATET
IME
DATETIME
NULL
The date and time when the supplemental diagnosis

detail record was created by the issuer.
SERVICE_FROM_DATE
DATE
NULL
Indicates the first day the service occurred that

supports the submission of a supplemental diagnosis.
SERVICE_TO_DATE
DATE
NULL
Indicates the last day the service occurred that

supports the submission of a supplemental diagnosis.
ISSUER_IDENTIFIER
VARCHAR(80)
NULL
VARCHAR(80)
NULL
Unique identifier for the enrollee. This represents a

cardholder ID. Issuers should use the same Unique
Enrollee ID if the enrollee switches plans within the
issuer.
ORIGINAL_CLAIM_IDENTIFIER
VARCHAR(50)
NULL
The medical Claim ID to which the supplemental

claim corresponds that was submitted on a previous
claim file and was accepted by the EDGE server.
ORIGINAL_SUPPLEMENTAL_DETAIL_ID
VARCHAR(50)
NULL
Identifies the original supplemental diagnosis detail

record when processing a VOID supplemental detail
record.
NULL
Identifies if a supplemental diagnosis is added.

Identifies if a previously submitted diagnosis is
deleted. Identifies if a previously accepted
supplemental diagnosis file is to be voided.
Valid values are:
A Add
D Delete
V Void
ADD_DELETE_VOID
47
VARCHAR(1)
Table Name: SUPPLEMENTAL_CLAIM (Cont.)
Group: Claim Table

Table Definition: This table stores the information related to supplemental claims.
Column Name
Data Type
Null Option Type
Column Definition
Indicates if the Diagnosis Code is
International Classification of Diseases 9CM (ICD 9-CM) or International
Classification of Diseases 10-CM (ICD 10CM).
Refer to the DGNS_CD_TYPE for valid
values.
Identifies the source of the supplemental
diagnosis. MR for medical record EDI for
electronic data interchanges. Only one (1)
code per supplemental diagnosis. Valid
values are:
MR Medical record
EDI Electronic data

interchange
DIAGNOSIS_TYPE_CODE
VARCHAR(2)
NULL
SUPPLEMENTAL_DIAGNOSIS_CODE
VARCHAR(30)
NULL
SOURCE_CODE
VARCHAR(3)
NULL
CREATION_DATE
DATETIME
NULL
Date when this row/claim was created in

the database.
LAST_MODIFIED_DATE
DATETIME
NULL
Date when this claim was last modified in

the database.
CREATED_BY
VARCHAR(255)
NULL
Deprecated.
MODIFIED_BY
VARCHAR(255)
NULL
Deprecated.
LAST_CONFIRMED_DATE
DATETIME
NULL
Date when this claim was last updated by

an inbound XML file.
INACTIVATION_DATE
DATETIME
NULL
Date when this claim was inactivated, null

if claim active.
MEDICAL_CLAIM_FAMILY_ID
BIGINT(19)
NULL
Unique identifier for a group of claims that

belong to the same claim family.
48
35.
SUB_PLCY_CLM_ASSOC
Table Name : SUB_PLCY_CLM_ASSOC

Group: Member Table
Table Definition: This table has the association between the sub policy and the medical claims.
Column Name
Data Type
Null Option Type
Column Definition
UID
BIGINT(19)
NOT NULL
Unique ID.
CLAIM_TYPE
VARCHAR(2)
NOT NULL
Claim type.
CLAIM_UID
BIGINT(19)
NOT NULL
Claim Unique ID.
SUB_PLCY_UID_FK
BIGINT(19)
NOT NULL
Sub policy unique ID foreign key.
49
36.
SUB_CLM_DGNS_CD_ASCTN
Table Name : SUB_CLM_DGNS_CD_ASCTN

Group: Claim Table
Table Definition: This table has the ingested Diagnosis Codes from the supplemental claims.
Column Name
Data Type
Null Option Type
Column Definition
UID
BIGINT(19)
Not Null

database row.
SUPPLEMENTAL_CLAIM_UID_FK
INT(10)
Null
The unique identifier of the supplemental

claim in the supplemental claim table that
this Diagnosis Code is associated. This is
a foreign key reference to
SUPPLEMENTAL_CLAIM.UID.
CREATN_DT
DATETIME
Null
This date is used to indicate when the

record is created.
CREATD_BY
VARCHAR(255)
Null
Deprecated.
LAST_MDFYD_DT
DATETIME
Null
The date and time the record is modified.
MDFYD_BY
VARCHAR(255)
Null
Deprecated.
ACTV_IND
VARCHAR(1)
Null
Deprecated.
DGNS_CD
VARCHAR(30)
Null

Refer to DGNS_CD_TYPE for valid
values.
DGNS_QLFYR_CD
VARCHAR(2)
Null
Indicates if the Diagnosis Code is ICD 9 or

ICD 10. Refer to DGNS_CD_QLFYR for
valid values.
50

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Centers for Medicare & Medicaid Services

EDGE Server Production and Test Schema

Document Version History

Added new tables: RISKSCORE, STNG_RADV_POPULATION,

Added new tables: SUBPLCY, SUB_PLCY_CLM_ASSOC, EDGE_EVENT_LOG,

Added a new column: MEDICAL_SRVC_LINE_NUM in table

Added group tag to the tables to group them logically. Changed

Added a new column: CLAIM_TYPE in table STNG_REINSURANCE.

Added a new table: SUP_CLM_DGNS_CD_ASCTN.

Added new tables: MMBR_INSRNC_PLCY_CVRG_CRSS_YR_HSTY,

HCC_UNIQUE_COUNT in table RISCKSCORE, V3_INDICATOR in table

Removed constraints from these staging tables: SUB_PLCY to

Added new columns: MEDICAL_CLAIM_FAMILY_ID in table

Added new columns: INSRNC_PLAN_ID_REP, PLCY_RATG_AREA_CD,

Null Option Type

Unique Liquibase ID.

EDGE server system.

XML file name in Liquibase.

Liquibase execution date.

UID that Liquibase is executed.

Checksum value of the changeset.

Specify the tag name when launching

Null Option Type

Number of records locked when launching

Date that lock is granted.

User that locked records when launching

Null Option Type

Unique database row identifier.

Unique identifier for each record in the received file.

The record level is used to record the different levels in

The element name represents the XML tag name of the

The value of the element as it was received on

Text description of error specific type that relates to

The code associated with the error.

A system generated Error Message for exceptions.

A pre-defined Error Message that corresponds to the

Reference to the job that inserted this record.

Type of record submitted. Valid values are:

Description of the error type associated with

2 For face validity

2 For face validity

Null Option Type

Describes the status type of the processed

The unique identifier for a claim.

Medical service line number.

Null Option Type

Unique identifier (Primary Key) of the

Reference to the job that inserted the

Defines the type of job the EDGE server

Condition of the job processed. Valid

Short description of the job processed.

Full Description of the job processed.

0 The job ran but there are

1 The job ran successfully

Order in which the event occurred in the

Null Option Type

Unique database row identifier.

Reference to the job that inserted this

Date of birth of the enrollee.

Creation date of the row in the database.

Date enrollee was inactivated (null if

Date the enrollee data on this row was last

The last date and time the enrollee

Unique identifier of enrollee. This