Okaloosa County BOCC — 2013 meeting #1139 (date undetermined) — MEDICAID ORIGINAL 2009 — reading text

(one per batch - first record in file) Total FieldName Format Benin End Positions Description Edits RecordType X(01) 1 1 1 Header Record Must = H Indicator CTC_EIN 9(09) 2 10 9 CTC Federal Numeric EmployerlD Batch_Number 9(09) 11 19 9 Unique ID for batch Numeric with leading (batches with zeroes duplicate IDs will be rejected) File_Type X(01) 20 20 1 If a File_Type = T is T = test file, P = sent to the Production file. Any other production machine value will cause entire the entire file will be file to be rejected. rejected. If a File_Type = P is sent to the test machine then the entinnlle will be rejected. Claim (trip) Records (maximum 5000 per batch) Total FleldName Format . Begin End Positions Description Edits RecordType X(01) 1 1 1 Claim Record Must =C Indicator UniqueTriplD X(15) 2 16 15 Unique Trip ID Generated by CTC software Trip_Void X(01) 17 17 1 Place "V" in = Must V or blank field to void previously submitted claim record (determined by UniqueTriplD) CTC_EIN 9(09) 18 26 9 CTC Federal Numeric EmployerlD CTC_MedicaidlD 9(10) 27 36 10 CTC Medicaid Numeric - passes check ID digit validation 2008/2009 Medicaid Non-Emergency Transportation Subcontracted Transportation Provider Contract Page 98 of 117  Bene_Lname X(15) 37 51 15 Beneficiary Length> 0 Last Name Bene_Fname X(15) 52 66 15 Beneficiary Length> 0 First Name Bene_MI X(01) 67 67 1 Beneficiary None Middle Initial Bene_MedicaidlD X(10) 68 77 10 Beneficiary Numeric - passes check MedicaidlD digit validation Bene_HomeAddr X(30) 78 107 30 Beneficiary Length> 0 Home Address Bene_HomeCity X(20) 108 127 20 Beneficiary Length> 0 Home City Bene_HomeCounty 9(02) 128 129 2 Beneficiary Validated against attached Home County table Bene_HomeState X(02) 130 131 2 Beneficiary Validated against 50 States Home State Bene_HomeZip 9(05) 132 136 5 Beneficiary Numeric (5 digit zip only) Home Zip Bene_DOB 9(08) 137 144 8 Beneficiary Numeric and valid date Date of Birth CCVYMMDD Bene_Gender X(01) 145 145 1 Beneficiary = = M male, F female, U - Gender Unknown Bene_SSN 9(09) 146 154 9 Beneficiary Numeric SSN Reservation_Date 9(08) 155 162 8 Date Numeric and valid date - reservation call CCVYMMDD received Reservation_Time 9(04) 163 166 4 Time Numeric and valid time - reservation call HHMM (24 hour - 1:OOpm = received 1300) Reservation_Pickup_Date 9(08) 167 174 8 Original Numeric and valid date - Scheduled CCVYMMDD Pickup Date Reservation_Pickup_Time 9(04) 175 178 4 Original Numeric and valid time - Scheduled HHMM (24 hour-1:00pm = Pickup Time 1300) Reservation_AppCTime 9(04) 179 182 4 D(s or Facility Numeric and valid time - AppOintment HHMM (24 hour - 1:OOpm = Time = 1300) for Trip_Indicator "I", = Blank for TripJndicator "T" or"R" Trip_Origin_Address X(30) 183 212 30 Trip origination Length> 0 address Trip_Origin_City X(20) 213 232 20 Trip origination Length> 0 city Trip_Origin_County 9(02) 233 234 2 Trip origination Validated against attached county table Trip_Origin_Code X(01) 235 235 1 Trip origination Validated against attached code table Trip_Trans_Mode X(02) 236 237 2 Trip Validated against attached transportation table mode TripJndicator X(01) 238 238 1 Trip indicator Validated against attached table Trip_NoShow X(01) 239 239 1 No Show N if No Show othelWise blank Trip_Miles 9(04).9 240 245 6 Trip miles = Insert decimal. 4 miles 4.0. Must be valid miles. Maximum value is 9999.9. = Trip miles 0.0 for , = Trip Trans Mode BP. All 2008,2009 Medicaid Non -Emergency Transportation .. ' Subcontracted Transportation Provider Contract Page 99 of 117  other Trip_Trans_Mode > O. May delete leading zeros above first zero (example- can have 0.0 but not .0) (example - 0001.0 can be 1.0) Trip_Cost 9(03).99 246 251 6 Trip cost No $ but insert decimal. =