NYSDOH Stop Loss File Specifications
Format Specifications:
File format should be submitted as tab-delimited text
First row must contain field names
Please include ALL columns in layout whether or not they are to be used
DO NOT submit IP, MH, or RHCF claims in the same file
Field Name | Field Type | Field Length | Field Description | Values | Required | Required Claim Type |
---|---|---|---|---|---|---|
ClmType | Text | 4 | Value Indicating NYSDOH Stop Loss Form Rate Type Based on Admission Date (IP) or Rate (MH, SNP, or RHCF). IMPORTANT: Please include only 1 benefit year per file for all claim types | IP Rate: 2299, MH Rate: 2295, SNP Rate: 2296, RHCF Rate: 2297 | Yes | All |
Date | Date | 8 | Date of file submission | m/d/yyyy | Yes | All |
Plan Name | Text | 55 | Plan Name | Yes | All | |
Plan ID | Text | 8 | Plan Medicaid Identification Number (MMIS) | Yes | All | |
Contact Name | Text | 55 | Plan Contact Name | Yes | All | |
Contact Phone | Text | 15 | Plan Contact Phone | (999)999-9999 | Yes | All |
Text | 55 | Plan Contact E-mail | Yes | All | ||
Patient Name | Text | 55 | Enrollee Name | Last, First | Yes | All |
CIN | Text | 8 | Enrollee Client Identification Number | Yes | All | |
TCN | Text | 16 | Transaction Control Number (If submitting an adjustment) | Yes, if applicable | All | |
Benefit Year | Text | 4 | Year (YYYY) of Claim based on Date of Admission | i.e. 2018 ,2019, 2020, 2021 | Yes | All |
Ttl Stays | Integer or Long | 1 | Count of Stay | 1 | Yes | All |
Stop Loss Threshold | Double | 15 | Stop Loss Dollar/Day Threshold | IP: $100,000, $250,000 SNP: $100,00, $300,000 MH: 100% after 100 days RHCF: 100% after 60 days After 1/1/2022 IP: $200,000, $350,000 SNP: $200,00, $400,000 MH: 100% after 100 days RHCF: No coverage | Yes | All |
Amt Over Threshold | Double | 15 | Dollar/Day Amount Over Threshold | Yes | All | |
Plan Liability | Double | 15 | Dollar Amount of Plan Liability | Yes, if applicable | All | |
Liability Type | Text | 40 | Specify Any Applicable Dollar Liability Type e.g. Copay, Third Party Payment | Yes, if applicable | All | |
Net Amt Due | Double | 15 | Net Dollar Amount Due | Yes | All | |
HCO | Boolean or Integer | 1 | True if Claim includes stays to be reviewed as High Cost Outlier | 1 = True, 0 = False | Yes | IP, SNP |
HCO Stays | Integer | 1 | Count of HCO Stay | 1 | Yes, if applicable | IP, SNP |
HCO Date From1 | Date | 8 | Date Span Admit Date 1 | m/d/yyyy | Yes, if applicable | IP, SNP |
HCO Date To1 | Date | 8 | Date Span Discharge Date 1 | m/d/yyyy | Yes, if applicable | IP, SNP |
HCO Date From2 | Date | 8 | Date Span Admit Date 2 | m/d/yyyy | Yes, if applicable | IP, SNP |
HCO Date To2 | Date | 8 | Date Span Discharge Date 2 | m/d/yyyy | Yes, if applicable | IP, SNP |
HCO Date From3 | Date | 8 | Date Span Admit Date 3 | m/d/yyyy | Yes, if applicable | IP, SNP |
HCO Date To3 | Date | 8 | Date Span Discharge Date 3 | m/d/yyyy | Yes, if applicable | IP, SNP |
HCO Date From4 | Date | 8 | Date Span Admit Date 4 | m/d/yyyy | Yes, if applicable | IP, SNP |
HCO Date To4 | Date | 8 | Date Span Discharge Date 4 | m/d/yyyy | Yes, if applicable | IP, SNP |
HCO Date From5 | Date | 8 | Date Span Admit Date 5 | m/d/yyyy | Yes, if applicable | IP, SNP |
HCO Date To5 | Date | 8 | Date Span Discharge Date 5 | m/d/yyyy | Yes, if applicable | IP, SNP |
HCO Date From6 | Date | 8 | Date Span Admit Date 6 | m/d/yyyy | Yes, if applicable | IP, SNP |
HCO Date To6 | Date | 8 | Date Span Discharge Date 6 | m/d/yyyy | Yes, if applicable | IP, SNP |
HCO Date From7 | Date | 8 | Date Span Admit Date 7 | m/d/yyyy | Yes, if applicable | IP, SNP |
HCO Date To7 | Date | 8 | Date Span Discharge Date 7 | m/d/yyyy | Yes, if applicable | IP, SNP |
HCO Date From8 | Date | 8 | Date Span Admit Date 8 | m/d/yyyy | Yes, if applicable | IP, SNP |
HCO Date To8 | Date | 8 | Date Span Discharge Date 8 | m/d/yyyy | Yes, if applicable | IP, SNP |
HCO Date From9 | Date | 8 | Date Span Admit Date 9 | m/d/yyyy | Yes, if applicable | IP, SNP |
HCO Date To9 | Date | 8 | Date Span Discharge Date 9 | m/d/yyyy | Yes, if applicable | IP, SNP |
HCO Date From10 | Date | 8 | Date Span Admit Date 10 | m/d/yyyy | Yes, if applicable | IP, SNP |
HCO Date To10 | Date | 8 | Date Span Discharge Date 10 | m/d/yyyy | Yes, if applicable | IP, SNP |
HCO Date From11 | Date | 8 | Date Span Admit Date 11 | m/d/yyyy | Yes, if applicable | IP, SNP |
HCO Date To11 | Date | 8 | Date Span Discharge Date 11 | m/d/yyyy | Yes, if applicable | IP, SNP |
Hospital Name | Text | 55 | Hospital Name | Yes | All | |
Out Of State | Boolean or Integer | 1 | True if Out of State Hospital | 1 = True, 0 = False | Yes | All |
Out of State Address | Text | 55 | Out of State Address for Hospital Facility | Yes, if applicable | All | |
MMIS ID | Text | 8 | Hospital Medicaid MMIS ID # | Yes | All | |
NPI | Text | 10 | National Provider Identification Number | Yes | All | |
Admit Date | Date | 8 | Admission Date | m/d/yyyy | Yes | All |
Discharge Date | Date | 8 | Discharge Date | m/d/yyyy | Yes | All |
LOS | Long | 4 | Length of Stay (Number of Days in Stay) | Yes | All | |
Acute Care Days | Long | 4 | Total Number of Acute Care Days | Yes | IP, SNP | |
ALC Days | Long | 4 | Total Number of Alternate Level of Care Days | Yes, if applicable | IP,SNP, MH | |
DOB | Date | 8 | Date of Birth | m/d/yyyy | Yes | All |
Age | Long | 3 | Age at Time of Discharge | Yes | All | |
Sex | Text | 1 | Sex (Gender) | M, F | Yes | All |
Birth Wgt | Long | 4 | Birth Weight (Must be included for newborns up to 28 days old) | In grams | Yes, if applicable | IP, SNP |
Disposition | Text | 2 | Disposition (Status) | 01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 13, 20, 21, 30, 40, 41, 42, 43, 50, 51, 61, 62, 63, 64, 65, 66, 70 | Yes | All |
Admitting Dx | Text | 6 | Admitting Diagnosis | ICD10 Diagnosis Code : NO DECIMAL | Yes | All |
Ttl Hospital Charges | Double | 15 | Total Hospital Charges | Yes | All | |
Plan Per Diem Rate | Double | 15 | Plan Per Diem Rate | Yes, if applicable | MH, RHCF, IP | |
RHCF Per Diem Rate | Double | 15 | RHCF Per Diem Rate | Yes, if applicable | RHCF | |
Principal DX | Text | 6 | Principal Diagnosis | ICD10 Diagnosis Code : NO DECIMAL | Yes | IP,SNP, MH |
POAP | Boolean or Integer | 1 | True if Present on Admission: Principal Diagnosis | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Other DX1 | Text | 6 | Other Diagnosis 1 | ICD10 Diagnosis Code : NO DECIMAL | Yes, if applicable | IP,SNP, MH |
POA1 | Boolean or Integer | 1 | True if Present on Admission: Diagnosis 1 | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Other DX2 | Text | 6 | Other Diagnosis 2 | ICD10 Diagnosis Code : NO DECIMAL | Yes, if applicable | IP,SNP, MH |
POA2 | Boolean or Integer | 1 | True if Present on Admission: Diagnosis 2 | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Other DX3 | Text | 6 | Other Diagnosis 3 | ICD10 Diagnosis Code : NO DECIMAL | Yes, if applicable | IP,SNP, MH |
POA3 | Boolean or Integer | 1 | True if Present on Admission: Diagnosis 3 | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Other DX4 | Text | 6 | Other Diagnosis 4 | ICD10 Diagnosis Code : NO DECIMAL | Yes, if applicable | IP,SNP, MH |
POA4 | Boolean or Integer | 1 | True if Present on Admission: Diagnosis 4 | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Other DX5 | Text | 6 | Other Diagnosis 5 | ICD10 Diagnosis Code : NO DECIMAL | Yes, if applicable | IP,SNP, MH |
POA5 | Boolean or Integer | 1 | True if Present on Admission: Diagnosis 5 | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Other DX6 | Text | 6 | Other Diagnosis 6 | ICD10 Diagnosis Code : NO DECIMAL | Yes, if applicable | IP,SNP, MH |
POA6 | Boolean or Integer | 1 | True if Present on Admission: Diagnosis 6 | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Other DX7 | Text | 6 | Other Diagnosis 7 | ICD10 Diagnosis Code : NO DECIMAL | Yes, if applicable | IP,SNP, MH |
POA7 | Boolean or Integer | 1 | True if Present on Admission: Diagnosis 7 | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Other DX8 | Text | 6 | Other Diagnosis 8 | ICD10 Diagnosis Code : NO DECIMAL | Yes, if applicable | IP, SNP |
POA8 | Boolean or Integer | 1 | True if Present on Admission: Diagnosis 8 | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Other DX9 | Text | 6 | Other Diagnosis 9 | ICD10 Diagnosis Code : NO DECIMAL | Yes, if applicable | IP, SNP |
POA9 | Boolean or Integer | 1 | True if Present on Admission: Diagnosis 9 | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Other DX10 | Text | 6 | Other Diagnosis 10 | ICD10 Diagnosis Code : NO DECIMAL | Yes, if applicable | IP, SNP |
POA10 | Boolean or Integer | 1 | True if Present on Admission: Diagnosis 10 | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Other DX11 | Text | 6 | Other Diagnosis 11 | ICD10 Diagnosis Code : NO DECIMAL | Yes, if applicable | IP, SNP |
POA11 | Boolean or Integer | 1 | True if Present on Admission: Diagnosis 11 | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Other DX12 | Text | 6 | Other Diagnosis 12 | ICD10 Diagnosis Code : NO DECIMAL | Yes, if applicable | IP, SNP |
POA12 | Boolean or Integer | 1 | True if Present on Admission: Diagnosis 12 | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Other DX13 | Text | 6 | Other Diagnosis 13 | ICD10 Diagnosis Code : NO DECIMAL | Yes, if applicable | IP, SNP |
POA13 | Boolean or Integer | 1 | True if Present on Admission: Diagnosis 13 | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Other DX14 | Text | 6 | Other Diagnosis 14 | ICD10 Diagnosis Code : NO DECIMAL | Yes, if applicable | IP, SNP |
POA14 | Boolean or Integer | 1 | True if Present on Admission: Diagnosis 14 | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Other DX15 | Text | 6 | Other Diagnosis 15 | ICD10 Diagnosis Code : NO DECIMAL | Yes, if applicable | IP, SNP |
POA15 | Boolean or Integer | 1 | True if Present on Admission: Diagnosis 15 | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Other DX16 | Text | 6 | Other Diagnosis 16 | ICD10 Diagnosis Code : NO DECIMAL | Yes, if applicable | IP, SNP |
POA16 | Boolean or Integer | 1 | True if Present on Admission: Diagnosis 16 | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Other DX17 | Text | 6 | Other Diagnosis 17 | ICD10 Diagnosis Code : NO DECIMAL | Yes, if applicable | IP, SNP |
POA17 | Boolean or Integer | 1 | True if Present on Admission: Diagnosis 17 | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Other DX18 | Text | 6 | Other Diagnosis 18 | ICD10 Diagnosis Code : NO DECIMAL | Yes, if applicable | IP, SNP |
POA18 | Boolean or Integer | 1 | True if Present on Admission: Diagnosis 18 | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Other DX19 | Text | 6 | Other Diagnosis 19 | ICD10 Diagnosis Code : NO DECIMAL | Yes, if applicable | IP, SNP |
POA19 | Boolean or Integer | 1 | True if Present on Admission: Diagnosis 19 | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Other DX20 | Text | 6 | Other Diagnosis 20 | ICD10 Diagnosis Code : NO DECIMAL | Yes, if applicable | IP, SNP |
POA20 | Boolean or Integer | 1 | True if Present on Admission: Diagnosis 20 | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Other DX21 | Text | 6 | Other Diagnosis 21 | ICD10 Diagnosis Code : NO DECIMAL | Yes, if applicable | IP, SNP |
POA21 | Boolean or Integer | 1 | True if Present on Admission: Diagnosis 21 | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Other DX22 | Text | 6 | Other Diagnosis 22 | ICD10 Diagnosis Code : NO DECIMAL | Yes, if applicable | IP, SNP |
POA22 | Boolean or Integer | 1 | True if Present on Admission: Diagnosis 22 | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Other DX23 | Text | 6 | Other Diagnosis 23 | ICD10 Diagnosis Code : NO DECIMAL | Yes, if applicable | IP, SNP |
POA23 | Boolean or Integer | 1 | True if Present on Admission: Diagnosis 23 | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Other DX24 | Text | 6 | Other Diagnosis 24 | ICD10 Diagnosis Code : NO DECIMAL | Yes, if applicable | IP, SNP |
POA24 | Boolean or Integer | 1 | True if Present on Admission: Diagnosis 24 | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Permanent | Boolean or Integer | 1 | True if Patient's placement status in a Residential Health Care Facility is permanent | 1 = True, 0 = False | Yes, if applicable | RHCF |
Temporary | Boolean or Integer | 1 | True if Patient's placement status in a Residential Health Care Facility is temporary | 1 = True, 0 = False | Yes, if applicable | RHCF |
Principal Proc | Text | 6 | Principal Procedure | ICD10 Procedure Code : NO DECIMAL | Yes, if applicable | IP,SNP, MH |
Other Proc1 | Text | 6 | Other Procedure 1 | ICD10 Procedure Code : NO DECIMAL | Yes, if applicable | IP,SNP, MH |
Other Proc2 | Text | 6 | Other Procedure 2 | ICD10 Procedure Code : NO DECIMAL | Yes, if applicable | IP,SNP, MH |
Other Proc3 | Text | 6 | Other Procedure 3 | ICD10 Procedure Code : NO DECIMAL | Yes, if applicable | IP,SNP, MH |
Other Proc4 | Text | 6 | Other Procedure 4 | ICD10 Procedure Code : NO DECIMAL | Yes, if applicable | IP,SNP, MH |
Other Proc5 | Text | 6 | Other Procedure 5 | ICD10 Procedure Code : NO DECIMAL | Yes, if applicable | IP,SNP, MH |
Other Proc6 | Text | 6 | Other Procedure 6 | ICD10 Procedure Code : NO DECIMAL | Yes, if applicable | IP,SNP, MH |
Other Proc7 | Text | 6 | Other Procedure 7 | ICD10 Procedure Code : NO DECIMAL | Yes, if applicable | IP, SNP |
Other Proc8 | Text | 6 | Other Procedure 8 | ICD10 Procedure Code : NO DECIMAL | Yes, if applicable | IP, SNP |
Other Proc9 | Text | 6 | Other Procedure 9 | ICD10 Procedure Code : NO DECIMAL | Yes, if applicable | IP, SNP |
Other Proc10 | Text | 6 | Other Procedure 10 | ICD10 Procedure Code : NO DECIMAL | Yes, if applicable | IP, SNP |
Other Proc11 | Text | 6 | Other Procedure 11 | ICD10 Procedure Code : NO DECIMAL | Yes, if applicable | IP, SNP |
Other Proc12 | Text | 6 | Other Procedure 12 | ICD10 Procedure Code : NO DECIMAL | Yes, if applicable | IP, SNP |
Other Proc13 | Text | 6 | Other Procedure 13 | ICD10 Procedure Code : NO DECIMAL | Yes, if applicable | IP, SNP |
Other Proc14 | Text | 6 | Other Procedure 14 | ICD10 Procedure Code : NO DECIMAL | Yes, if applicable | IP, SNP |
Other Proc15 | Text | 6 | Other Procedure 15 | ICD10 Procedure Code : NO DECIMAL | Yes, if applicable | IP, SNP |
Other Proc16 | Text | 6 | Other Procedure 16 | ICD10 Procedure Code : NO DECIMAL | Yes, if applicable | IP, SNP |
Other Proc17 | Text | 6 | Other Procedure 17 | ICD10 Procedure Code : NO DECIMAL | Yes, if applicable | IP, SNP |
Other Proc18 | Text | 6 | Other Procedure 18 | ICD10 Procedure Code : NO DECIMAL | Yes, if applicable | IP, SNP |
Other Proc19 | Text | 6 | Other Procedure 19 | ICD10 Procedure Code : NO DECIMAL | Yes, if applicable | IP, SNP |
Other Proc20 | Text | 6 | Other Procedure 20 | ICD10 Procedure Code : NO DECIMAL | Yes, if applicable | IP, SNP |
Other Proc21 | Text | 6 | Other Procedure 21 | ICD10 Procedure Code : NO DECIMAL | Yes, if applicable | IP, SNP |
Other Proc22 | Text | 6 | Other Procedure 22 | ICD10 Procedure Code : NO DECIMAL | Yes, if applicable | IP, SNP |
Other Proc23 | Text | 6 | Other Procedure 23 | ICD10 Procedure Code : NO DECIMAL | Yes, if applicable | IP, SNP |
Other Proc24 | Text | 6 | Other Procedure 24 | ICD10 Procedure Code : NO DECIMAL | Yes, if applicable | IP, SNP |
APRDRG | Text | 6 | APR - DRG | Yes | IP, SNP, MH | |
SevLevel | Text | 1 | Severity Level | 1, 2, 3, 4 | Yes | IP, SNP |
SIW | Double | 8 | Service Intensity Weight as indicated by APR - DRG | Yes | IP, SNP | |
Low | Long | 3 | Low Trim Point as indicated by APR - DRG | Yes, if applicable | IP | |
High | Long | 3 | High Trim Point as indicated by APR - DRG | Yes, if applicable | IP | |
Upstate ALOS | Long | 3 | Upstate Average Length of Stay as indicated by APR - DRG | Yes, if applicable | IP | |
Downstate ALOS | Long | 3 | Downstate Average Length of Stay as indicated by APR - DRG | Yes, if applicable | IP | |
ALOS | Long | 3 | Average Length of Stay (12/1/09 - ) | Yes, if applicable | IP | |
APR ExcInc | Text | 7 | Applies to APR rates used on inpatient stays after 7/1/08 and before 1/1/2010: based on whether the plan has a contracted rate: Exclude if Yes, Include if No | "Exclude", "Include" (Always "Include" after 1/1/10) | Yes | IP, SNP |
Amt Paid | Double | 15 | Amount Paid by Plan | Yes | All | |
Detox Code | Text | 4 | Rate Code for IP Chemical Dependency Detox | 4800,4801,4802,4803, 4804 | Yes, if applicable | IP, SNP |
Blank2 | Null | For future use | ||||
Inlier | Boolean or Integer | 1 | True if stay is calculated as an Inlier | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Long Stay | Boolean or Integer | 1 | True if stay is calculated as a Long Stay | 1 = True, 0 = False | Yes, if applicable | IP |
Short Stay | Boolean or Integer | 1 | True if stay is calculated as a Short Stay | 1 = True, 0 = False | Yes, if applicable | IP |
Transfer | Boolean or Integer | 1 | True if stay is calculated as a Transfer | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Exempt Unit | Boolean or Integer | 1 | True if stay is calculated as an Exempt Unit | 1 = True, 0 = False | Yes, if applicable | IP,SNP, MH |
Exempt Desc | Text | 55 | Exempt Unit Description | Specialty Hosp, Drug Exempt, Other Exempt (includes Critical Access), Medical Rehab, and Psych Rehab. | Yes, if applicable | IP,SNP, MH |
Top 20 DRG | Boolean or Integer | 1 | True if stay is calculated as a Top 20 DRG | 1 = True, 0 = False | Yes, if applicable | IP |
HCO | Boolean or Integer | 1 | True if stay is calculated as a High Cost Outlier | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
DRG | Boolean or Integer | 1 | True if stay is calculated as DRG | 1 = True, 0 = False | Yes, if applicable | IP, MH |
Per Diem | Boolean or Integer | 1 | True if stay is calculated as Per Diem | 1 = True, 0 = False | Yes, if applicable | All |
Other | Boolean or Integer | 1 | True if stay is calculated as Other | 1 = True, 0 = False | Yes, if applicable | IP, SNP |
Other Desc | Text | 55 | Other Description | Yes, if applicable | IP, SNP | |
Respite Days | Long | 4 | Total Number of Respite Days Authorized | Yes, if applicable | RHCF | |
Reservation Days | Long | 4 | Total Number of Reservation Days Authorized | Yes, if applicable | RHCF | |
Reserve Date From | Date (m/d/yy) | 8 | First Date of Bed Reservation Day | Yes, if applicable | RHCF | |
Reserve DateTo | Date (m/d/yy) | 8 | Last Date of Bed Reservation Day | Yes, if applicable | RHCF | |
Occupy Rate | Percent | 5 | RHCF Occupancy Rate on Date of First Bed Reservation Day | Yes, if applicable | RHCF | |
Reserve Per Diem | Double | 15 | Per Diem Rate Paid to RHCF for Bed Reservation Days | Yes, if applicable | RHCF | |
adjust | Boolean or Integer | 1 | True if =Claim Adjustment | 1 = True, 0 = False | Yes, if applicable | All |
adjustnbr | Long | 3 | Number of claim adjustments | Yes, if applicable | All | |
resubmit | Boolean or Integer | 1 | True if =Claim Resubmission | 1 = True, 0 = False | Yes, if applicable | All |
resubmitnbr | Long | 3 | Number of claim resubmissions | Yes, if applicable | All | |
Any additional columns that the Plan wishes to add should be added after the final column | Text |