Last Revised Date: 8.20.2004
PURPOSE: The purpose of this document is to identify the naming convention, which should be followed by all boards. Although the boards are able to implement the system to meet their own needs, please follow the structure below. If there are any questions, please contact MACSIS Support.
Keywords are maintained by the state. Any requests for changes must go through the proper change control channels.
If you want to default the start date within a keyword to an earlier date, use 01/01/1901.
Use 01/01/2010 to default to a future date, if required.
Identify board or group of boards
Characters 1-4: 1st 4 letters of board or group of boards
e.g. SUMMB for SummitCounty
MCD = Medicaid
Must have at least 5 codes representing:
Can define further at local level if desired.
Group Level 3: 1st four characters of county name (e.g. WARR)
Group Level 2: Board Name (eg. Warren/Clinton)
Group Level 1: Name of board or consortium (e.g. BHG)
1st two characters identify service type:
Characters 3-5 identify Medicaid status:
Characters 6-7 identify board number:
Characters 8-10 are reserved for county use
MHMCD25XXX - Mental Health Medicaid FranklinCounty SMD
ADNON25XXX - AOD Non-Medicaid Franklin County SMD
1st two characters = board #
3rd character = board type
***other codes besides “M, A & B” are reserved for local use; AOD codes are limited to A-L, MH are limited to M-Z; it is recommended that Dual-funded panels begin with D.
Each provider will be assigned 5 price schedules:
3 primary price schedules for Medicaid reimbursable services
2 alternate price schedules for Non-Medicaid reimbursable services
Price Rules are attached to the provider contract (PROVC) and identify the pricing method for each procedure code.
PRULE 1 will always be used for professional pricing.
PRULE 2 will always be used for institutional pricing.
PRULE 1 will always be OH. It identifies all of the procedure codes to be paid at fee schedule.
PRULE 2 must be maintained at the local level because the method of paying institutional claims differs by board.
Attached to a member’s eligibility period when the member qualifies for a sliding scale.
If a sliding scale rider is attached in Member, a BRULE must be attached to the BENEF record. The BRULE will identify the amount of the sliding scale and MUST have the corresponding RIDER code indicated in the rider column.
Riders 0-9 will be used to identify specific co-pay amounts.
Riders A-S identifies sliding scale percentages in 5% increments. Boards/consortiums are limited to the codes listed, but can use the codes as needed within their groups. However, they must use the codes consistently within their group.
Benefit types are attached to the BENEF causing Diamond to apply certain benefits during claims adjudication.
Examples of BRULE types are coinsurance or sliding scale, exclusions, message and pend, limit and copay.
If a particular service requires authorization a BRULE is attached to the BENEF indicating the requirement.
Characters 1-2 :Board Number
Character 3: Board type or diagnosis type. Valid codes are:
Characters 4-10: available for local use
Boards may want to use statewide sliding scale rules (associated with rider codes), which all begin with OH.
Any further description given in the name will only assist the boards in clarifying information.
Six BRULES must be included in ALL benefit packages, both Medicaid and non-Medicaid: