KY MMIS 834 Companion Guide - Kymmis.com

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Commonwealth of Kentucky – MMISKY MMIS 834 Companion Guide834 Benefit Enrollment and Maintenance61 2000 DTP DTP03 – Eligibility End Date Date Medicaid EligibilityEnds59 2000 DTP DTP01 – Date Time Qualifier ‘473’ – Medicaid Begin Date60 2000 DTP DTP02 – Date Time Period FormatQualifier‘D8’ – indicates formatCCYYMMDD61 2000 DTP DTP03 – Medicaid ApplicationStart DateDate Medicaid Applicationwas entered into CountyOffice System59 2000 DTP DTP01 – Date Time Qualifier ‘474’ – Medicaid End Date60 2000 DTP DTP02 – Date Time Period FormatQualifier'D8’ – indicates formatCCYYMMDD61 2000 DTP DTP03 – Medicaid Re-Determination DateDate County Office redeterminesMember Medicaideligibility qualifications62 2100A NM1 NM101 –Entity Identifier Code ‘74’ – Corrected Insured63 2100A NM1 NM102 – Entity Type Qualifier 1' - Person‘IL’ – Insured or Subscriber63 2100A NM1 NM103 – Member Last Name Member Last Name63 2100A NM1 NM104 – Member First Name Member First Name63 2100A NM1 NM105 – Member Middle Initial Member Middle Initial64 2100A NM1 NM108 - Identification CodeQualifier‘34’ – Member SSN64 2100A NM1 NM109 – Member Identifier 9 digit SSNDMS Approved 12/02/2011 Page 13
Commonwealth of Kentucky – MMISKY MMIS 834 Companion Guide834 Benefit Enrollment and Maintenance66 2100A PER PER01 – Contact Function Code ‘IP’ – Insured Party66 2100A PER PER03 - Communication NumberQualifier‘TE’ – Telephone66 2100A PER PER04 - Communication Number Member Telephone Number ifon file68 2100A N3 N301 - Member Address Line When applicable MemberAddress68 2100A N3 N302 – Member Address Line When applicable MemberAddress69 2100A N4 N401 – Member City Name When applicable MemberCity, State, Zip Code69 2100A N4 N402 – Member State Code When applicable MemberCity, State, Zip Code70 2100A N4 N403 – Member Zip Code When applicable MemberCity, State, Zip Code70 2100A N4 N405 - Location Qualifier ‘CY’ – County70 2100A N4 N406 - Location Identifier Three digit Kentucky assignedcounty code71 2100A DMG DMG01-Date Time Period FormatQualifier‘D8’ – Date Expressed inFormat CCYYMMDD71 2100A DMG DMG02 – Member Birth Date Member Date of Birth72 2100A DMG DMG03 – Gender Code Member GenderF= FemaleM = MaleU = Unknown (This code is tobe used only when the genderis unknown or when it cannotbe sent due to reportingrestrictions.)DMS Approved 12/02/2011 Page 14
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KY MMIS 834 Companion Guide - Kymmis.com

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