Data Dictionary

Membership Elements / Medical Claims Elements / Episode Risk Group (ERG) Elements:

Membership Elements

Element Name	Field Attributes	SAS Variable Name	Description
Logical Person Key	unsigned int	lpk	Logical Person represents Wellmark's best attempt at identifying individual persons. This number is found on the membership extract and the claims extract so that comparisons can be done between the two files.
Member Number	numeric(2)	mem_num	A unique identifier for each of the family members associated with a given encrypted certificate number. 00 = Plan member 01 to 09 = Spouse—the different values accommodate different spouses over time--e.g., divorce and remarriage 10 to 98 = Dependent children
Encrypted Certificate Number	char(20)	enc_cert_n	A unique number, based upon the plan member (contract holder), that identifies all members who have coverage through that plan member. It can be used as a proxy for family identifier.
Exposure Count	numeric (4,2)	exp_cnt	Member exposure is calculated according to the amount of time a member is active. Exposure count is taken from health only. If a member has been identified as having drug coverage only, the exposure count will = 0. This data extract includes only those members that have a fully insured financial arrangement enrolled with Wellmark. One plan member effective for one month is an exposure count of 1. One plan member effective for 15 days of a 30 day month is 0.5 exposure count. If an account has an arrangement with Wellmark to not maintain dependent demographic information we use factors to estimate the member counts depending on the type of contract. A single type of contract uses a factor of 1, two-person contract uses a factor of 2, and family contract uses a factor of 3.94. Another situation when the member exposure could exceed one is if a member has double health coverage for a period of time period.
Birth Year	date yyyy	birth_yr	Birth year associated with a person.
Gender	char(1)	gender	The code that represents the gender associated with a person. F= Female M= Male
Member Zip Code	char(3)	mem_zip	First three digits of the zip code assigned by the United State Postal Service for the plan member’s residence.
Member City	char(20)	mem_city	The name of a city or town of the plan member’s residence.
Member State	char(2)	mem_state	The state code as assigned by the US post office for the plan member’s residence.
Primary Product Type Description	char(255)	prim_prod_type	Specifies a high level categorization of a product Indemnity, Managed Indemnity, PPO (Preferred provider Organization), Medicare Supplement (health is med supp only included where drug card was fully insured), HMO – Gatekeeper, HMO –Open Access, HMO –POS, Drug (IPSC or Drug Card)
Health Flag	char(1)	hlth_flag	Identifies if member has health benefits. Y = Yes, member has a fully insured health benefit N = No – the member may have a free standing health benefit OR the member may have a health benefit under a different financial arrangement.
Drug Flag	char(1)	drug_flag	Identifies if member has drug benefits, includes CMM (drugs paid under medical benefit) and Drug Card. Y = Yes, member has a fully insured drug benefit N = No – the member may have a free standing drug benefit OR the member may have a drug benefit under a different financial arrangement.
Year	char(4)	year	The value of the year for the corresponding date for membership exposure. YYYY
Month Number	numeric(2)	month	The month – one or two digit numeric – of the corresponding date for membership exposure.

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Medical Claims Elements

Element Name	Field Attributes	SAS Variable Name	Description
Logical Person Key	unsigned int	lpk	Logical Person represents Wellmark's best attempt at identifying individual persons.
Line Item Number	smallint	line_item_n	A three digit number indicating specific claim line. If the third position is Ø (Ø1Ø, Ø2Ø, Ø3Ø, etc.), the line is a "base" line. Any other digit in the third position indicates a line that has "split" to another benefit level for processing.
First Service Date	date	frst_serv_date	Date of first service for line item MMDDYYYY
Last Service Date	date	last_serv_date	Last date of service for service billed on line item MMDDYYYY
Paid Date	date	paid_date	Posted date which the claim paid MMDDYYYY
Admission Date	date	admit_date	Date patient was admitted to hospital or other facility for the service being billed on this claim. MMDDYYYY
Discharge Date	date	disch_date	Date patient was discharged from hospital or other facility. MMDDYYYY
Patient Status Code	char(1)	pt_status	Defines the status of the patient in an inpatient facility as of the bill date. 1 = Discharged 2 = Died 3 = Dead on Arrival 4 = Transferred 5 = Still Confined (Interim Billing) 6 = Patient Discharged (Interim Billing)
Type of Service	char(1)	serv_type	The general category of services rendered. List of type of service values (pdf)
Place of Service	char(1)	serv_place	Indicates where provider services were performed (inpatient setting, outpatient setting, home, etc.) List of place of service values (pdf)
Trend Line of Business Rollup Description	char	trend_lob_rollup	Identifies facility claims, practioner claims, drug card claims, and CMM drug claims
Drug Days Supply	numeric(4,0)	drug_days	The number of days this prescription is to be utilized.
National Drug Code	char(11)	ndc	The NDC serves as a universal product identifier for human drugs.
Primary Valid Diagnosis Code	char(5)	diag1	The primary diagnosis code
Secondary Valid Diagnosis Code	char(5)	diag2	The secondary (non-primary) diagnosis code
Diagnosis 3 Valid Code	char(5)	diag3	Used only if and after the first and second diagnosis codes are assigned
Diagnosis 4 Valid Code	char(5)	diag4	Used only if and after the first and second diagnosis codes are assigned
Diagnosis 5 Valid Code	char(5)	diag5	Used only if and after the first and second diagnosis codes are assigned
Primary Diagnosis Cluster Code	char(5)	diag_cluster	A higher level grouping of clinically meaningful conditions, based upon review of diagnosis codes. List of primary diagnosis cluster code and descriptions (pdf)
Procedure Code	char(5)	cpt	A code designating a specific treatment provided by the clinicians (non-facility providers), or a UB92 "Revenue Code" or "Ancillary Code" on facility claims. May be a CPT-4, a HCPC, or ADA dental (leading D). Revenue codes will have a leading X for room and board charges and a leading Y for ancillary services.
Procedure Code Modifer	char(2)	cpt_mod1	Modifiers are used in conjunction with a CPT-4 procedure code to more accurately describe the service which was performed.
Procedure Code Modifer 2	char(2)	cpt_mod2	Modifiers are used in conjunction with a CPT-4 procedure code to more accurately describe the service which was performed.
Procedure Code Modifer 3	char(2)	cpt_mod3	Modifiers are used in conjunction with a CPT-4 procedure code to more accurately describe the service which was performed.
Procedure Code Modifer 4	char(2)	cpt_mod4	Modifiers are used in conjunction with a CPT-4 procedure code to more accurately describe the service which was performed.
CPT or HCPC Facility Code	char(5)	cpt_hcpc	CPT or HCPC procedure or service performed by the clinician or physician, on a facility claim.
CPT or HCPC Facility Mod Code	char(2)	cpt_hcpc_mod1	CPT or HCPC And Modifier Facility. Modifers are used in conjunction with a CPT-IV procedure code to more accurately describe the service that was performed.
CPT or HCPC Facility Mod Code 2	char(2)	cpt_hcpc_mod2	CPT or HCPC And Modifier Facility. Modifers are used in conjunction with a CPT-IV procedure code to more accurately describe the service that was performed.
CPT or HCPC Facility Mod Code 3	char(2)	cpt_hcpc_mod3	CPT or HCPC And Modifier Facility. Modifers are used in conjunction with a CPT-IV procedure code to more accurately describe the service that was performed.
CPT or HCPC Facility Mod Code 4	char(2)	cpt_hcpc_mod4	CPT or HCPC And Modifier Facility. Modifers are used in conjunction with a CPT-IV procedure code to more accurately describe the service that was performed.
UA AP DRG Code	char(3)	drg	All Patients Diagnostic Related Group: An AP- DRG code represents a grouping of diagnoses. AP-DRG code is calculated for a claim based on several elements including diagnosis codes, procedure codes, patient age, patient sex, and patient discharge status. List of UA AP DRG code and descriptions (pdf)
UA MDC Code	char(3)	mdc	A code that provides a higher level of classification based on UA AP DRG Code – only populated on inpatient and skilled, place of service 1 and 8. List of UA MDC Code and descriptions (pdf)
Surgical Procedure Valid Code	char(5)	surg1	ICD-9-CM procedure code for surgery (from Diagnosis file). These procedure codes are used by hospitals, surgical centers, etc., but not physicians (the latter use CPT-4). Purpose: Identifies specific surgical procedures.
Surgical Procedure Valid Code 2	char(5)	surg2	ICD-9-CM procedure code for surgery (from Diagnosis file). These procedure codes are used by hospitals, surgical centers, etc., but not physicians (the latter use CPT-4). Purpose: Identifies specific surgical procedures.
Surgical Procedure Valid Code 3	char(5)	surg3	ICD-9-CM procedure code for surgery (from Diagnosis file). These procedure codes are used by hospitals, surgical centers, etc., but not physicians (the latter use CPT-4). Purpose: Identifies specific surgical procedures.
Surgical Date 1	date	surg1date	The date the first surgical procedure was performed.
Surgical Date 2	date	surg2date	The date the second surgical procedure was performed.
Surgical Date 3	date	surg3date	The date the third surgical procedure was performed.
Units of Services	numeric(6,0)	serv_unit	A number quantifying a specific aspect of the services provided. Units vary according to the claim type. For inpatient claims, Units are days; for pharmacy claims, Units are doses, etc.
Allowed Amt	numeric	allowed_amt	An amount that is used to determine any copay, coinsurance, and deductible amounts applicable to a claim.
Member Liability Amount	numeric	mem_liability	The amount for which the member is liable. This field does not include contractual limitation amounts for which the member may also be responsible for paying.
Claims Paid Amount	numeric(14,2)	paid_amt	Wellmark's maximum potential financial liability for the covered service.
Provider ID – Encrypted	char(15)	prov_id	An identifier assigned by Wellmark to a provider working under a specific tax ID that uniquely identifies the provider under the ID.
Provider Specialty Code	tinyint	prov_spec	The provider specialty. List of provider types and specialties (pdf)
Provider Type	char(2)	prov_type	Identifies the type of provider for claims payment purposes. Note that a provider's type can vary over time and with provider line of business. List of provider types and specialties (pdf)
Provider Zip Code	char(3)	prov_zip	The first 3 digits of the ZIP code assigned by the United States Postal Service.
Provider City	char(18)	prov_city	The city associated with an address.
ProviderState	char(2)	prov_state	The code assigned by the United States Postal Service to identify a state.
Provider Birth Year	char(4)	prov_birthyr	The birth year of a physician For non physician related claims the birth year will default to 1800 2)For physician claims where no birth date on file will default to 1800

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Episode Risk Group (ERG) Elements:

Element Name	Field Attributes	SAS Variable Name	Description
Logical Person Key	numeric (8)	Lpk	Logical Person represents Wellmark's best attempt at identifying individual persons. This number is found on the membership extract and the claims extract so that comparisons can be done between the two files.
Age	numeric (8)	age	Member’s age as calculated from Date of Birth and the year being processed.
Gender	char (1)	gender	The code that represents the gender associated with a person. M = Male F = Female U = Unknown
Retrospective Risk Score	numeric (8)	rrsk	Retrospective risk score represents the Logical Person’s risk score as calculated from the claims experience for a base year to measure risk for that same year. It is a floating point number with four digits to the right of the decimal point. A score of 1 represents the average of the population as a whole; scores above 1 represent higher risk; below 1, lower risk. Episodes for each Logical Person are categorized into one of 119 Episode Risk Groups (ERGs). The ERGs are markers of member risk that combine ETG episodes of similar clinical and risk characteristics. A Logical Person’s risk score is the sum of the weights attached to each ERG and demographic characteristic observed in the Logical Person's ERG profile.
Prospective Risk Score	numeric (8)	prsk	Prospective risk score represents the person’s risk score as calculated from the claims experience for a base year to measure risk for a future year. It is a floating point number with four digits to the right of the decimal point. A score of 1 represents the average of the population as a whole; scores above 1 represent higher risk; below 1, lower risk. Episodes for each Logical Person are categorized into one of 119 Episode Risk Groups (ERGs). The ERGs are markers of member risk that combine ETG episodes of similar clinical and risk characteristics. A Logical Person’s risk score is the sum of the weights attached to each ERG and demographic characteristic observed in the Logical Person's ERG profile.
Demographic Risk Score	numeric (8)	drsk	Demographic risk score based on age-sex alone. May be used in lieu of a claims-based score, in the event the Logical Person has no claims within the ERG Risk Marker period. It is a floating number with four digits to the right of the decimal. A score of 1 represents the average of the population as a whole; scores above 1 represent higher risk; below 1, lower risk.
Prospective Risk Categories	numeric (8)	prskcat	There are more than 100 Episode Risk Groups (see link below). ERGs allows precise comparison of risk between individual members. To permit grouped comparisons by range of risk score, ERGs are further rounded into “risk categories”, which represent a range of values. These ranges can be used as a guideline for interpreting the level of risk of members included in a risk group. List of Prospective Risk Categories and Retrospective Risk Categories (pdf).
Retrospective Risk Categories	numeric (8)	rrskcat	See PRSKCAT
ERG Array	char (130)	ergarray	ERG array is an array of one-character flags indicating that the member either fit (“1”) or did not fit (“0”) a given Episode Risk Group. That is, the member had or did not have episodes with ETGs that mapped to the given ERG. List of ERG risk markers for the order and description of each (pdf).
Member Type	char (1)	memtype	Member type represents the model option used for the member. Member type descriptions can be found in the appendix.
Error Status	numeric (8)	errstat	Error status indicates the result of the ERG processing. “0” = no error; “1”=age-sex field(s) not described in this model. This may indicate bad data in the gender or date of birth fields (e.g. birth date giving age of 500 years).
Eligibility	numeric (8)	insfelig	Indicates if the Logical Person has less than seven months of eligibility during the ERG snapshot period.
Grouping End Date	numeric (8)	grpenddt	Grouping end date is the same as the claims date end in the input file. Because ERGs are based on an annual cycle, this field allows you to easily identify from which “year” the ERG scores were generated.
Version of Grouper	numeric (8)	version	This field simply identifies the version of the grouper used on the claims data.
Version of Risk Weights	numeric (8)	dbversn	This field identifies which version of the risk weights were used to calculate the scores.

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