Wellmark Repository Data Dictionary
Membership Elements
| Element Name | Description |
|---|---|
| Logical Person Key | Identifies data from the same individual across files. |
| Encrypted Certificate Number | 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. |
| Member Number | A unique identifier for each of the family members associated with a given encrypted certificate number. |
| Gender | |
| Birth Month | |
| Birth Year | |
| Exposure Count | 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. 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 3 | First three digits of the zip code. |
| Member Zip Code 5 | Five digit zip code. |
| National County Code | |
| National County Code Name | |
| Product | Insurance product |
| Primary Product Type Description | Specifies a high level categorization of a product type: Indemnity, Managed Indemnity, PPO, Medicare Supplement, HMO–Gatekeeper, HMO–Open Access, HMO–POS, Drug Card. |
| Health Flag | Indicates if the member had health coverage for time period. |
| Drug Flag | Indicates if the member had drug coverage for time period. |
| Risk Pool | A code that categorizes financial arrangements and market segments. |
Medical Claims Elements
| Element Name | Description |
|---|---|
| Logical Person Key | Identifies data from the same individual across files. |
| Internal Control Number | Uniquely identifies each claim |
| Line Item Number | Used to indicate a specific claim line. |
| Adjustment Indicator | Indicates if claim has undergone an adjustment. |
| Line of Business Roll-up | Identifies facility claims, practitioner claims, drug card claims, and CMM drug claims |
| SUD Indicator | Substance use disorder indicator. |
| First Service Date | Date of first service for line item. |
| Last Service Date | Last date of service for service billed on line item. |
| Settled Date | The date the claim has been finalized. |
| Admission Date | Date patient was admitted to hospital or other facility for the service being billed on this claim. |
| Discharge Date | Date patient was discharged from hospital or other facility. |
| Patient Status Code | Designates the status of the patient in an inpatient facility as of the billing date. |
| Type of Service | The general category of services rendered. |
| CMS Place of Service | Indicates where provider services were performed: inpatient setting, outpatient setting, home, etc. |
| Primary Diagnosis Code | The primary ICD-10 diagnosis code. |
| Secondary Diagnosis Code | The secondary (non-primary) ICD-10 diagnosis code. |
| Diagnosis 3 Code | Used only if and after the first and second diagnosis codes are assigned. |
| Diagnosis 4 Code | Used only if and after the first and second diagnosis codes are assigned. |
| Diagnosis 5 Code | Used only if and after the first and second diagnosis codes are assigned. |
| Primary Diagnosis Cluster Code | A code that represents a specified range of diagnosis codes. |
| Procedure Code | Primary code for the medical procedure performed. Typical standards include CPT4 and HCPCS. |
| Procedure Code Modifier 1 | Modifiers are used in conjunction with a CPT procedure code to more accurately describe the service which was performed. |
| Procedure Code Modifier 2 | Modifiers are used in conjunction with a CPT procedure code to more accurately describe the service which was performed. |
| Procedure Code Modifier 3 | Modifiers are used in conjunction with a CPT procedure code to more accurately describe the service which was performed. |
| Procedure Code Modifier 4 | Modifiers are used in conjunction with a CPT procedure code to more accurately describe the service which was performed. |
| Revenue Code | First three positions of a Procedure Code, where the value populating that Procedure Code is a UB-92 Procedure Code. |
| DRG Code | DRG Code used to pay the claim. |
| MDC Code | A higher level of classification based on grouping DRG Codes |
| Surgical Procedure Code 1 | |
| Surgical Procedure Code 2 | |
| Surgical Procedure Code 3 | |
| Surgical Date 1 | Date of Surgical Procedure 1. |
| Surgical Date 2 | Date of Surgical Procedure 2. |
| Surgical Date 3 | Date of Surgical Procedure 3. |
| Allowed Amount | Amount that reflects the total liability (all payors combined) for a line. |
| Member Liability Amount | The sum of Coinsurance Amount, Deductible Amount, and Copayment Amount applied to the claim or claim line. |
| Claims Paid Amount | Insurer’s maximum potential financial liability for the covered service. |
| Drug Days Supply | The number of days this prescription is to be utilized. |
| National Drug Code | The NDC serves as a universal product identifier for human drugs. |
| Units of Services | A number quantifying a specific aspect of the services provided. Units vary according to the claim type and/or other attributes. |
| Encrypted Provider ID | An 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 Type | Identifies the type of provider for claims payment purposes. |
| Provider Zip Code | The first 3 digits of the ZIP code assigned by the United States Postal Service. |
| Provider City | |
| Provider State | |
| Provider Zip Code 3 | First three digits of provider zip code. |
| Provider Zip Code 5 | |
| Provider Birth Year | |
| COB Savings Category Code | Designates whether Coordination of Benefits savings was recorded as Medicare, Subrogation, WC, or other carrier liability. |
| Provider Taxonomy Code | A code designating a classification of provider. |
| Risk Pool | A code that categorizes financial arrangements and market segments. |