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-G-2 - Maine Health Data Organization Capitated Payments File Mapping to National Standards

Current through 2024-29, July 17, 2024
Data Element #
Data Element Name
UB-04 Form
								Locator
CMS 1500
								#
HIPAA Reference ASC
								X12N/005010A1 Transaction Set/Loop Segment ID/Code Value/ Reference
								Designator
CF001
Submitter
N/A
N/A
N/A
CF002
Payor
N/A
N/A
N/A
CF003
Insurance Type/Product Code
N/A
N/A
835/2100/CLP/06
CF004
Subscriber Social Security Number
N/A
N/A
835/2100/NM1/MI/09
CF005
Member Identification Code
N/A
N/A
835/2100/NM1/34/09
CF006
Plan Specific Contract Number
60 (A-C)
1a
835/2100/NM1/MI/09
CF007
Member Suffix or Sequence Number
N/A
N/A
N/A
CF008
Carrier Specific Unique Member (CSUM)
								ID
N/A
N/A
N/A
CF009
Insured Group or Policy Number
62 (A-C)
11
837/2000B/SBR/03
CF010
Monetary Amount/Provider Adjustment
								Amount
N/A
N/A
835/PLB/CT/04
CF011
Payment Subcategory
N/A
N/A
N/A
CF012
Performance Period Year
N/A
N/A
N/A
CF013
Performance Period Month
N/A
N/A
N/A
CF014
Withhold Amount
N/A
N/A
835/PLB/E3/04
CF015
Member Gender
11
3
837/2010BA/DMG/03, 837/2010CA/DMG/03
CF016
Member Date of Birth
10
3
837/2010BA/DMG/D8/02,
								837/2010CA/DMG/D8/02
CF017
Rendering Provider Specialty
N/A
N/A
professional:
837/2420A/PRV/PXC/03;
837/2310B/PRV/PXC/03;
institutional:
837/2000A/PRV/PXC/03
CF018
Rendering Provider Number
57
N/A
835/2100/REF/1A/02, 835/2100/REF/1B/02,
835/2100/REF/1C/02, 835/2100/REF/1D/02,
835/2100/REF/G2/02, 835/2100/NM1/BD/09,
835/2100/NM1/BS/09, 835/2100/NM1/MC/09,
835/2100/NM1/PC/09
CF019
Rendering Provider Tax ID
5
25 (only if EIN)
835/2100/NM1/FI/09
CF020
National Provider ID - Rendering
								Provider
56
24J
835/PLB/01;
professional:
837/2420A/NM1/XX/09; 837/2310B/NM1/XX/09;
institutional:
837/2010AA/NM1/XX/09
CF021
Rendering Provider Last Name or Organization
								Name
1
31
professional:
837/2420A/NM1/82/1/03;
								837/2310B/NM1/82/1/03;
institutional:
837/2010AA/NM1/85/2/03
CF022
Rendering Provider First Name
N/A
31
professional:
837/2420A/NM1/82/04; 837/2310B/NM1/82/04;
institutional:
N/A
CF023
Billing Provider Number
57
33b
837/2010BB/REF/G2/02
CF024
Billing Provider Tax ID
NA
NA
837/2010AA/REF/EI/02
CF025
National Provider ID - Billing
								Provider
56
33a
837/2010AA/NM1/85/ /XX/09
CF026
Billing Provider Last Name or Organization
								Name
1
33
837/2010AA/NM1/85/ /03
CF027
Member First Name
8b
2
837/2010CA/NM1/ /04, 837/2010BA/NM1/
								/04
CF028
Member Middle Name
8b
2
837/2010CA/NM1/ /05, 837/2010BA/NM1/
								/05
CF029
Member Last Name
8b
2
837/2010CA/NM1/ /03, 837/2010BA/NM1/
								/03
CF030
Member Address Line 1
9a
5
837/2010BA/N3/01, 837/2010CA/N3/01
CF031
Member Address Line 2
9a
5
837/2010BA/N3/02, 837/2010CA/N3/02
CF032
Member City Name
9b
5
837/2010BA/N4/01, 837/2010CA/N4/01
CF033
Member State or Province
9c
5
837/2010BA/N4/02, 837/2010CA/N4/02
CF034
Member ZIP Code
9d
5
837/2010BA/N4/03, 837/2010CA/N4/03
CF035
Substance Use Disorder (SUD)
								Indicator
N/A
N/A
N/A
CF899
Record Type
N/A
N/A
N/A