(a) The following files, as specified in the Data Submission Guide in conjunction with the APCD-CDL™, shall be submitted.
(1) Member Eligibility File (ME)--contains demographic information for each individual member residing in California, regardless of whether the member utilized services during the reporting period.
(2) Medical Claims File (MC)--contains service-level medical claims and encounter data processed during the reporting period, that were not fully denied, except as prohibited by federal or state law.
(3) Pharmacy Claims File (PC)--contains detailed pharmacy claims and encounter data processed during the reporting period, that were not fully denied, except as prohibited by federal or state law.
(4) Dental Claims File (DC)--contains service-level dental claims and encounter data processed during the reporting period, that were not fully denied, except as prohibited by federal or state law.
(5) Provider File (PV)--contains demographic-type data on every provider included on the ME, MC, PC, or DC files during the reporting period.
(b) Files shall exclude data for any members who are exclusively enrolled in Medi-Cal or one of the following types of coverage:
(1) Supplemental (including Medicare supplemental).
Credits
Note: Authority cited: Section 127673, Health and Safety Code. Reference: Sections 127671.1, 127673 and 127673.1, Health and Safety Code.
1. New section filed 12-20-2021 as an emergency; operative 12-20-2021 (Register 2021, No. 52). Pursuant to Health and Safety Code section 12763(f), a Certificate of Compliance must be transmitted to OAL by 12-20-2023 or emergency language will be repealed by operation of law on the following day. For prior history of chapter 11, see Register 87, No. 15.
2. Certificate of Compliance as to 12-20-2021 order transmitted to OAL 10-13-2023 and filed 11-17-2023 (Register 2023, No. 46).
This database is current through 4/19/24 Register 2024, No. 16.
Cal. Admin. Code tit. 22, § 97342, 22 CA ADC § 97342
