Data Dictionary

Membership Elements

Element NameDescription
Logical Person KeyIdentifies data from the same individual across files.
Encrypted Certificate NumberA 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.
Member NumberA unique identifier for each of the family members associated with a given encrypted certificate number.
Gender
Birth Month
Birth Year
Exposure CountMember 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.
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
Coverage Month
Coverage Year
Member City
Member State
Member Zip Code 3First three digits of the zip code.
Member Zip Code 5Five digit zip code.
National County Code
National County Code Name
ProductInsurance product
Primary Product Type DescriptionSpecifies a high level categorization of a product type: Indemnity, Managed Indemnity, PPO, Medicare Supplement, HMO–Gatekeeper, HMO–Open Access, HMO–POS, Drug Card.
Health FlagIndicates if the member had health coverage for time period.
Drug FlagIndicates if the member had drug coverage for time period.
Risk PoolA code that categorizes financial arrangements and market segments.

Medical Claims Elements

Element NameDescription
Logical Person KeyIdentifies data from the same individual across files.
Internal Control NumberUniquely identifies each claim
Line Item NumberUsed to indicate a specific claim line.
Adjustment IndicatorIndicates if claim has undergone an adjustment.
Line of Business Roll-upIdentifies facility claims, practitioner claims, drug card claims, and CMM drug claims
SUD IndicatorSubstance use disorder indicator.
First Service DateDate of first service for line item.
Last Service DateLast date of service for service billed on line item.
Settled DateThe date the claim has been finalized.
Admission DateDate patient was admitted to hospital or other facility for the service being billed on this claim.
Discharge DateDate patient was discharged from hospital or other facility.
Patient Status CodeDesignates the status of the patient in an inpatient facility as of the billing date.
Type of ServiceThe general category of services rendered.
CMS Place of ServiceIndicates where provider services were performed: inpatient setting, outpatient setting, home, etc.
Primary Diagnosis CodeThe primary ICD-10 diagnosis code.
Secondary Diagnosis CodeThe secondary (non-primary) ICD-10 diagnosis code.
Diagnosis 3 CodeUsed only if and after the first and second diagnosis codes are assigned.
Diagnosis 4 CodeUsed only if and after the first and second diagnosis codes are assigned.
Diagnosis 5 CodeUsed only if and after the first and second diagnosis codes are assigned.
Primary Diagnosis Cluster CodeA code that represents a specified range of diagnosis codes.
Procedure CodePrimary code for the medical procedure performed. Typical standards include CPT4 and HCPCS.
Procedure Code Modifier 1Modifiers are used in conjunction with a CPT procedure code to more accurately
describe the service which was performed.
Procedure Code Modifier 2Modifiers are used in conjunction with a CPT procedure code to more accurately
describe the service which was performed.
Procedure Code Modifier 3Modifiers are used in conjunction with a CPT procedure code to more accurately
describe the service which was performed.
Procedure Code Modifier 4Modifiers are used in conjunction with a CPT procedure code to more accurately
describe the service which was performed.
Revenue CodeFirst three positions of a Procedure Code, where the value populating that Procedure Code is a UB-92 Procedure Code.
DRG CodeDRG Code used to pay the claim.
MDC CodeA higher level of classification based on grouping DRG Codes
Surgical Procedure Code 1
Surgical Procedure Code 2
Surgical Procedure Code 3
Surgical Date 1Date of Surgical Procedure 1.
Surgical Date 2Date of Surgical Procedure 2.
Surgical Date 3Date of Surgical Procedure 3.
Allowed AmountAmount that reflects the total liability (all payors combined) for a line.
Member Liability AmountThe sum of Coinsurance Amount, Deductible Amount, and Copayment Amount applied to the claim or claim line.
Claims Paid AmountInsurer’s maximum potential financial liability for the covered service.
Drug Days SupplyThe number of days this prescription is to be utilized.
National Drug CodeThe NDC serves as a universal product identifier for human drugs.
Units of ServicesA number quantifying a specific aspect of the services provided. Units vary according to the claim type and/or other attributes.
Encrypted Provider IDAn identifier assigned by Wellmark to a provider working under a specific tax ID
that uniquely identifies the provider under the ID.
Rendering National Provider Identifier
Provider Specialty Code The provider specialty.
Provider TypeIdentifies the type of provider for claims payment purposes.
Provider Zip CodeThe first 3 digits of the ZIP code assigned by the United States Postal Service.
Provider City
Provider State
Provider Zip Code 3First three digits of provider zip code.
Provider Zip Code 5
Provider Birth Year
COB Savings Category CodeDesignates whether Coordination of Benefits savings was recorded as Medicare, Subrogation, WC, or other carrier liability.
Provider Taxonomy CodeA code designating a classification of provider.
Risk PoolA code that categorizes financial arrangements and market segments.