Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 590 - MAINE HEALTH DATA ORGANIZATION › Chapter 243 - UNIFORM REPORTING SYSTEM FOR HEALTH CARE CLAIMS DATA SETS › Appendix 590-243-F-1 - Maine Health Data Organization Dental Claims File Specifications

Current through 2024-29, July 17, 2024
Data Element
								#
Data Element
								Name
Date
								Effective
Type
Maximum
								Length
Description/Codes/Sources
DC001
Submitter
1/1/2003
Text
8
MHDO-assigned identifier of payor submitting claims
								data. Do not leave blank.
DC002
Payor
7/1/2012
Text
8
MHDO-assigned code of the insurer/ underwriter in
								the case of premiums-based coverage, or of the administrator in the case of
								self-funded coverage.
Do not leave blank.
DC003
Insurance Type/Product
								Code
1/1/2003
Text
2
Code identifying the type of insurance policy
								within a specific insurance program. Refer to Appendix A
DC004
Payor Claim Control
								Number
1/1/2003
Text
35
Must apply to entire claim and be unique within the
								payor's system
DC005
Line Counter
4/1/2004
Number
4
Line number for this service The line counter
								begins with 1 and is incremented by 1 for each additional service line of a
								claim.
DC006
Insured Group or Policy
								Number
1/1/2003
Text
30
Group or policy number - not the number that
								uniquely identifies the subscriber
DC007
Subscriber Social Security
								Number
1/1/2003
Text
9
Subscriber's social security number Leave blank if
								unavailable.
DC008
Plan Specific Contract
								Number
1/1/2003
Text
80
Plan-assigned contract number Leave blank if
								contract number = subscriber's social security number.
DC009
Member Suffix or Sequence
								Number
1/1/2003
Text
20
Uniquely numbers the member within the
								contract
DC010
Member Identification
								Code
1/1/2003
Text
50
Member's social security number Leave blank if
								unavailable.
DC011
Individual Relationship
								Code
1/1/2003
Text
2
Member's relationship to insured Refer to Appendix
								A
DC012
Member Gender
1/1/2003
Text
1
Refer to Appendix A
DC013
Member Date of Birth
1/1/2003
Text
8
CCYYMMDD
DC014
Member City Name
4/1/2004
Text
30
City name of member Refer to Appendix A
DC015
Member State or
								Province
4/1/2004
Text
2
As defined by the US Postal Service and Canada Post
								Refer to Appendix A
DC016
Member ZIP Code
1/1/2003
Text
11
ZIP Code of member - may include non-US codes Do
								not include dash.
Refer to Appendix A
DC017
Date Service Approved (AP
								Date)
1/1/2003
Text
8
CCYYMMDD
DC018
Rendering Provider
								Number
1/1/2003
Text
30
Payor-assigned provider number
DC019
Rendering Provider Tax ID
								Number
1/1/2003
Text
10
Federal taxpayer's identification
								number
DC020
National Provider ID - Rendering
								Provider
4/1/2004
Text
20
National Provider ID This data element pertains to
								the entity or individual directly providing the service.
Refer to Appendix A
DC021
Rendering Provider Entity Type
								Qualifier
4/1/2004
Number
1
HIPAA provider taxonomy classifies provider groups
								(clinicians who bill as a group practice or under a corporate name, even if
								that group is composed of one provider) as a "person", and these shall be coded
								as a person.
Refer to Appendix A
DC022
Rendering Provider First
								Name
1/1/2003
Text
40
Individual first name Leave blank if provider is a
								facility or organization.
DC023
Rendering Provider Middle
								Name
1/1/2003
Text
25
Individual middle name or initial Leave blank if
								provider is a facility or organization.
DC024
Rendering Provider Last Name or Organization
								Name
1/1/2003
Text
60
Full name of provider organization or last name of
								individual provider
DC025
Rendering Provider
								Suffix
1/1/2003
Text
10
Suffix to individual name Leave blank if provider
								is a facility or organization.
The service provider suffix shall be used to
								capture the generation of the individual clinician (e.g., Jr., Sr., III), if
								applicable, rather than the clinician's degree (e.g., MD, LCSW).
DC026
Rendering Provider
								Specialty
1/1/2003
Text
10
Refer to Appendix A
If defined by payor, then dictionary for specialty
								code values must be supplied during testing.
DC027
Placeholder
2/1/2016
N/A
0
Leave blank Service Provider City Name retired;
								refer to DC055 - Service Facility Location City Name
DC028
Placeholder
2/1/2016
N/A
0
Leave blank Service Provider State or Province
								retired; refer to DC056 - Service Facility Location Address State or
								Province
DC029
Placeholder
2/1/2016
N/A
0
Leave blank Service Provider ZIP Code retired;
								refer to DC057 - Service Facility Location Address State or
								Province
DC030
Place of Service -
								Professional
4/1/2004
Text
2
Refer to Appendix A
DC031
Claim Status
1/1/2003
Text
2
Refer to Appendix A
DC032
CDT Code
1/1/2003
Text
5
Common Dental Terminology code Refer to Appendix
								A
DC033
Procedure Modifier - 1
1/1/2003
Text
2
Procedure modifier required when a modifier
								clarifies/improves the reporting accuracy of the associated procedure
								code
DC034
Procedure Modifier - 2
1/1/2003
Text
2
Procedure modifier required when a modifier
								clarifies/improves the reporting accuracy of the associated procedure
								code
DC035
Date of Service - From
1/1/2003
Text
8
First date of service for this service line
								CCYYMMDD
DC036
Date of Service - Thru
1/1/2003
Text
8
Last date of service for this service line
								CCYYMMDD
DC037
Charge Amount
1/1/2003
Number
10
Do not code decimal point. Two decimal places
								implied.
DC038
Paid Amount
1/1/2003
Number
10
Do not code decimal point. Two decimal places
								implied.
DC039
Co-pay Amount
1/1/2003
Number
10
The preset, fixed dollar amount for which the
								individual is responsible Do not code decimal point. Two decimal places
								implied.
DC040
Coinsurance Amount
1/1/2003
Number
10
The dollar amount an individual is responsible for
								- not the percentage Do not code decimal point. Two decimal places
								implied.
DC041
Deductible Amount
1/1/2003
Number
10
Do not code decimal point. Two decimal places
								implied.
DC042
Billing Provider
								Number
1/1/2010
Text
30
Payor-assigned billing provider number. This number
								should be the identifier used by the payor for internal identification
								purposes, and does not routinely change.
DC043
National Provider ID - Billing
								Provider
1/1/2010
Text
20
National Provider ID for billing provider Refer to
								Appendix A
DC044
Billing Provider Last Name or Organization
								Name
1/1/2010
Text
60
Full name of provider billing organization or last
								name of individual billing provider.
DC045
Billing Provider Tax
								ID
2/1/2016
Text
10
Federal taxpayer's identification
								number
DC046
Billing Provider Address Line
								1
2/1/2016
Text
55
Address information for billing
								provider
DC047
Billing Provider Address Line
								2
2/1/2016
Text
55
Address information for billing
								provider
DC048
Billing Provider City
								Name
2/1/2016
Text
30
City name of billing provider Refer to Appendix
								A
DC049
Billing Provider State or
								Province
2/1/2016
Text
2
As defined by the US Postal Service and Canada Post
								Refer to Appendix A
DC050
Billing Provider Zip
								Code
2/1/2016
Text
11
Zip Code of billing provider - may include non-US
								codes Do not include dash Refer to Appendix A
DC051
Service Facility Location
								Name
2/1/2016
Text
60
Laboratory or service facility name If not
								available or not specified, do not populate.
DC052
National Provider ID - Service
								Facility
2/1/2016
Text
20
National Provider ID for laboratory or service
								facility If not available or not specified, do not populate.
Refer to Appendix A
DC053
Service Facility Location Address Line
								1
2/1/2016
Text
55
Address information for laboratory or service
								facility If not available or not specified, do not populate.
DC054
Service Facility Location Address Line
								2
2/1/2016
Text
55
Address information for laboratory or service
								facility If not available or not specified, do not populate.
DC055
Service Facility Location City
								Name
2/1/2016
Text
30
City name of laboratory or service facility If not
								available or not specified, do not populate. Refer to Appendix A
DC056
Service Facility Location State or
								Province
2/1/2016
Text
2
As defined by the US Postal Service and Canada Post
								If not available or not specified, do not populate.
Refer to Appendix A
DC057
Service Facility Location Zip
								Code
2/1/2016
Text
11
Zip Code of service facility - may include non-US
								codes Do not include dash If not available or not specified, do not
								populate.
Refer to Appendix A
DC058
Service Facility
								Number
2/1/2016
Text
30
Payor-assigned service facility number. This
								number
should be the identifier used by the payor for
								internal identification purposes and does not routinely change. If not
								available or not specified, do not populate.
DC101
Subscriber Last Name
1/1/2010
Text
60
The subscriber last name
DC102
Subscriber First Name
1/1/2010
Text
35
The subscriber first name
DC103
Subscriber Middle Name
1/1/2010
Text
25
The subscriber middle name or initial
DC104
Member Last Name
1/1/2010
Text
60
The member last name
DC105
Member First Name
1/1/2010
Text
35
The member first name
DC106
Member Middle Name
1/1/2010
Text
25
The member middle name or initial
DC107
Member Address Line 1
2/1/2019
Text
55
DC108
Member Address Line 2
2/1/2019
Text
55
DC109
Member Country Code
2/1/2019
Text
2
Use ISO 3166-1 alpha-2 country codes. Refer to
								Appendix A.
DC110
In-Plan Network
								Indicator
2/1/2021
Text
1
A yes/no indicator that specifies if the Billing
								Provider (not the benefit) is within the health plan network. Valid codes are:
								N=No; Y=Yes.
DC111
Placeholder
2/1/2025
N/A
0
Leave blank. Payment Arrangement Type Indicator
								retired
DC112
Oral Cavity 1
2/1/2025
Text
2
Always report the area of the oral cavity when the
								procedure reported in field DC032 (CDT Code) refers to a quadrant or arch and
								the area of the oral cavity is not uniquely defined by the procedure's
								nomenclature.
Area of the oral cavity is designated by a
								two-digit code, selected from the following code list:
00=entire oral cavity;
01=maxillary arch;
02=mandibular arch;
10=upper right quadrant;
20=upper left quadrant;
30=lower left quadrant;
40=lower right quadrant.
DC113
Oral Cavity 2
2/1/2025
Text
2
Always report the area of the oral cavity when the
								procedure reported in field DC032 (CDT Code) refers to a quadrant or arch and
								the area of the oral cavity is not uniquely defined by the procedure's
								nomenclature.
Area of the oral cavity is designated by a
								two-digit code, selected from the following code list:
00=entire oral cavity;
01=maxillary arch;
02=mandibular arch;
10=upper right quadrant;
20=upper left quadrant;
30=lower left quadrant;
40=lower right quadrant.
DC114
Oral Cavity 3
2/1/2025
Text
2
Always report the area of the oral cavity when the
								procedure reported in field DC032 (CDT Code) refers to a quadrant or arch and
								the area of the oral cavity is not uniquely defined by the procedure's
								nomenclature.
Area of the oral cavity is designated by a
								two-digit code, selected from the following code list:
00=entire oral cavity;
01=maxillary arch;
02=mandibular arch;
10=upper right quadrant;
20=upper left quadrant;
30=lower left quadrant;
40=lower right quadrant.
DC115
Oral Cavity 4
2/1/2025
Text
2
Always report the area of the oral cavity when the
								procedure reported in field DC032 (CDT Code) refers to a quadrant or arch and
								the area of the oral cavity is not uniquely defined by the procedure's
								nomenclature.
Area of the oral cavity is designated by a
								two-digit code, selected from the following code list:
00=entire oral cavity;
01=maxillary arch;
02=mandibular arch;
10=upper right quadrant;
20=upper left quadrant;
30=lower left quadrant;
40=lower right quadrant.
DC116
Oral Cavity 5
2/1/2025
Text
2
Always report the area of the oral cavity when the
								procedure reported in field DC032 (CDT Code) refers to a quadrant or arch and
								the area of the oral cavity is not uniquely defined by the procedure's
								nomenclature.
Area of the oral cavity is designated by a
								two-digit code, selected from the following code list:
00=entire oral cavity;
01=maxillary arch;
02=mandibular arch;
10=upper right quadrant;
20=upper left quadrant;
30=lower left quadrant;
E40=lower right quadrant.
DC117
Tooth Number or Letter
								(1)
2/1/2025
Text
2
Required when DC032 = D2000 thru D2999. Enter the
								appropriate tooth number or letter when the procedure directly involves a tooth
								or range of teeth. If not available, leave blank. Tooth Number codes are
								maintained by the American Dental Association. See Appendix A.
DC118
Tooth - 1 Surface - 1
2/1/2025
Text
1
Report the tooth surface(s) on which this service
								was performed. Provides further detail on procedure(s). Required when Tooth
								Number/ Letter DC117 is populated.
DC119
Tooth - 1 Surface - 2
2/1/2025
Text
1
Report the tooth surface(s) on which this service
								was performed. Provides further detail on procedure(s). If not required to
								report an additional tooth surface, leave blank.
DC120
Tooth - 1 Surface - 3
2/1/2025
Text
1
Report the tooth surface(s) on which this service
								was performed. Provides further detail on procedure(s). If not required to
								report an additional tooth surface, leave blank.
DC121
Tooth - 1 Surface - 4
2/1/2025
Text
1
Report the tooth surface(s) on which this service
								was performed. Provides further detail on procedure(s). If not required to
								report an additional tooth surface, leave blank.
DC122
Tooth - 1 Surface - 5
2/1/2025
Text
1
Report the tooth surface(s) on which this service
								was performed. Provides further detail on procedure(s). If not required to
								report an additional tooth surface, leave blank.
DC123
Tooth Number or Letter
								(2)
2/1/2025
Text
2
Report the tooth identifier(s) when DC032 is within
								the given range if a second tooth is involved in the procedure. Required when
								DC032 = D2000 thru D2999.
See Appendix A.
DC124
Tooth - 2 Surface - 1
2/1/2025
Text
1
Report the tooth surface(s) on which this service
								was performed. Provides further detail on procedure(s). Required when Tooth
								Number/ Letter DC123 is populated.
DC125
Tooth - 2 Surface - 2
2/1/2025
Text
1
Report the tooth surface(s) on which this service
								was performed. Provides further detail on procedure(s). If not required to
								report an additional tooth surface, leave blank.
DC126
Tooth - 2 Surface - 3
2/1/2025
Text
1
Report the tooth surface(s) on which this service
								was performed. Provides further detail on procedure(s). If not required to
								report an additional tooth surface, leave blank.
DC127
Tooth - 2 Surface - 4
2/1/2025
Text
1
Report the tooth surface(s) on which this service
								was performed. Provides further detail on procedure(s). If not required to
								report an additional tooth surface, leave blank.
DC128
Tooth - 2 Surface - 5
2/1/2025
Text
1
Report the tooth surface(s) on which this service
								was performed. Provides further detail on procedure(s). If not required to
								report an additional tooth surface, leave blank.
DC129
Tooth Number or Letter
								(3)
2/1/2025
Text
2
Report the tooth identifier(s) when DC032 is within
								the given range if a third tooth is involved in the procedure. Required when
								DC032 = D2000 thru D2999.
See Appendix A.
DC130
Tooth - 3 Surface - 1
2/1/2025
Text
1
Report the tooth surface(s) on which this service
								was performed. Provides further detail on procedure(s). Required when Tooth
								Number/ Letter DC129 is populated.
DC131
Tooth - 3 Surface - 2
2/1/2025
Text
1
Report the tooth surface(s) on which this service
								was performed. Provides further detail on procedure(s). If not required to
								report an additional tooth surface, leave blank.
DC132
Tooth - 3 Surface - 3
2/1/2025
Text
1
Report the tooth surface(s) on which this service
								was performed. Provides further detail on procedure(s). If not required to
								report an additional tooth surface, leave blank.
DC133
Tooth - 3 Surface - 4
2/1/2025
Text
1
Report the tooth surface(s) on which this service
								was performed. Provides further detail on procedure(s). If not required to
								report an additional tooth surface, leave blank.
DC134
Tooth - 3 Surface - 5
2/1/2025
Text
1
Report the tooth surface(s) on which this service
								was performed. Provides further detail on procedure(s). If not required to
								report an additional tooth surface, leave blank.
DC135
Tooth Number or Letter
								(4)
2/1/2025
Text
2
Report the tooth identifier(s) when DC032 is within
								the given range if a fourth tooth is involved in the procedure. Required when
								DC032 = D2000 thru D2999.
See Appendix A.
DC136
Tooth - 4 Surface - 1
2/1/2025
Text
1
Report the tooth surface(s) on which this service
								was performed. Provides further detail on procedure(s). Required when Tooth
								Number/ Letter DC135 is populated.
DC137
Tooth - 4 Surface - 2
2/1/2025
Text
1
Report the tooth surface(s) on which this service
								was performed. Provides further detail on procedure(s). If not required to
								report an additional tooth surface, leave blank.
DC138
Tooth - 4 Surface - 3
2/1/2025
Text
1
Report the tooth surface(s) on which this service
								was performed. Provides further detail on procedure(s). If not required to
								report an additional tooth surface, leave blank.
DC139
Tooth - 4 Surface - 4
2/1/2025
Text
1
Report the tooth surface(s) on which this service
								was performed. Provides further detail on procedure(s). If not required to
								report an additional tooth surface, leave blank.
DC140
Tooth - 4 Surface - 5
2/1/2025
Text
1
Report the tooth surface(s) on which this service
								was performed. Provides further detail on procedure(s). If not required to
								report an additional tooth surface, leave blank.
DC899
Record Type
1/1/2003
Text
2
DC