MAX files are created by state, calendar year and file type. The records included in MAX files, by file type, are as follows:
Person Summary File
• There is a record in this file for each person who was eligible for Medicaid or a Medicaid-expansion Child Health Insurance Program (M-CHIP) in the year. Medicaid enrollees covered by Section 1115 Demonstrations or other Medicaid waiver programs are included.
• Each record shows 12 monthly observations of enrollment in the year and a summary of service utilization. If an enrollee did not use any services during the year, only the section of the record on eligibility characteristics will contain data.
• States are also invited to submit records of enrollment for stand-alone (or separate) CHIP program enrollees (S-CHIP) in MSIS. Those records are included in MAX for states that choose to submit eligibility data on S-CHIP enrollees. Persons enrolled in S-CHIP only will have no months of Medicaid enrollment for the months they are enrolled in S-CHIP.
However, in the past, states were instructed not to report utilization for S-CHIP enrollees.
For a variety of reasons, there may be no MSIS enrollment records for some Medicaid service recipients. This can occur because eligibility and services (claims) data may be captured in different state data systems. Different reporting and batching cycles may result in mismatches between the two types of data. The number and types of persons for whom these records are missing varies from state to state, but is usually a very small proportion of the total state enrollees. There is a MAX Person Summary File record for each of these persons that includes ONLY the Medicaid identification number for the person in the section of the record on eligibility characteristics. Other eligibility characteristics are missing for these persons. In MAX, these eligibility characteristics are unknown (e.g. gender, date of birth and basis of eligibility). Enrollees with no MSIS enrollment records are identified by the data element “Missing Eligibility Data Switch.”
General Information Concerning Services Files
These files include three major types of records: (1) fee-for service records, including utilization and payment information (2) premium payments for persons enrolled in prepaid plans (in the MAX Other Services file only), and (3) “encounter” records for persons enrolled in prepaid managed care plans, including utilization but not payment information (because premium was paid in advance for care provided by the plan). Most states do not submit encounter records to MSIS for all services provided to persons enrolled in prepaid managed care plans. The degree of completeness and consistency in reporting of encounter records is not fully documented at this time. The introductory page(s) of each MAX data dictionary, for each of the four file types, provide additional details about the specifications of the file. The four types of services files are discussed below in more detail.
Inpatient Hospital File - This file contains records of inpatient hospital stays (MSIS and SMRF Type of Service = 01, 24, 25 and 39), regardless of length of stay. Stays of greater than one day are included in a MAX file based on the last day of service for the stay. For example, the record for a stay that began on December 27, 2007 and ended on January 4, 2008 is reported in the 2008 MAX file. Not all stay records may show a patient status code indicating that the patient was discharged. Data users should exercise caution in examining stays for mothers and their newborns because there are alternative ways in which these types of stays appear in the MAX files:
• mother and newborn with different Medicaid identification numbers on different records,
• mother and newborn with the same Medicaid identification number on different records, and
• mother and newborn both included on a combined record where it is not possible to separate the services delivered to the mother from those delivered to the newborn, as reported on the MSIS record.
Long-Term Care File - The records in this file are typically weekly, biweekly or monthly records of long-term care services (MSIS and SMRF Types of Service = 02, 04, 05 or 07). Because long-term care stays may be quite long, often covering multiple years, it is not practical to create a long-term care stay record file. Also, original admission date may be unreliable. For some states, there may be multiple records for the same person, dates of service and facility. In the case of these multiple records, some records may be for per-diem amounts and others for ancillary services, such as physical therapy. However, it is not possible to identify exactly which services were provided under each record.
This file contains records for services provided by long-term care facility, e.g. Nursing Facilities (NFs) and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs-IID). Other services provided to residents of these facilities, that were not provided by the long-term care facility itself, can be found in other files. For example, physician and podiatrist services are found in the other services (OT) file. Most states do not include prescribed drugs in their nursing facility payment rates. For this reason, prescribed drugs for nursing facility residents are usually found in the RX file. However, for 1999, three states (Delaware, New York and South Dakota) did include prescribed drugs in their nursing facility payment rates. To the best of our knowledge, this information has not been updated since 1999. So, for these three states, it is likely that neither the RX nor the LT file will contain a complete record of prescribed drugs for nursing facility residents. In contrast to prescribed drugs, most states included non-legend (over-the-counter) drugs in their nursing facility payment rates. For states that included non-legend drugs in their nursing facility payment rates, neither the RX nor the LT file will contain a complete record of non-legend drugs provided to nursing facility residents.
Prescription Drug File - The records in the RX file represent drugs and other services provided by a free-standing pharmacy and include all service records that contain a National Drug Code (NDC). Drug records in the RX file have MSIS and SMRF Types of Service (TOS) = 16. Other records in the RX file have MSIS TOS = 19 (other services) and SMRF TOS = 51 (Durable Medical Equipment – DME – and Supplies). Drug records include original filled prescriptions, refills, over-the-counter drugs, and other NDC-coded items. For example, DME and supplies are included if they contain NDCs. In contrast, DME and supplies that are billed by other types of providers and contain service codes (e. g. HCPCS or other state-specific procedure codes) are reported in the MAX Other Services File. Likewise, injectable drugs that patients may receive from non-pharmacy providers, such as physicians and clinics, that contain procedure (service) codes (known as j-codes) are also reported in the MAX Other Services File. It should be noted that certain drugs are not reported in the Prescription Drug File:
• Injectable drugs (J-code drugs) that must be administered by medical personnel are included in the Other Services File.
• Drugs provided during an inpatient hospital stay: Detail on these drugs is not available, but payments for these drugs are included in the inpatient hospital payment amount.
• As noted above for a small number of States, drugs provided during a nursing facility stay are included in the per-diem reimbursement to the nursing facility and detail on the drugs is not available. This last recorded survey of state reimbursement for nursing facilities, conducted for 1999, showed that this policy was in effect only in Delaware, New York and South Dakota. For all other States, drugs provided during a nursing facility stay, at that time, were included in the Prescription Drug File.
Other Services File - The MAX Other Services File contains all Medicaid records not reported in any of the other MAX services files. This file contains three types of records:
• Fee-for-service records for any types of services not reported in the other three MAX files (e.g. physician, outpatient hospital, clinic, laboratory, radiology, home health, transportation, etc),
• Managed care “encounter” records for persons enrolled in prepaid managed care plans, which can be identified using Type of Claim = 3, and
• Payment records for premiums paid to prepaid managed care plans, which can be identified using MSIS and SMRF Types of Service = 20, 21 and 22.
DME and supplies that are billed by non-pharmacy providers and contain service codes (i.e. HCPCS or other state-specific procedure codes rather than NDCs) are reported in the MAX Other Services File. Likewise, injectable drugs that patients receive from non-pharmacy providers, such as physicians and clinics, which contain procedure (service) codes (known as j-codes) are also reported in the MAX Other Services File. In contrast, DME and supplies are included in the RX file if they contain NDCs.