ID Load and Response Files

17 min

Introduction

PBM/payers use the ID Load file to provide Surescripts with their member roster to populate the Surescripts master patient index (MPI). Surescripts uses these files from the PBM/payers to establish uniqueness for individuals across PBM/payers. Surescripts’ search process uses demographics to identify a patient and then uses the PBM/payer's unique member ID to communicate with the PBM/payers.

Surescripts responds to PBM/payer ID Loads with a Member Directory Response File indicating the status of each load, including details at both the file and detail level. Information provided by Surescripts indicates if a file loaded successfully, loaded with errors or was not loaded at all. Affected records are detailed in the response file which indicates the specific reason each line had an error or warning.

Surescripts will also provide statistical data about the processing for a given Delimited File received from a PBM/payer. The Member Directory Response Summary File will allow PBM/payers new insight into the processing of MPI files, and will allow them to better determine whether all of the records sent to Surescripts were loaded as expected.

ID Load Process Flow

The following steps depict the flow of the ID load:

The PBM/payer creates a directory of patients, assigning each occurrence a unique member ID.

Note: It is recommended to update the MPI daily.

The PBM/payer submits the initial load to Surescripts.

Surescripts populates the MPI internal directory with the initial file load.

Surescripts creates a response file for the PBM/payer indicating the process success and failure details.

Note: All date/times within response files are in UTC.

The PBM/payer creates an update file to keep the Surescripts MPI internal directory up-to-date.

Note: Updates should only be sent if there is a change in the members’ demographic data that Surescripts has defined in the file layout. If other member information not contained in the file layout changes, no update should be sent.

Surescripts processes the updates.

Surescripts sends a response to the PBM/payer indicating the process success and failure details.

Format to be Used

Surescripts has implemented a custom specification that contains demographic and PBM/payer specific information in a delimited field file format. Use the same character set as referenced in Character SetCharacter Set except for the “^” character – decimal 94 which cannot be used in the ID Load Process.

Notes:

Delimited files designated in the header record as a Full file that contain more than 8M records must be scheduled with Surescripts Support, and will be manually processed.

File name cannot contain a hyphen.

Member Processing Examples

Purpose	File Type	Method
Terminate a member	Update	Send the cancellation or termination date (past/present/future) along with the 024 – Cancel code.
Terminate a member	Full Refresh	Either send the cancellation/termination date (past/present/future) along with the 024 – Cancel code. Or Do not include the member in the full refresh file.
Add new member	Full Refresh or Update	Send the new member data in the full refresh or update file along with the 021 – Addition code.
Update member demographics	Full Refresh or Update	Send the updated member demographics along with the 001 – Change code.
Reinstate a previously terminated member where the record has not been removed via the full refresh process	Update	Send either a future termination date or leave the termination field blank along with the 025 – Reinstatement code.

Future Effective Date Examples

Purpose	Method
Update future coverage for existing member	1. Add expiration date for current coverage to the existing member. 2. Add new Demographic details of existing member to a new PBM Unique Member ID with future effective date. Note: The Master Patient Index will not accept multiple instances of a PBM Unique Member ID to reflect a future coverage change. The Master Patient Index accepts the latest record with a PBM Unique Member ID as an update, nullifying any previous record(s) with that ID. Future changes to a member utilizing the future effective date need to include a new PBM Unique Member ID.
Update effective date for future member	Update the member’s future effective date along with the 001 - Change code. Note: The Master Patient Index uses the latest update as the member’s current demographics.
Extend an existing member	Send new future effective date for member and use the same PBM Unique Member ID along with the 001 - Change code. Example: If original coverage is 1/1/2024 – 12/31/2024 and coverage remains the same through 2025 in the new record, keep the same effective date as 1/1/2024 and the new term date would be 12/31/2025.
Add a future member	Send future effective date for new member and use a new PBM Unique Member ID along with the 021 – Addition code. Example: If the coverage begins 1/1/2025, send record with an effective date of 1/1/2025 and new PBM Unique Member ID.

Error Scenarios

Note: Error scenarios do not vary based on file type (full refresh or update).

Code Sent in MPI Full Refresh or Update File	MPI Database Record Status	Response File Action	Error Code and Message
Change (001)	Record does not exist	Add the MPI database record.	W04 - Change Record not found, record added.
Addition (021)	Record already exists	Change the MPI database record.	W05 - Record to Add exists, record updated.
Cancellation or Termination (024)	Record does not exist	Add the MPI database record with the termination date. The record must contain a termination date or it will be rejected.	W06 - Record to Term does not exist, record added.
Reinstatement (025)	Record does not exist	Add the MPI database record. The record must contain a future termination date or no termination date.	W07 - Record to Reinstate not found, record added.

Requirement Designation

Code	Description
mandatory	The element must be used per the specification (e.g., XML schema validation). Note: The term mandatory applies to mandatory and required fields in the different standards.
business rule	If sent, the element must be used per the Surescripts business rule. Note: Not all business rules reside in this table.
conditional	The element is to be used per the conditions specified. Note: The term conditional applies to conditional and situational fields in the different standards. For example, X12 uses the term situational.
recommended	Surescripts recommends sending the element as a best practice.
optional	Some fields do not have specific conditions. Data should be sent if available.
not used	Not used by Surescripts.

Member Directory Maintenance Delimited File from PBM/Payer

Each field is delimited by the pipe character (|). Each line is separated by a new line (Hex 0A) character. The tilde character (~) is used as a repetition character – currently only supported in the postal code field.

Header Info

Field #	Field Name	Type	Required	Comments	Examples
1	Record Type	AN 3/5	mandatory	Identifies record type Value: HDR
2	Version/Release Number	AN 3/5	mandatory	Version Number of this specification Value: 3.0
3	Sender ID	AN 3/30	mandatory	ID as assigned by Surescripts identifying customer sending the file.	P11111111111111
4	Sender Participant Password	AN 10/10	mandatory	Password for this customer identified in field 3 (Sender ID).	ABCDE12345
5	Receiver ID	AN 1/30	mandatory	ID identifying the receiver of the file. Value: RXHUB
6	Source Name	AN 1/35	not used	Future use
7	Transmission Control Number	AN 1/10	mandatory	Unique identifier defined by the sender	0000001000
8	Transmission Date	DT 8/8	mandatory	Date message was created ( CCYYMMDD)	20170701
9	Transmission Time	TM 8/8	mandatory	Time message was created (HHMMSSDD)	12200101
10	Transmission File Type	AN 1/3	mandatory	Identifier telling the type of message Value: MPI
11	Transmission Action	AN 1/1	optional	Values: U=Update F=Full file If blank, default to U=Update	U
12	Extract Date	DT 8/8	mandatory	Date File was created (CCYYMMDD)	20170630
13	File Type	AN 1/1	mandatory	Test or Production Values: T=Test P=Production	P

Detail Info

Field #	Field Name	Type	Required	Comments	Examples
1	Record Type	AN 3/3	mandatory	Identifies record type Value: MEM
2	Record Sequence Number	AN 1/10	mandatory	Number for this detail row in the message
3	PBM Unique Member ID	AN 1/60	mandatory	Unique ID as identified by the PBM/payer for the member
4	PBM Unique ID for Subscriber	AN 1/60	optional	Unique ID as identified by the PBM/payer for the subscriber of the member
5	Health Plan Member Number	AN 1/30	optional	Health Plan Unique Member identification number on the Health Plan card identifying the patient (Either a subscriber or a dependent)
6	Health Plan Subscriber Number	AN 1/30	optional	Health Plan Unique Subscriber identification number - Number on the Health Plan card identifying the subscriber
7	Policy Number	AN 1/30	optional	Health Plan policy or group number
8	Member Expiration Date	DT 8/8	optional	Date that the member is no longer eligible (CCYYMMDD) If multiple dates are available (i.e. Term Date, Expired Date, End Date), use the earliest date of the three.
9	Last Name	AN 1/35	mandatory	Last Name of the Member
10	First Name	AN 1/25	mandatory	First Name of the Member
11	Middle Name	AN 1/25	recommended	Middle Name of the Member Recommended to send to aid in patient matching.
12	Prefix	AN 1/10	optional	Member Prefix
13	Suffix	AN 1/10	recommended	Member Suffix Recommended to send to aid in patient matching.
14	Social Security Number	N 9/9	optional	Member SSN - No dashes
15	Address Line 1	AN 1/55	recommended	First Line of the Address (No C/O type info) Recommended to send to aid in patient matching.
16	Address Line 2	AN 1/55	recommended	Second Line of the Address (No C/O type info) Recommended to send to aid in patient matching.
17	City Name	AN 2/30	recommended	Member City Name Recommended to send to aid in patient matching.
18	State or Province Code	AN 2/2	recommended	Member State Code Recommended to send to aid in patient matching.
19	Postal Code	AN 3/15	recommended	Member zip code 5 or 9 numeric no punctuation.	55123
20	Country Code	AN 2/3	optional	Member Country Code
21	Comm Number 1 Type	AN 2/2	recommended	1st Comm. Number Type Values: EM = Email EX = Telephone Extension FX = Facsimile HP = Home Phone TE = Telephone WP = Work Phone Recommended to send to aid in patient matching.
22	Communication Number 1	AN 1/80	recommended	1st Communication Number Recommended to send to aid in patient matching.
23	Communication Number 2 Type	AN 2/2	recommended	2nd Communication Number Type Values: EM = Email EX = Telephone Extension FX = Facsimile HP = Home Phone TE = Telephone WP = Work Phone Recommended to send to aid in patient matching.
24	Communication Number 2	AN 1/80	recommended	2nd Communication Number Recommended to send to aid in patient matching.
25	Communication Number 3 Type	AN 2/2	optional	3rd Communication Number Type Values: EM = Email EX = Telephone Extension FX = Facsimile HP = Home Phone TE = Telephone WP = Work Phone
26	Communication Number 3	AN 1/80	optional	3rd Communication Number
27	Date of Birth	DT 8/8	recommended	Member DOB (CCYYMMDD) Recommended to send to aid in patient matching.
28	Gender	AN 1/1	recommended	Member Gender (M,F,U) Recommended to send to aid in patient matching.
29	Employer Name	AN 1/35	optional	Employer Name
30	Transaction Type	AN 3/3	mandatory	Type of Action needed Values: 001 – Change 021 – Addition 024 - Cancellation or Termination 025 – Reinstatement
31	Member Active Date	DT 8/8	recommended	Date member becomes active (CCYYMMDD) If field is left blank, member will be active on date of load. Recommended to send to aid in patient matching.

Trailer Info

Field #	Field Name	Type	Required	Comments	Examples
1	Record Type	AN 3/3	mandatory	Identifies record type Value: TRL
2	Total Records	N 1/10	mandatory	Total Records Processed

Member Directory Response Delimited File to PBM/Payer

The file name reflects the file name from the PBM/payer with a .rsp file extension.

Example: NewPatient_TestingPBMC_MPI.1450188243095.rsp

Note: If the source file had an extension, the extension remains and the .rsp is added after it. For example: NewPatient_TestingPBMC_MPI.1450188243095.txt.rsp

Header

Field	Description	Type	Required	Comments	Examples
Record Type	Identifies record type	AN 3/3	mandatory	Value: SHD
Version/Release Number	Version Number of this specification	AN 1/2	mandatory	Value: 3.0
Recipient ID	ID assigned by Surescripts for the recipient of the response file (original sender of the ID load file)	AN 3/30	mandatory	If the inbound MPI file included an invalid Sender ID, Sender Participant Password, Transmission Date, or Transmission time, this field in the response file will be populated with: “INV_HEADER”.	P11111111111111
Sender ID	ID as assigned by Surescripts identifying Surescripts	AN 3/30	mandatory	Value: RXHUB
Recipient Participant Password	Password assigned by Surescripts for accessing the PBM/payer system.	AN 10/10	mandatory	If the inbound MPI file included an invalid Sender ID, Sender Participant Password, Transmission Date, or Transmission time, this field in the response file will be populated with: “INV_HEADER”.
Transaction Control Number	Unique identifier defined by the sender	AN 1/10	mandatory
Transaction Date	Date message was created	DT 8/8	mandatory	CCYYMMDD
Transaction Time	Time message was created	TM 8/8	mandatory	HHMMSSDD
Transaction File Type	Identifier telling receiver the type of file.	AN 1/3	mandatory	Value: MPR
Transaction Number - Originating	Number of the original report message	AN 1/10	mandatory
Transaction Date- Originating	Date Original Incoming File was created	DT 8/8	mandatory	CCYYMMDD If the inbound MPI file included an invalid Sender ID, Sender Participant Password, Transmission Date, and/or Transmission time, this field in the response file will be populated with: “20000101”.
Transaction Time- Originating	Time Original Incoming File was created	TM 8/8	mandatory	HHMMSSDD If the inbound MPI file included an invalid Sender ID, Sender Participant Password, Transmission Date, and/or Transmission time, this field in the response file will be populated with: “00000000”.
File Type	Test or Production (T/P)	AN 1/1	mandatory	Values: T=Test P=Production
Load Status	Code Explaining the status of the load.	AN 2/2	mandatory	See Member Directory CodesMember Directory Codes

Detail Info

Field	Description	Type	Required	Comments
Record Type	Identifies record type	N 1/1	mandatory	Value: SDT
Record Sequence Number	Number that identified the row in the incoming message	AN 1/10	mandatory
PBM Unique ID for the member	Unique ID as identified by the PBM/payer for the member	AN 1/60	optional
Error Code	Describes error for this row W - Signifies a Warning E - Signifies a Error	AN 3/3	mandatory	See Member Directory CodesMember Directory Codes

Trailer Info

Field	Description	Type	Required	Notes	Examples
Record Type	Identifies record type.	AN 3/3	mandatory	Value: STR
Total Rows in Error		N 1/10	mandatory

Member Directory Response Summary Delimited File to PBM/Payer

File Naming Convention:

A human readable file (on Workbench) will have a .smt file extension. Example: erx_RXHUB_member_directory_02082015_201919.1423456259313.smt

A pipe delimited file (on FTP) will have a .smd file extension.

Note: The PBM/payer needs to request an opt-in from Surescripts in order to receive this .smd file.

Example: erx_RXHUB_member_directory_02082015_201919.1423456259313.smd

Field #	Field	Description	Type	Comments	Example
1	File Load Date	Date the MPI file was processed by Surescripts. UTC Date in MM/DD/CCYY format.	DT 10/10		12/05/2014
2	Transmission Control Number	Unique identifier defined by the sender from inbound MPI file.	AN 1/10		0000001000
3	Participant ID	Surescripts ID assigned to the PBM/payer.	AN 3/30		P111111111111111
4	Sender ID	The Sender ID is Surescripts.	AN 3/30	Value: Surescripts
5	Incoming File Received	Date time that Surescripts received the inbound file. 24 hour time used - UTC Datetime in MM/DD/YYYY HH:MM:SS format.	AN 19/19		12/05/2014 04:34:02
6	Total Number of Active Lives in MPI Before Processing	Number of active lives in the MPI before processing. This does not include future lives. If future lives were included in the file, they will be excluded from the active lives count. Note: Number of active lives reflects the customer's requested lag days. For example, if the customer's lag day value is 7, all members in their MPI file are considered active for 7 days beyond the Member Expiration date provided by the customer in the MPI file.	N 1/12		10000
Incoming File Record Count
7	Total Records in File	Number of patient records in the MPI file.	N 1/12		1000
8	Number of Adds	Number of records in the inbound MPI file where Transaction Type == 021.	N 1/12		200
9	Number of Terms	Number of records in the inbound MPI file where Transaction Type == 024.	N 1/12		300
10	Number of Changes	Number of records in the inbound MPI file where Transaction Type == 001.	N 1/12		500
11	Number of Reinstatements	Number of records in the inbound MPI file where Transaction Type == 025.	N 1/12		5
12	Number of Records with a Member Active Date	Number of records in the inbound MPI file with a Member Active Date.	N 1/12		500
13	Number of Records with a Future Member Active Date	Number of records in the inbound MPI file with a future Member Active Date.	N 1/12		500
Results of Processing the File
14	Requested Number of Records Added	Number of records with Transaction Type == 021 that were added.	N 1/12		300
15	Requested Number of Records Changed	Number of records with Transaction Type == 001 that were changed.	N 1/12		600
16	Requested Number of Records Termed	Number of records with Transaction Type == 024 that were terminated.	N 1/12		50
17	Requested Number of Reinstatements	Number of records with Transaction Type == 025 that were reinstated.	N 1/12		4
18	Number of Errors	Number of errors generated.	N 1/12		50
19	Number of Adds That Already Existed	Number of cases on update file loads where a record in the inbound file had Transaction Type == 021, but the patient already existed in the Surescripts system.	N 1/12		75
20	Number of Changed that Did Not Exist	Number of cases on update file loads where a record in the inbound file had Transaction Type == 001, but the patient record did not exist in the Surescripts system.	N 1/12		100
21	Number of Terms that Did Not Exist	Number of cases on update file loads where a record in the inbound file had Transaction Type == 024, but the patient record did not exist in the Surescripts system.	N 1/12		50
22	Number of Reinstatements that Did Not Exist	Number of cases on update file loads where a record in the inbound file had Transaction Type == 025, but the patient record did not exist in the Surescripts system (patient was not found in either an active or inactive state).	N 1/12		1
23	Total Number of Active Lives in MPI After Processing	Number of active lives in the MPI after processing. This does not include future lives. If future lives were included in the file, they will be excluded from the active lives count. After processing the new file, the number of records where the Member Expiration Date is >= to today's date in the Surescripts system.	N 1/12		10300
24	Processing Start Time	Date time the new MPI file began processing in 24 hour clock - UTC Datetime in MM/DD/YYYY HH:MM:SS format	AN 19/19		12/05/2014 05:04:00
25	Processing End Time	Date time the new MPI file began processing in 24 hour clock - UTC Datetime in MM/DD/YYYY HH:MM:SS format	AN 19/19		12/05/2014 07:16:02
26	Processing Time for File	Time it took to process the file in HHH:MM:SS format.	DT 9/9		002🕛02
27	Member Directory Response Summary Version ID	Version ID of the Member Directory Response Summary.	AN 3/3		3.0

Member Directory Codes

Header Response Codes

Code	Description
01	File loaded correctly.
02	File loaded with errors.
03	Invalid file format - File Not loaded.
04	System error - Please resend.
05	Invalid header section ID - File not loaded (Not Used).
06	Invalid header Participant ID or password - File not loaded.
07	Invalid header transaction number format - File not loaded.
08	Invalid header transaction datetime format - File not loaded.
09	Invalid header usage indicator - File not loaded.
10	Invalid header filler - File not loaded.
11	Invalid header new line character - File not loaded.
12	Invalid trailer section ID – Trailer not validated - File not loaded.
13	Invalid trailer filler - Trailer not validated. - File not loaded.
14	Invalid reported number of records - File not loaded.
15	Contract does not exist - File not loaded.
17	Invalid header version number - File not loaded (Not Used).
18	Invalid receiver ID – File not loaded.
19	Invalid Source Name – File not loaded.
20	Invalid File Type – If the file type is not MPI, ALT, or RLE. File not loaded.
21	Invalid Transmission Action – If the transmission action is not “U” or “F” – File not loaded.
22	Invalid Number of Fields – File not loaded. Note: Applies if the header does not have all of the fields. Only applies to versions 2.0 and 3.0.

Detail Error/Warning Codes

Code	Description
E01	Missing PBM Unique Member ID, record not loaded.
E02	Missing required fields, record not loaded.
E03	Invalid characters in row, record not loaded.
E04	Invalid record length, record not loaded.
E05	Invalid record type, record not loaded.
E07	Invalid transaction type, record not loaded.
E09	Missing Term Date, record not loaded.
E10	Maximum repetitions exceeded.
E13	Term Date must be a future date or not populated when 25-Reinstatement Transaction Type is used.
E14	Invalid Member Active Date (wrong format or invalid date).
E15	Member Active Date is greater than Member Expiration Date.
W04	Change Record not found, record added.
W05	Record to Add exists, record updated.
W06	Record to Term does not exist, record added.
W07	Record to Reinstate not found, record added.
W08	Duplicate PBM Unique Member ID found in update file, record not loaded. This warning will only occur for the membership update process. If a duplicate PBM Unique Member ID is found in the initial membership load, no records are loaded and the entire file is rejected.